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EURO-PIZZA LENAS ORIGINAL - ESTABLISHMENTS LENA'S ORIGINAL 134 NORTH STREET i _ I I h it li I i I IMPORTANT MESSAGE FOR / v A. DATE �//a TIME ' M A /-P�� CJ✓ OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN. WANTS TO SEE.YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU. MESSAGE �c(�� by, )& ru t,< sade_wLc-",a- l SI NED 06 FORM 4009 MADE IN U.S.A. NOTES s v • � �r rw h _Ialna4__ / , i �,� \ �, � r �'� �� % , � �, � � , �_ � l /�=G1 � i1t,ler�, earl/ C�o � Ui7�ti / �AS r Co i i 0134 North Street Lena's Original/J&M Sub Shop City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 978-741-0002 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:The Whirlpool freezer has an accumulation of frost. Thoroughly clean and defrost this freezer. Joseph & Gina Coppola PIC: Physical Facility FAIL Non-Critical BLUE Joseph Cappola Comment:There is an area of water damage on the bathroom ceiling. Investigate the source of the leak and repair. Repair and Inspector: repaint the ceiling. David Greenbaum GENERAL COMMENTS: Date Inspected:Correct By: All other violations cited in the 2126107 inspection report have been corrected. 3/5/2007 Risk Level: Permit Number: BHP-2007-0358 Status: SIGNED OFF #of Critical Violations: 0 Time IN: Time OUT: l Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 05,2007 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 05,2007 ) Page 2 oft 0134 North Street Lena's Original/J&M Sub Shop City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 978-741-0002 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: Comment:Sanitizing solution not available at the front prep area. Provide sanitizing solution of proper concentration at all work Joseph & Gina Coppola Ustations at all times. PIC: The�tting boards are stained and scored. Resurface or replace all cutting boards. Joseph Cappola I/ Inspector: I K ' es found stored between equipment. Properly clean and sanitize all knives and store in an appropriate knife rack. David Greenbaum ' y knives stoored in the knife rack. Properly clean and sanitize all knives prior to storage in the knife rack Date Inspected:Correct By: Handwash Facil'i s FAIL Critical ❑0 RED 2/26/2007 Risk Level: Comment: The front hand wash sink and bathroom hand wash sink missing soap. Provide soap at all hand wash sinks at all times. Violatiblfs Related to Good Retail Practices (Blue Items) Permit Number: Equipmen4annsils FAIL Non-Critical BLUE BHP-2007-0358 a front deli unit needs a thorough cleaning. Status: a ca VIOLATION nopener has an accumulation of grime. Thoroughly clean and scour the canopener. #of Critical Violations: The Whirlpool freezer has an accumulation of frost. Thoroughly clean and defrost this freezer. 2 The crowave needs a thorough cleaning. Time IN: Time OUT: Physical Facil' FAIL Non-Critical BLUE Urgency Description(s): omment: There is an unfinished wall in the back room. Seal wall to be impervious and easily cleanable. BLUE: Violations Related to Good There is an area of water damage on the bathroom ceiling. Investigate the source of the leak and repair. Repair and repaint the Retail Practices (Critical ceiling. violations must be corrected GENERAL COMMENTS: immediately or within 10 Reinspection in one week, all violations to be corrected. days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 26,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 26,2007 ) Page 2 oft Page 1 of 1 Joanne Scott From: Bonnie Celi Sent: Mon 1/8/2007 8:22 AM To: Health Department Cc: Subject: 134 North Street Attachments: Salem 5 has agreed to pay back taxes for 134 North Street, we should have a payment by Wednesday. Thanks again for your assistance with this matter. Bonnie Collector City of Salem 93 Washington Street Salem, MA 01970 978-619-5620(Telephone) 978-745-7185(Fav) http://89.0.122.62/exchange/JScott/Inbox/134%2ONorth%2OStreet.EML?Cmd—open 1/8/2007 E ri4w '` , `� a, a }f1+ rIF*Yt p.ur p-. ae �F� e✓ a Aq{ { 4 nn u z ,W Bowra or xealth IGmbetiey DnSooll, 120 Washington Street,4th Floor Mayof , SALEM,MA 01970 DATE PRINTED: 01/08/2007 ESTABLISHMENT NAME: Lena's Original/J&M Sub Shop File Number:BHF-2004-000017 .134 North Street Salem MA 01970 LOCATED AT: 0134 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0358 Jan 8,2007 Dec 31,2007 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 Board of Health Page 4 of 6 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH RECEIVED 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 DEC - 7 2006 TEL. 978-741-1800 FAx 978-745.0343 CITY OF SALEM Kimberley Driscoll W W W.SALEM.COM BOARD OF HEALTH Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TOOtPERATE A FOOD ESTABLISHMENT �} NAME OF ESTABLISHMENT LE W S fQA t �'-t II14C S(J TEL# 977 � � I- (� J o -f ADDRESS OF ESTABLISHMENT U /V 0 ST— FAX# MAILING ADDRESS (if different) L'�/'/.,__ — f2 1 ;Z-0 EMAIL--Business': Owner's OWNER'S NAME 1 AI A � y ( Qg -D ( 14- TEL# 'A;* AIL- �1 ADDRESS S` d& / 11— le I5-.5- EET �J CITY STATE L' ZIPPY CERTIFIED FOOD MANAGER'S NAME(S)� 1T ._ �-� CERTIFICATE#(S) '7 7 (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# tlpYSpFOPFNATION Monday _ Tuesday Wednesday Thursday Friday Saturday Sunday NOaNSO teInti time ��^ i �� Please write In time pf day. (far example flam-ttpm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. $100 more than 10,000sq.ft. j0 - ... _... NO le-- ---- --- -- ---.....--....__._--..__Ie--_ss-... than'2-5---seats.., ---- ---- =-$1-`0--0 - RESTAURANT YES 25-99 seats =$150 more than 99 seats =$200 --.------ -- --- -- ---- --------............. - _.-------- .- -- ADDITION ----- ----- ...... BED/BREAKFAST YES NO $100 -- - .___ --- -...__... - - .._............__... - __...._...... ....... ...__._. .._...... AL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES O $5 OBACCO 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`s4t*1 h must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all s to tax returr>5d6'and paid ail state taxes required under the law. gna Date Social�i 4r Fed ral Identification Number - --------------------------------- - -------------- -------------- ------ ----------- - - - --- -- --- - ------- --------------------------- Revised 11/13/06 FOODAP2007.adm C'heOH 8 Date +[ �_ n 0134 North Street Lena's Original/J&M Sub Shop City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: I PROTECTION FROM ONTAMINATION 978-741 0002) Food Contact daces Cleaning and Sanitizing FAIL Critical ❑d RED Owner: - � ' ,. mment:The cutting boards are stained and scored. Resurface or replace the cutting boards. Joseph &'Gina Coppola Hand ash Fac']it FAIL Critical ❑d RED PIC: 4 ` �omment:The front hand wash sink has no soap. Provide soap at this hand wash sink at all times. Joseph Cappola. Inspector: Violations Related to Good Retail Practices (Blue Items) David Greenbaum Equipment and U sils FAIL Non-Critical BLUE Date Inspected: Correct By: corp The front deli cooling unit needs a thorough cleaning. 9/14/2006 e pener has accumulation of grime. Thoroughly clean the canopener. Risk Level: e b Beverage air reach in has an accumulation of mold. Thoroughly clean this unit. Permit Number: Tive/11 g freezer needs a visible,accurate thermometer. BHP-2006-0131 Status:' he Whidpool freezer needs a thorough cleaning and defrosting. VIOLATION Physical Facility FAIL Non-Critical BLUE #of Critical Violations: Comment:There is a leak in the restroom. Repair the leak and ceiling. 2 Time IN: Time OUT: f�_The wood wall in the back room needs to be painted. GENERAL COMMENTS: Urgency Description(s): 822:Reinspection in one week. All violations to be corrected. BLUE: Violations Related to Good Retail Practices (Critical= violations must be corrected immediately or within 10 days)(Non-critical violations" must be corrected immediately or within 90 days) u ` City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 14,2006 ) Page I oft Item Status Violation Critical Urgency RED- Violations Related to;; I Foodborne lllness Interventions and Risk Factors (Require?,f " immediate corrective action),-„x z City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 14,2006 ) Page 2 of " 0134 North Street Lena's Original/J&M Sub Shop City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 978-741-0002 Physical Facility FAIL Non-Critical BLUE Owner: Comment:There is a leak in the restroom. Repair the leak and ceiling. Joseph & Gina Coppola PIC: The wood wall in the back room needs to be painted. Joseph Cappola These items to be corrected by the next routine inspection. Inspector: GENERAL COMMENTS: David Greenbaum Date Inspected:Correct By: 851:All other violations cited in the 9/14/06 inspection report have been corrected. 9/22/2006 Risk Level: Permit Number: BHP-2006-0131 Status: SIGNED OFF # of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 27,2006 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) U City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 27,2006 ) Page 2 oft Massachusetts Department of v 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 NameT Date e of O eration s Type of Inspection o 1 U Food Service ❑ Routine Address V Ris ❑ Retail IQ Re-inspection Level El Residential Kitchen Previous Inspection Telephone r7 i ❑ Mobile Date: 311 Owner --T 'W HACCP Y/N ❑ Temporary ❑ Pre-operation D E-12AG ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) If Time ❑ Bed&Breakfast ❑General Complaint In: [-] HACCP Inspector � Out: 6 Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTEC710N MANAGQIJIEN7 z� ��0 ;4 4, - -�._._h -112. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El 13 Handwash Facilities ;�EMPI.OYEEHEALTH "n'' ,an�ns'„xd:e„»rye s PROTECTION FROM CHEMICALS t n,:a . _ ❑ 2. Reporting of Diseases by Food Employee and PIC =1• M -k=-n m�a��? >„-' ! r �a " ` i.43l ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals )`FOOD FROM APPROVEDTIMER'EMPERATURE CONTROLS Poieettiall HazardoitsFoods r i ❑ 4. Food and Water from Approved Source ey r� „ I ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling y"PROTECTION FROM CONTAMINATION "'��""�"��F e,: i` x.. �` [119. Hot and Cold Holding i%,1 �� Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ _ Cross-contamination 1 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge" Cooked and RTE Foods* 2-103.11. Person in charge-duties _ Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* _ 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge' Contamination from the Consumer 590.003(G) Reporting by Person in Charge' 3-306.14(A)(B) Returned Food and Reeervice of Food- .3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions - Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem eratures* - 3-201.13 Fluid Milk and'Milk Products* 4-501.1't2 Mechanical Warewashina Hot Water 3-202.13 Shell Eggs* Ssmitization Tem eratures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical.Sanitisation-temp.,pH, 3-202.16 lee Made From Potable Drinking Water* concentration and hardness. * 5-101.1.1 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Sheltrlsh and Fish From an Approved Source Contact Surfaces and Utenstils%r 4-702.1 I 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 Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstoc:k Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1.7 Game Animals* 1.1 Good Hygienic Practices $ Receiving/Condition 2401.11. Eating,Drinking or Usina Tobacco* 3-202.11 - PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and - 3-202.15 Package Irate it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F,) Preventing Contarnination from 3-203.1.2 ShellstockIdentification Maintained* Emoloyecs* Tags/Records: Fish Products 13 Handwash Facilities 3402.11. Parasite Destruction* Conveniently Located end Accessible - 3-402.12 Records,Creation and Retention* 5-203.11. Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* g Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance /HACCP Pians - Supplied with Soap and Hand Drying 3502.11 Specialized Processing_Methods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11. Handwashin Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Dng Provision 'Denotes,critical item in the fede d 1999 Foal Cale or 105 CMR 590.010. n CITY OF SALEM BOARD OF HEALTH � ! Establishment Name: �O/14J ���i Date: 3// IUG Page: of _ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY X of� fl /�. I (� T C •-"7 v 1 1401 �4 // /^ T 1 C N DLA / V 3 Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all vzfVoluntary Compliance L3 Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension qomply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspe'nTsioonn/rreevocation of ❑ Embargo ❑ Emergency Closure your food permit. LlVoluntary Disposal LIOther: 3-50114(C) PHFs Received at"Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1.22) (Cont) 41`F745°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.0 Cooling Methods forPHFs 14 Food or Calor Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PftFs Maintained at or below 3-202.12 Addinscs`° 590.004(F) 41°/45° F* 3-302.14 Protection from Unar,roved Additives'" 3_501.I6(A) Hot PHFs Maintained at or above IS Poisonous or Toxic Substances 14(1°F. * 7-101.11 Identifying Information-the igina( 3-501 16(A) Roasts Held at or above 130°F. Containers* 7-102.11 Common Namo-�'orkin*Containers* 2g Time as a Public Health Control 7-201.17 8e.enation-SPortg,e" 3-501.19 Time as a Public Health Control* 590.004(H) Variance Requirement 7-202.1 t Restriction-Presence and Use 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.17. Sauiti zers.Criteria-Chemicals* POPULATIONS HSP) _ 7-204-1.2 Chemicals for Washin¢Produce,Criteria* 21 3-801:11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning labels,' 7-204.14 Drdrn A>ents,Criteria* 3-801..11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact.Luhricants* 7-206.11 Restricted Use Pesticides, Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Kaw Seed S trouts Not Served. 7-206.12 Rodent Bait Stations* 1801.1i(C) Uno.coed Fax1 Pucka>e Not Re-served. 7-206.13 Tracking Powders,Pest Control and Mca)torin g* CONSUMER ADVISORY TIMEffEMPERATURE CONTROLS 22 3-60111 Consumer Advisory Pasted for Consumption of 16 Proper Cooking Temperatures for Animal Foods that are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-4_ 01.1 10(1)(2) Fggs- 155'F 15 Sec. Pathe enti E s-hnmedtatc Service 145°F15sec, 3-302.13 Pasteurized Fggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game E s* Animals- 155'F 15 sec.'r 3-401.1l(B)(1)(2) Pork and Beef Roast-130"F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155"F IS 590,009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering. mobile food, temporary and 3-401.11(-k)(3) Poultry,Wild Game, Stuffed PIIles, 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((7)(3) Whole-muscle,Intact Beef Steaks interventions and tisk factors. Other 14TT* _ 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should tie debited under 1629- Mlcrowave 165'"F* Special Requirements. 3401.11(Aul)(b) All Other PHFs- 145°F'15see. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(ll) 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 Timer' foodborne illness interventions and risk factors listed above, can be 3-403.11(C) ConzrnercWN Processed RTE Food- !bund in the following sections of the Food Code and 105 CMR _ 140°F* .590.000. _ 3-403.11(E) Remaining Umliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts* 23. Mena ement and Personnel _ FC-2 .003 78 Proper Cooling of PHFs 24. Food and Food Protection __ FC=3 .004 25. Equipment and Utensils FC 4 { .005 3-501..W(A) Cooling Cooked PHFs from 140'F to - - -- ---.006 26. W_a_ter, P_I_um_bit and Waste FC 5 _.006 _ 70'F Within 2 Flours and From 70°F 27. Ph sisal Facility FC-8 007 _ to 41.°F145°F Within 4 Hours. ` 28. Poisonous or Toxic Materials FC-7 .008 3-50IA4(B) Cooling PHFs Made From Ambient 29. Special R uirements .009 Temperature'Ingredients to 41°17/45'F 30Other Within 4 Hours" r's'"`'n".nvaa„ ".Denotes critical item in thcc Caderal 1999 Food Code or 105 CMl2 590.000. Massachusetts Department of Public Health Salem Board of Health c 120 Washington Street,41h Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name DT e of 0 erasion s Tvoe of Inspection at (V"S )b Food Service routine Address Rik ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ooa ❑ Mobile Date: yy/ iZ�� Owner HACCP YIN ElTemporary ElPre-dp ration f ��� ❑ Caterer ❑ Suspect Illness Person in Charge(PIC Time ❑ Bed& Breakfast ❑ General Complaint In: ElHACCP Inspector G Out , Permit No. El Other Each violation checked .equires 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. `7 FOODPROTECTIONMANAGEMENT,i`��' f ,�, ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE PROTECTION FROM CHEMICAL8 El 2. Reporting of Diseases by-Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals g FOOO FROM APPROVEp SOURCE � ,g TIMEITEMPERATURE CONTROLS Potential Haardous Foods ` E] 4. Food and Water from Approved Source 3 _ _ _ _ ( h ) E] 5. Receiving/Condition ❑�10 WCCooking Temperatures UA"17. Reheating E] 6. Tags/Records/Accuracy of Ingredient Statements !� 9 ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PRlTECTION FFSOM CONTA9AtNATION . i a , t^�_ y?r�y� r r, 'i , r ',�� ❑ 19. Hot and Cold Holding ., :...E-AI i G 1' El 8. Separation/Segregation/Protection -120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 1 I REOUIREMENTs FOR HIGHLY SUsOEPTIBLE POPUf.ATION&(HSP) El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices [CONSUMERADVISORY,„°' ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions I immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection - immediately or within 90 days as determined by the Board today, the'items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C ` N" by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 4. Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-4)(590.005) the food establishment permit and cessation of food X26. 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)(59o.o06) 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'5001ns IF.i 14.O �04I3, aoo� Inspect r's Signature: Print: PIC's Signature: Print: Page o�Pages �O v r Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Crossoontamination 1 �590.003(A) Assignment of Responsibility* 3-302.LI(A)(1) RAnfromaw mal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Foods* 2-103.11. Person in charge-duties Contamination from Raw ingredients 3-3011l(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require repotting by food employees and 3-302.11(.A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contac'with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(0) Reporting by Person in Charge* 3-306.14(A)(B) Rettimed Food and Re er2,ce of Food" 3 590.003(D) Exclusions aid Restrictions* - Disposition of Adulterated or Contaminated - 590.003{E) Removal of Exclusions tmd Restricions Food 3-701.11 Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501,111 Manual Warewasbing-Hot Water Sanitization Tem eratures* 3-201.12 Food in Hermetically Sealed Container* 4-501.1 t2 Mechanical Warewashin Hot Water 3-201.13 Fluid Milk and Milk Products* b- 3-202.13 Shell F*g*s* Sanitization Temperatures* 3-202.1.4 FgEs and Milk Products,Pasteurized* -T501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinkin.Water* concentration and hardness. 'w 5-101.11 Drinkin Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Ford- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4702.1 i Frequency of Sanitisation of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Coma Surfaces of ui ment* Shellfish* 4-703.11 Methods o£Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* IQ Proper,Adequate Handwashing Re Mato Authority hor" Game and Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms'` 3-202A S Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* ll Good Hygienic Practices 5 Receiving/Condition 2-401-11 Eatin ,Drinkin or Usin Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2-401,12 Discharges From the Eyes, Nose and 3-202.15 Package hate it y* Mouth* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contannnation When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em lovees* TagslRecords:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402. 5-203.11 Numbers and Capacities* 4( Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(1} Labeling of Ingredients' 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced ox°men acka 'na.criteria* 6-301.11 Handwashing Cleanser, Availability 8-103.12 Crntformance with A roved Procedures* 6-301.1.2 Hand Drying Provision '4 Denoles critical item in the federal 1999 Foci Code a 105 CMR 59000_ CITY OF SALEM I BOARD OF HEALTH Establishment Name:T6Date: o G Page: a of d Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Retl Item Verified ` -... PLEASE PRINT CLEARLY t----57,L lI �— S 4JrkJ P Coco F r e �,n ins i § O/ er LA 0 e)A 49 A011110 kv F GC 16,Lro � � n Z T v /r" al Ecr T ,Ga/ U /�Qe G 'r A r PTIJ 1 LX Y r L4,4 / X/ 4 2- . n Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ { Exclusion violations before the next ins ection, to observe all conditions as described, and to P Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. Chi /I � p ❑ Voluntary Disposal ❑ Other: Ti n 1 r 3-501..14(C) PHFs Received at Temperatures Violations Related to Foodborne illness interventions and Risk According to Iaw Cooled to Factors(items 1.22) (Cont.) 41"F/45°F Within 4 Hours PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Calor Additives 14 PHF Hot and Cold Holding 3-501.16(B) Cold PL1Fs Maintained at or below 3-202.12 Addeuus" .590.0(14(F) 41"!45"F' 3-3(YZ.14 Protection from Ung roved Additives* '3-501.I fi(A) ,Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. " 7-101.11 kntiiners lnfonnaeion-Original 3-501,16(A) Roasts Held at or above 130"F. Containers" 7-102.11 Compton Name-Working Containers*' 20 Time as a Public Health Control 3-501.19 Time as a Public Health Control* Soe 7-202.11 Re 7-202.11 Re "ration-striction-Presence and Use'" 590.004(H) Variance Requirement 7-202AT-7 Conditions of If se" 7-203.11 'PoxicContainers-Prohibitions- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sattitizers, criteria-Chemicals"' POPULATIONS(HSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.'1l(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drvin A gots.Criteria* Beverages with Warning Labels* 3-801..11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact.Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.'11. Restricted Use Pesticides.C_rlteria* Raw Seed S rictus Not Served. ' 1-206.12 Rodent Bait'Stations*` 7-206.13 Tracking Powders,Pest Control and 3-801.11(7) Udo cited Foal Packa>e Not Re-served. Monitoring^- CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Fords That are Raw.Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate Eirective 3-40'2.11-4(1)(2) Eggs- t55P15Sec. Pathogens.* 1/112001 _Eggs-immesh rte Service 1.45"FlSsec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-4(11.11(-4)(2) Comminuted Fish, Meats&Game Eggs* Animals-155'F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast- 130"F 121 mm* SPECIAL REQUIREMENTS 590.009(-4)-(D) Violations of Section 590.009(-4)-(D)in 3-401.11(A)(2) Rntitas,Injected Meats- 155'F 1.5 sea * catering; mobile food, temporary and 3-401.11(A)0 Poultry, Wild Game,Stuffed P11179, residential kitchen operations should he Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°17 15 sec. * above if related to foodborne illness 3-40111(0)(3) Whole-muscle,Intact Beef Steals interventions and risk Tactors. Other 1.450F* 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. 3401,11(A)(1)(b) All Other PHFs- 145'F 15 sec 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1 1(A)hc(D) PHFs 1650F 15 sec. 44 Litems 23-30) 3-403.11(B) Microwave- 165"F 2 Minute Standing Critical and non-critical violations, which do not relate to the 3-4Time"` foodborne illness interventions and risk factors listed above, can be 03.11(0) Commercially Processed RTE Food- found in the following sections q/the Food Code and 105 CMR AAF* 590.000. _ 3-103.11(E) RemainingUnslicedPortions ofBeef Item Good Retail Practices FC 590.000__ Roasts" 23. Mona ement an_d Personnel__ ___ FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC--3 .004 _ 3-501.14(-4) Conlffig Conked PHFs from 140` _25. Equipment and Utensils FC-_4 .005 'F to 26 Water, Plumbingand Waste FC-5 .006 70°F Within 2 Hours and From 70"F 27. Physical FacilityFC-6 1 .007 to 41.°14/450F Within 4 Hous. * 28. Poisonous or Toxic Materials _ FC-7 .008 3-50'L14(B) Cooling PHFs Made From Ambient 29. Special R uirements _ .009 Temperature Ingredients to 41°F145`'F _30_ _ Other - Witlun 4 1-Into s* ssoor,,,m.Kw-zn., ''�Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM 1 BOARD OF HEALTH Establishment Name: !P/y, S✓ Date: Page:_'C;;�-� of Item Code C-Critical Rem DESCRIPTION.OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item -Verified PLEASE PRINT CLEARLY (� _ �_ 1 i t tJ _ s r N JA a 1,94 _ mayak oa _ I i t t 7 7 3t i 1 Corrective Action R uiredi ❑ No es Discussion With Person in Charge: eQ have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p Re-inspection Scheduled ❑ Emergency Suspension \' comply with all mandates of the Mass/Federal Food Code. I understand that - noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. O_ (� ❑ Voluntary Disposal ❑ Other: 5 3-501.14(0) PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to Factors(items 1.22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs ' 1=419 PHF Hot and Cold Holding Food or Color Additives 3-501.16(B) Cold PlIN Maintained at or below 3-24)2.12 Additises" 590.004(F) 41%45' F* 3-302.14 Protection fraLLina) robed Additives* 3-SOl.lti(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F. 7-101.11 Identifying Information-Or iginal 3-501.16(A) Roasts Held at or above 130'F. Container' - 7-102.11 Common Name-Workine Containers" 2Q Time as a Public Health Contra[ 3-501.19 Time as a Public Health Conn'o'--* 7-201.11 Se arstion-Stoi aee* 7-202.tI Restriction-Presence and Use' 590.004(H) Variance Re uiremenf 7-202.12 Conditions of Use" 7.203.11 Toxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sanitizets,Criteria-Chemic ds' POPULATIONS(HSP) 7-204.12 Chemicals for W whine Produce,Criteria'` 21 3-801.17(A} Unpasteurized Pre-packaged els*es atul 7-204.14 Drying Agents.Criteria* UseBevof P s with Warning S.,abcls* 3-801.11(B) Use of Pasteurized fi2�s' 7-205-11 Incidental Food Contact. Lubricants* and 7-206.11 Restricted Use Pesticides.Criteria* 3-80L11(D) Raw or Partially Cooked Animal Food Raw Seed Sprouts Not Served. 7-206.12 Rodent Ba,Po Stations* 3-801.11(C) Uno ened Food Package Not Re-served. 7-?06.13 'fracking Powders,Pest Control and Monitorinn* 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 11 Al (2) Eggs- 155`F 15 Sec. Pathb ens Frrecd� tool E is hmmedtatc.Service 145'Flisec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Camtniuoted Fish,Meats&Game Eggs* A intals- 155'E 15 sec SPECIAL REQUIREMENTS 3-401.1l(,B)(1)(2) Pork and Beet Roast -130'F 1.21 min* 3-401.11(A)(2) Ratites,Injected Meats-155'F t5 590.009(A)-(D) Violations of Sect on 590.009(A)-(D)in see.* catering. mobile focal, temporary and 3-401.11(A)(3) Poultry, Wild Came,Stuffed Pt[Fs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 see. "` above if related to foodborne Illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under//29- Mierowave 165'F* Special Requirements. 3-401,11(A)(1)(b) All Other PHFs- 145'F'15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3 403,11(A)&(D) PHFs 165'F 15 sec. *- (Items 23-30) 3-403.11(B) Microwave- 165' F 2 Minnie ie Standing Critical and non-critical violrnions, which do not relate to rhe Tinge* ,foodborne illness interventions and risk faelors listed above,can he - 3-403.1 1(C) Commercially Ptneessed RTE Faod- !bund in the follonring sections of the Food Code and 105 CMR 140'F- 590.000. ___ 3-10 11.1(E) Rzmaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts* 23. Management and Personnel FC-2 .003 Ig Proper Cooling of PRFs 24. Food and Food Protection_ _ FC_ 3 .004 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26Wata_Rumbin and Waste FC-5 .006__ 70'F Within 2 Hours and From 70'F 27. Physical Facility ____ FC-6 -007 to 41.'17/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC--7 .008 3-50'1,14(B) Cooling PHFsMade Front Ambient 29. S ecialRo uirements _ 009 Tempe,attire ingredients to4l'F145°F 30.___ Other Within 4 Hours)' *Denoies milel item in the tedcral 1999 Food Code or 105 CMR 590.000- 4 . Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/27/2005 WHO'S PLACE OF BUSINESS IS: Lena's Original/J&M Sub Shop File Number:BHF-2004-0017 134 North Street - Salem MA 01970 LOCATED AT: 0134 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions Notes FOOD SERVICE BHP-2006-0131 Jan 3,2006 Dec 31,2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 3l, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 5 of 9 �. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH j z 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAx 978-745-0343 6��/ry 0 MAYOR WWW.SALEM.COM '9i9O QA� "CO04 JOANNE SCOTT, MPH, RS, CHO pS",9 HEALTH AGENT •'FgF'Li 2006 APPLICATION FOR P,ATIII TSO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT T/'► P�Il R��Y"0- TEL#�� ' 7�,u� d O'O ADDRESS OF ESTABLISHMENT J3�6 &,D L'TL��7��,,y MAILING ADDRESS (if different) �.JS1 T/� � /�}/ L/ A --. OWNER'S NAME�bS P// 4—aik)/`J' C0eq(QLI� TEL# ADDRESS15q rt o CITYA - STATE JT L ZIP CERTIFIED FOOD M AGER'S NAME(S) CERTIFICA E#(s) -;Z14 4/9 r�I IV O.P0 I Y� (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Cj I A/ A CO f 80 L# HOME TEL# ,78'1-30K- 3 G HOURS OF OPERATION: Mon. Tue. Wed.—,,Thu. Fri. Sat. Sun. ) �- 9 M - TYPE OF ESTABLISHMENT C FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 -------------------------- ------------------------------------------------ ------- - --------------- -------...._----------------- - RESTAURANT YES NO less than 25 seats $100 ^/ 25-99 seats =$150 '- 1 " Y' more than 99 seats =$200 -----------------------------------------------------------------------------------$'1'0"0----------------- BED/BREAKFAST YES NO ADDI T IONAL PERiyiTS --------------------------------------------------------------------------------------------------------------------------- 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 I n 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. I natur Date Social Security or Federal Identification Number - - ------------------------------------------- - -- - ------- -------------------------------------------- ------ ------- -- - ---- Y� Revised 11/03/05 FOODAP2.adm Check#&Dale_/S0� I2- (/S Massachusetts Department of Public Health Salem Board Health S p ,20 Washington Street,4'" Floor Division of Fbod and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978) 745-0343 Name Date Tvoe of Operations Type of Inspection { Food Service ❑ Routine Address isk ❑ Retail -gl Re-inspection 1 . Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: tt4-W Owner HACCP YIN ❑ Temporary ElPre-operation [I❑ Caterer Suspect Illness Person in Charge{PI ) 1 ❑ Bed&Breakfast ❑ General Complaint Time _ Time4 ❑HACCP Inspector Out: Permit No. ❑Other _ Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.1)09(E) ❑ 590.009 IF) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT' . . _. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION.FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE - ❑ 4. Food and Water from Approved Source TIMEt'fEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)' ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below F6_F_N1_1 by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) by 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 30. Other Mn OF RE-INSPECTION: 5:5901nsp FFPn 14,dw ' Inspector's Signature: I41 t _Print: ` t PLC's Signature: 11)A �/ Print S Page ofPages G ` Violations Related to Foodborne Illness - Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 _ Cross-contamination I 590-003(A) Assignment of Responsibilitv* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(R) Demonstration of Knowledge* Cooked and RPE Foods" 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-30111(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other;. 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require repotting by food employees and 3-302A I(A) Food Protection°' at licams- 3-302.15 WashingFmitsandVe�eaables 59O.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report'To The Person ht Utensils' Charne* Contamination from the Consumer 590.003(G) Reporting b Person in Charge': 3-306.14(A)¢3) Returned Foal and Rcservice of Food* 3 590.003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclasiuns and Re frictions Food 3-701.11 Discarding of Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food' 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-R) Compliance with Food Law* 4-501.1.11 Manual Warewashing-[lot Water 3-201,12 Food in a Hermetically Sealed Container* Sanitization lUm reratnres* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical W trewashing-Hot Water 3-202.1:3 Shell E"*s* Sanitization Tem eraturest 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3--302.16 Ice Made Front Potable Drinking,Water* concentration and hardnes,s. "' 5-101.11 Drinkingn tauter from an Approved System" 4-601.1 I(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) BafWater tled erMectsSt Water* 4-602.11 CleaningFrequencyofEquipmentFood- 590.006(}3) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and Utensils* ShelNish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201..14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E of ment* Shellfish* 4-703.11. Methods of Sanitization -Hot Water and 3-201.15 ;Molluscan Shellfish from NSSP Listed Chemical* Sources* 1p Proper,Adequate Hantlwashing Game and Wild Mushrooms Approved by e uiato Authority 2-301.11 Clean Condition-Hands and Anus* R 3-2011.$ Shellstock Identification Present* 2-301.12 Cleaning Procedure', 590.004(0) Wild Mushrooms* 2-301.14 When to Wash" 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401-11 Fining,Drinkin=ar Llsing Tobacar* 3-202.11. PKFs Roceived at Pttt ser Tem rerauu.es:, 2-401.12 Discharges From the Eyes Now and 3-20215 Package hneeril * Month* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastin'" 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 18 Sltellstock Identification* 590.004(E) Preventing Contmnination from-3-20'.. 3-203.12 Shellstock Identification Maintained* Em Wvees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destmetion* 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 mid Placement' 9 Conformance with Approved Procedures 5-205.11 Aecessibilit O erntion and Mahttonance /HACCP Plans Supplied with Soap and Hand Drying 3-502.1.1 S lzed rMeo * Devices 3-50212 Reduced oxygen packaging,criteria" 6-301..1.1 liandwashing Cleanser.Availabdity 8-103.12 Conformance with Approved Procedures* 6-301,11 Hand Dr-in=Promion "Donate,critical ilenn in the federal 1999 Food(:ode or 105 CMR 590.000. l ' CITYOFSALEM ii BOARD OF HEALTH # Establishment Name: I1�e)C Date: ka Page: of r } Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLE "' I r < reGr I r 0, Pr � I &er f . t I , Y`r ' e t r - v r I ° 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/ 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 't _noncompliance may result in daily fines of twenty-five dollars or suspension/revocation\of ❑ Embargo ❑ Emergency Closure your food permit. n /� _ p v �✓l.�a"~`3-- ❑ Voluntary Disposal ❑ Other: i r 3-501..14(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk .According to haw Cooled to Factors(items 1.22) (Cont.) _ 41°FI=45°F Within 4 Hours. ` PROTECTION FROM CHEMICALS 3-501.'15 Cooling Methods for PHFs 1.4 Food or Color Additives 19 PHF Hot and Cold Holding 3-501,16(B) Cold PHFs Maintained at or below 1-20212 Addrules'* 590.004(F) 41145°F* 3-302.14 Protection from(ilia roved Additives* 3-501.16(A) Hot PHFs Mainttined at or above 1=515 Poisonous or Toxic Substances - t40"F. 7-101.11 k(ent(tying information-Original 3-501.1.6(A) Roasts Held at or above 130'F. Containers" 7-102.11 Common Natnu-Workim�Containers* eg Time as a Public Health Control 7-201.1 1 1 Sa aration-Stora e* 3-501.19 Time as a Public Health Connor* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of 0,e- 7-201.11 Toric Containers-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Stuntizers.Criteria-Chemicals* POPULATIONS HSP 7-204.1.2 Chemicals for Washing Produce.Criteria* 21 3-801.t (A) Unpasteurized Pre-packaged Juices and 7-20b.14 Beverages with Waimng l abcls- DI. eats. Criteria' 3-801.11($) Use of Pasteurized Eg s* 7-205.11 Incidental ental Food Contact,Ieibricants* 7"206.11 Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or Parfially Cooked Animal Food and 7-206.12 Rodent Hair Statiotts* Raw Seed Sprouts Not Served. 7-206.1'3 Tracking Powders,pest Control and 3-801.11(C) Unopened Food Package Not Re-served. Monitoring' CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of I6 Proper Cooking Temperatures for Animal Foods'rhat are Raw,Undercooked or l PHFs Not Otherwise Processed to Eliminate FRective virB001 3-401.t1A(1)(2) Eggs- i55F'15Sec. Pathogens.* )✓ is-Lmhlultatc Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw,Shell 3-40LI UA)(2) Cotruninute�d Fish,Meats&Game E S* Animals-155°F 15 sec. 3-401.)103)(1)(2) Pork and Beef Roast-130°F 121 nein* SPECIAL REQUIREMENTS _ 3-401.11(A)(2) Ratites,Injected Meats-155°F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec, r catering, mobile food, temporary and -T40 Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stifling Contairting Fish,Meat, - debited under the appropriate sections Poultry or Ratites-165°.F 15 sec. above if related to foodborne illness 3.401.1 1(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F 590.009 violations relating to good retail 3-401.12 Raw Animal,Foods Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F15sec. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(.AWD) PHFs 165`F 15 sec.' (Items 23-30) 3-403.11($) Microwave- 165°F 2 Minute Standing Critical and non-(ritical violations, which do riot i elate to the Time* ,foodborne illness title)ventions and risk factors listed above can he 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code aia1105 CMR 140`F' - 590.000. 3-403.1.1(E) Remaining Unsliced Portions of Beef Item I Goad Retail Pra_c_Uces FC 590.000 Roasts* 23. Mane ement and Personnel _ FC--2 .003 I8 Proper Cooling of PHFs 24. Food and Food Protection _FC-3 o04 25. Equipment and Utensils FC_-4 005 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. _Water, Plumbin and Waste FC-5 .006 _ 70'F Within 2 Flours and From 70°F 27. Physical Facility__ FC-6 - .007 _ to 41°'.FJ45°F Within 4 Hours.* 28. Poisonous or"roxis Materials FC-7 .008 3-50L14(B) Cooling PHFs Made From Ambient 29. Special Requirements Temperature hhgredients to 41`F(45"P 30, Other Within 4l4ours'x ssnorr,+,n.,rs"zm *Denotes criocal iton in the federal 1999 Food Code or 105 CNIR 590.000. 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 / Tvpe of Operations) Type of Inspection Da 7 t7 � Food Service Routine Address Risk Retail Re-inspection Level ❑ Residential Kitchen Previous Inspection El Mobile Telephone Mobile ,/ Date: 3115-1 3 z- OwnerHACCP YIN ElTemporary 1-1Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) I r Time ❑ Bed&Breakfast ❑ General Complaint In: c J ❑ HACCP Inspector Out: .S-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-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009F) [j action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT E] 1. PIC Assigned Knowledgeable Duties , 12. Prevention of Contamination from Hands / / EMPLOYEE HEALTH " ° ' El 13. Handwash Facilities " "PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION -" ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY"SUSCEPTIBLE POPULATIONS(HSP) ❑ 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 ofCHealNth. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other a DATE OF RE-INSPECTION: I JPµ 5:5901nsOscfFoim6-14400 5 0!�SL Inspector's Signature: Print- PIC's Signature: Print: Page-of ZPages / lJ U Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.1 I(A)(1) Raw Animal Fonds Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTL Foods* 2-103.11 Person in charge--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(x) Food f'rce Ilion" applicants* 3-302.15 Washing Fruits and Vqc abler 59UO3(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Chazge'k Contamination from the Consumer 590.003(G) Re or ng b Person in Charge' 3-306A4(A)(B) Returned Food and Reservice of Food" 3 590.003(D) Exclusions and Restrictions* Disposition of Adukerated or Contaminated 590.003(B) Removal of Exclusions and Restrict ons Food 3=701.11 Discarding or Reconditioning Unsare _FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Com liance with F'a>d Law* 4-501.111 Mantra]Warewashing-Hot Water 3-201..12 Food in a Hernnetieslly Sealed Container* - Sanitization'paeratures* 3-201.13 Fluid Milk and Milk Products* 4501.112 Mechanical.Warewashing-Hot Water 3-202.13Shell Eggrg. Sanitization Temperatures* 3-202.14 E t s and Milk Products.Pusteurized'r 4-501.1:14 Chemical Sanitization-temp.,pH, 3-202.16 lee Made From Potable Drinking Water' concentration and hardness. 5-101.11 Drinking Water from an A roved System* 4-601.11(A) Equipment Foxxt Contact Snrfacas and Utensils Clean* 590.006(A) 13otrvdDrinking Water* 590.006(B) WaterMeets 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 4-70211 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Snrfaczs of 13(vi anent* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2 Re uiatoAuthorit -301,11 Clean Condition-Herds and Arms'` 3-202.15 Shellstock Identification Present' 2301.12 Cleaning Procedure* 590.004(0 Wild Mushrooms* 2-301.14 Wlteu to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11 F.afin ,Drink;in or IIsin*Tobacco* 3-202.11 PI1Fs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes.Nose and 3-202-15 Package bu"Tity* Month* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastin * 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.15 Shellstock Identification* 590.004(E) Preventing Contamination from 3-213.12 Shellstock Identification Maintained* Eni lovers'- t3 Conveniently Facilities TagstRecords: Fish Products Convenfentty Located and Accessible 3-402.11 Parasite Desh:nerion"` 3-402.12 Records.Creation and Retention* 5-20311 Numbers and Ciiacities" _ 590.0040) Labeling of Ingredients` 5-204.11 Location mud Placement* 7 Conformance with Approved Procedures 5-'205.11 Accessibility,O eration mid Maintenance AiACCP Plans Supplied with Soap and Hand Drying 3-502.1E S eciah7.edPracessm,Methods^ Devices Reduced oxygen packaging,eri[eria" 6-301.11 flandwashingCleanser.Availability 3-50212 8-103.1.2 Conformance with Approved Procedures"` 6-301.12 Haul Drvio provision 'Denote,critical item in the federal 1999 Food Code or 105 CMR 590,000. CITY OF SALEM BOARD OF HEALTH Establishment Name: S Date:__10 O la// 65--- Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference ; R—Red Item Verified -PLEASE PRINT CLEARLY P er-7 hontlLn, sed ff i r l 0 re W D c 5 rw1 So,n.-Nz, 4:53 -rn c.,.�o err A Nil `� aJLA, aj� sv r I , rcCA f Sj _e N n , c� 4, clt k— fe J c,. cl(\ er)A 2 / r7SjC J1/ U /p Pr !G I c. t4ocAt. G Discussion With Person in Charge: Corrective Action Required: - ❑ No Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to ' / Exclusion ti p r� Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: F , 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(items 1-22) (Cont) 41'F/450F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coaling Methods for PHk lA Food or Color Additives I4 PHF Hot and Cold Holding 3-202.12 A 3-501.16(B) Cold PHFs Maintained at or below 3-302.14 Protection from Unapproved Additives* 590 004(F) 41V450 F, t-501.16(A) Hot PHFs Maintained at or above 1 j Poisonous or Toxic Substances - 7-101.1 t _IdcCon[ainers*nriiners'nformation-Or140+. * iginal 3-501.16(A) Roasts Held at or above 130°F. Containers' 7-102.11 Common Nante-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 590.004(FD Variance Requirement 7-202.ll R�arricti tm-Presence and Use* 7-202.12 Conditions of Use" 7-203.1.1 Toxic Containers-Prohibitions* POPULATION (HSP)S FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 7-20412 Chemicals for Washing Produce,Criteria''' 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning,Labels* 7-204.14 Drying Agents.Criteria` 3-801.11(B) Use of Pasteurized Eegs* 7-205.11 Incidental Food Contact, Lubricants* 3-801.11(T)) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Ilse Pesticides.Criteria" Raw Seed S xoats Not Served. '% 7-206.12 Rodent Bait Stations" 3-801.11(C) Unopened,Food Package Not Re-served. 7-306.13 'Prackmg Powders.Pest Control and Monitoring** CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Annual Foods,chat are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-40'1.11A(I)(,2) Eggs- 155'F 15 Sec. Pathogens erreuv vvaooi Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game Eggs* Animals-155°F 15 sec. 3-401.11(13)(1)(2) 7,Aand Beef Roast- 13(`F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and _T401 1 l(A)(3) Poultry,Wild Game,Stuffed PUN, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections 1'oultr or Ratites-1fi5°.F 15 sea " above if related to foodborne illness 3-401.1 1(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F" 590.009 violations relating to good retail. 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3-401,11(Ahl)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.tl(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-4(13.11(B) Microwave- 165°F 2 Minute Standing Critical and non-(ritical violations, which do not relate to the Time' foodborne illness interventions and risk factors listed above, can be ,403.11(C7) Commercially Processed RTE Food- found in the folh>ning sec tions of the Food Code and 105 CMR 740°F* 590.000. 3-40311(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 680.000 Roasts* 23. Mena ement andPersonnel FC-2 .003 F,_g Proper Cooling of PHFs 24. Food and Food Protection _ FC-3 .004 25_ Equipment and Utensils FC 4 _.005 3-501.14(A) Cooking Cooked PHFs from 140°F to 26. Water,Plumbin and Wasie FC-5 1 .006 70°F Within 2 1fours and From 70'11' 27, Physic Facility F___ .007 .007 _ to 41°F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials______ FC-7 .008 - is 3-501.14(B) Cooling PHFs Made Froru Ambient 29 -special Re ulrements .009 Temperature Ingredients to41`F/45`F 30._.... Other _. Within 4 Hours* �rnv -zoo *Denoles critical item in Ilia f deral 1999 Food Code or 105 CNM 590o00, Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name r Date Tvpe of Ogeration(s) Tvoe of Insoection Address K Food Service ❑ Routine Ris Retail Re-inspection Telephone Level ❑ Residential Kitchen Previous I spa tion 03 0 ❑ Mobile Date: l J�i,�j� Owner HACCP Y/N ❑ Temporary op t' G-� L ,7 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint r ❑ HACCP Inspector Out:) - jr Permit No. El Other Each violatio check d requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. „ FOOD PROTECTION MANAGEMENT - ' ; ❑ 12. Prevention of Contamination from Hands E] 1. PIC Assigned/Knowledgeable/Duties ❑ EMPLOYEE HEALTH 13. Handwash Facilities PROTECTION FROM CHEMICALS " ❑ 2. Reporting of Diseases by Food Employee and PIC Approved Food or Color Additives El 3. Personnel with Infections Restricted/Excluded E] 14. t FOOD FROM APPROVED SOURCE 15.Toxic Chemicals _ k E) 4. Food and Water from Approved Source TIMEIfEMPERATURECONTROLS(Potentially Hazardous Foods) ` ❑ 5. Receiving/Condition [:116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ""' ' ' ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE.POPULATIONS(HSP)` 10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP ❑ ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ' " ....."� [:122. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions I 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 ofCHealL 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 8. 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 1 DATE OF RE-INSPECTION: \ S 5e Mm tFor 14 doo IV 'J4 CAA Inspector's Signature: \ Print: % 11�, PIC's Signature: ^ Q Print: , - Pagel of4�Pages L Violations Related to Foodborne Illness - Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Crass-contaminaton 590.003(A) Demons rat on Re of Knowle iry��--�--------� 3-302.11(A)(]) Raw ed inial nRTE Separated from 590 003(B) Demonstration of Knoviedge"' Cooked and RTE Frwds* z-103 i l Person in charge-Buttes Contamination from Raw Ingredients 3-302.1.10)(2) Raw Animal Forxls Separated from Each EMPLOYEE HEALTH Other` 2 590.003(Cl Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and - 3-302.11.(A) food Protection* - a icans -i-.302.15 VJashin Fruits and Vegetatiles 590.003(F) Responsibility Of A Food Employee Or An 3-304.11. Food Contact with Equipment and Applicant To Report'Fo The Person In (Rensils* Charge* Contaminationfrom the Consumer 590.003(0) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of fundi 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(13) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reamditioning Unsafe FOOD FROM APPROVED SOURCEFood* 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 540.004(A=R) Compliance with Food Taw* 4-501_111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Seated Container* Sanitization TemMeratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-HotWater 3-202.13 Shell Eggs*s* Sanitization Tent eratnres* 3-202.14 Ev�s and Milk Products.Pasteurized* 4-501.114 Chemical Sartitiaation-temp., pH, 3-201 16 i'ce Made From Potable Drinking Water* mncentintion and hardness, ie 5-'LOl 11 Drinkin>Water from an A roved S •stem' 4-601.91(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of EquipmentFexxl- 590.006(B) Water Meets Standards in 310 CMR 229* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-70111 1 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP listed ChemicaP" Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Aous" Re Mato Author - 3-20118 Shellstock.Identification Present* 2-301.12 Cleaninn Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Gane Animals* 1.1 Good Hygienic Practices Receiving/Condition 2-401.11 Eating,Drinkml,or Usin Tobacco* 3-203.1L PHFs Received at Pro er Tem erahnes* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity"it „ Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 1 Preventin Contamination When Tasting* 6 Tags/Records: Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.D04(E) Preventing Contamination from 3-203.12 -Sb lknock Identification Maintained* Em lovees* Tags/Records: Fish Products 13 Handwash Facilities Convereendy Located and Accessible 3-402.11 Parasite Destruction* 3-402.12 Records._Creation and Retention* 5-203.i1 Numbers and Capacities* r Labeling ofln redients" 5-204.1.1 Location and Placement* 5?0.004(1) 9 g Conformance with Approved Procedures 5-205.11 Accessibility. 0 eration and Maintenance ry IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods` Devices 3-502.12 Reduced ox• en acka ring,criteria* 6-301.11 Hattdwashuna Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-3(11.1.2 Hand Dryin*Provision ''Denotes critical item in the rederal 1999 Hood Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: /1 Date: / 'S / Page: CR ' Item Code C-Critical Item . DESCRIPTION OF VIOIATlONJ PLAN OF CORRECTION Date I. No. Reference R-Red Item. - - - Verified PLEASE PRINT CLEARLY I y G F- ccs C_ l Q m , (oar _ -- I I (S n o 1 C ✓ ro lin CON1,4)Zel- J n J - _ SA.t G Ci w �1 45 a> s w l Discussion With Person in Charge: Corrective Action Required: ❑ No es ❑ voluntary Compliance 1 have read this report, have had the opportunity to ask questions and agree to correct all o Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that ' noncompliance may result in daily fines of twenty-five ollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. f ❑ Voluntary Disposal ❑ Other: v r 3-501.1,E(C') PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(teems 1-22) (Cont,) 41`17145°F Within 4 flours. PROTECTION FROM M CHEMICALS 3-501.15 Coatin° Methods for PHFs 19 14 v Food or Color Additives PHF Hot and Cold Holding 7202.12 Additives`" 3-501.16(B) C Ad PI Ws Maintained at or below 590.004(17} 41°145°F* 3-302.14 Protection from unapproved Additives° 590.0 4(F) Hot PHFs Maintained at orabove 15 Poisonous or Toxic Substances 3-50 1. 14WR * 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Coontainenerss* 7-102.11 Common Name-Working*Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora e* 3-501.19 Time as a Public Health Control* 7-202.1.1 Restriction-Presence and Ilse* 5)0.004('H) Variance Requirement 7-202.12 Conditions of Use" 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sanitizers,Criteria-Chcmicals* POPULATIONS HSP} -- 7-204.12 Chemicals for Washing PrMuce,Criteria* 21 3-80'1.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 7-204.14 Drying Agents.Criteria`. _ 3-801..11(B) Use of Pasteurized Fess* 7-205.11 Incidental Food ContacPesticides. Lubricants* 3-$01.11073 Raw or Partially Cooked Anined Food and 7-206.11 Restricted Use Pesticides.Criteria* Raw Seed S gouts Not Served. 's 7-206.12 1 Rodent Bait Stations* 3-801.11(C) Uho cued F<wd Package Not Re-served.7-206.13 Tracking Powders,Pest Control and Monitorim** CONSUMER ADVISORY TIMETTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of Animal Foods'lbat are Raw.Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3401.1 IA('U(2) Eggs- 155'F 15 Sec. Patho°ems Eggs-Immediate Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish, Meats&Game Animals- 155°F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast - 13WF 121 twin* SPECIAL REQUIREMENTS 3-401.11(A)(2) 'Ratites,Injected Meats- 155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(17)in sec. * catering, mobile food,temporary and 3-40 1.11(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under tate appropriate sections Ponitr or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and tisk factors. Other 145°F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under N29- Microwave 1650F* Special Requirements. 3-401,11(A)(I)(b) All OtherPHFs-- 145°F'15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(U) PHFs 165°P 15 sec, * (Items 23-30) 3-403.11(B) Microwave- 165°F'2 Minute Standing Chiral and non-critical violalm", which do not relate to the Tune* ,foodborne illness intervenlionc and riskfnrtors listed above, can be ,403.11(C) Commercially Processed RTE Food- found in the following sertions of the Food Code and 105 CMR 140°F* 590.000. 3-403.1.1(E) Remaining Uasliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts d Personnel FC-2 .003 * 23. Mang ement an - -_ _ 24 Food and Food Protection FC 3 .004 18 Proper Cooling of PHFs 25. _EquiRment and Utensils _ FC-4 _.005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbin and Waste FC 5 .006 70+Within 2 Hours and Front 70°F 27. -Physical Fad ity------ _ FC-6 1 007 to 41°F145°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S octal R ulremems _ .000 Temperature Ingredients rod1°17145°F 30 --..Other Within 4 Hous:` �r n:eeaeo� '4 Denotes critical item in tho.federal 1991)Food Code or 105 CMR 590 000. CITY OF SALE49 MASSACHUSETTS BOARD OF HEALTH ' g} 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 T 9 EL. 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: Lena's Original Address of Establishment: 134 North Street Owner's Name: Joseph & Gina Coppola Restrictions: Application Date: 12/3/2004 Permit for Food Establishment 155-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSE • � BOARD OF HEALTH gj 120 WASHINGTON STREET, 4TH FLOOR 302004 q o SALEM, MA 01970 NOV 3 0 2004 TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALEM STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT �// NAME OF ESTABLISHMENT L L- N 4 SS cS U e- TEL# O - T7 /' 0O 'U ADDRESS OF ESTABLISHMENT III MAILING ADDRESS (if different) OWNER'S NAME oloaoa �^ p 44 TEL# /-' ADDRESS O P o CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(sl (required in an establishment where potentially hazardous food is prepared.) qq EMERGENCY RESPONSE PERSONHOME TEL# O O • HOURS OF OPERATION: Mon./0--/qq Tue. Wed.—Thu.--Fri.—Sat.—Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft.X00 eh more than 10,000sq.ft. =$250 RESTAURANT YES NO �Gj eJ less than 25 seats =$100 J' 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 ndelief, have filed all state ta•�x�1returns and paid all state trax��elsjre wired under the law. Si ture Date Social Security or Federal Idee tification Number ------------------------------------------------------------------------------------- ----------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Dated 11 W----- -- `&7c) ✓ I� 0134 North Street Lenar s Original City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: _ Item Status Violation Critical Urgency Nature of problem or correction 978-741-0002 Non-compliance with: Not Done !Owner: m ` ,. Anti-Choking PASS ❑ Joseph & Gina Coppola Tobacco PASS ❑ PIC: Joseph CappOla FOOD PROTECTION MANAGEMENT Not Done :Inspector: PIC Assigned/Knowledgeable/Duties PASS ❑0 RED :DaVICIGreenbaurn EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 3/15/2005 Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level:"' FOOD FROM APPROVED SOURCE Not Done 'Permit Number. Food and Water from Approved Source PASS ❑J RED 4BHP-2005-0239 Receiving/Condition PASS ❑d RED Status: Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED SIGNED OFF #of Critical Violations' Conformance with Approved Hrdcetlures/HACCP PASS ❑+/ RED Plans 7 r ROTECTION rnOM CONTAMINATION Not Donc Time IN: Time OUT. Separation/Segregation/Protection PASS ❑d RED Notes m Food Contact Surfaces Cleaning and Sanitizing FAIL Critical 0 RED Cutting boards scored and stained. 24 Resurface or replace cutting boards. r t m € Prnpar ArlPrynatP Hanriwashing PASS n RFr) Urgency Description(s): Good Hygienic Practices PASS ❑d RED BLUE Violations Related to Good. Prevention of Contamination from Hands PASS RED Retail Practices (Critical Handwash Facilities PASS ❑/ RED violations must be corrected immediately or within.10 - days)(Non-critical violations GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 16,2005 ) Page 1 of 3 0134 North Street Lena's Original must be corrected Immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) ;, Approved Food or Color Additives PASS 0 RED RED: _ T Toxic Chemicals PASS RED Violations Relatedto r Foodb6me Illness Interventions TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require=,, r Cooking Temperatures PASS ❑d RED immediate corrective action) '- Reheating PASS ❑d RED Cooling PASS ❑Q RED Hot and Cold Holding PASS ❑Q RED Time As a Public Health Control PASS ❑d RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASSd❑ RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASSd❑ RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE Use a easily cleanable container to make bread crumbs. Do not use boxes from raw meat to prevent cross contamination. Equipment and Utensils FAIL Critical ❑ BLUE Whirlpool freezer has an accumulation of food debris. Thoroughly clean freezer. Knives stod between equipment. Knives to be cleaned and sanitized and stored in an appropriate rack or in a bucket of sanitizing solution. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 16,2005 ) Page 2 of i 0134 North Street Lena's Original GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 16,2005 ) Page 3 of ^ CITY OF SALEM, MASSACHUSETTS � BOARD OF HEALTH '� yf 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter I II, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Lena's Original Address of Establishment: 134 North Street Owner's Name: Joseph & Gina Coppola Restrictions: Application Date: 11/26/2003 Permit for Food Establishment 32-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT TTS CITY OF SALEM, MASSACHUSE1 n BOARD OF HEALTH '1II r^r�'',� 120 WASHINGTON STREET, 4TH FLOOR I)1� `A a SALEM, MA 01970 NOV 2 5 2003 TEL. 978-741-1800 FAX 978-745-0343 - "� SALEM STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT FN[ NAME OF ESTABLISHMENT 1(r'1 V*_TEL# S 71 - -7'1 / / ¢a� ' 0 ADDRESS OF ESTABLISHMENT N� 7-t �IJ'1 ,�^�• /�11� - `019 1�y CCN MAILING ADDRESS (if different) OWNER'S NAME , 'h 4-' V1m'4%. l U� TEL# 1/- ADDRESS If yf0M A � CITYo N MA STATE_ ZIP U o2./(_.� CERTIFIED FOODA AAGGY-EWS NAME(S) CERTIFICATE#(s)_!_7/_1 ZY 'S �( q (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# 1 HOURS OF OPERATION: Mon. j0-Sue.10- Wed.J g Thu.�v-9 FrC dJSat.��-A Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YE NO less than 25 seats =$100 25-99 seats =x150 ��//�� 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 know)�dg and belie , have filed all state tax returns and paid all state taxes required under the law. Ignat&e 1 Date Social Security or FederalDation Number ------------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date_ CITY OF SALEM BOARD OF HEALTH Establishment Name: L�/f aT D�/&it✓Az Date: //L2'//4 tf Page: of L Item Code C-Criticalitecn DESCRIPTION OF VIOLATION J PLAN OF CORRECTION Date No. References R-Red Item --0Verified ' - PLEASE PRINT CLEARLY 1W 1rJJrACrnarj &,rH.r czwooOArad oY+ .4 Ce.,4fl rrre+r- 174,our s le Attf c/hfdrir rva novJ aa o. s�S ,e C/� � �.ca.t.f Car l�/'�vls�vtY of aoJrurl. 5a-6 C lCdcw� IGe7.�S Go�c.r fr►� JNrd w,[ � � a(11 I K U.l � N Coot.(1L. M1.1 Sates R a f rf Y-A '1V C9 �1ClLp6et! Ito !'d/tN/ /►l Cl7jL�yL, rtic.c,. I!ea gi, mztLa AW Poto pk t rim Pr Brs+Rd fAe CaL*06-40S ISA44iroy 1 . fj4eW,acvt*qaR oer r4 olc�?607 Frac n c O V J o c.sit errt No t^tC0AC fliftf P/r4� Discussion With Person in Charge: Corrective Action Required:'" ❑ No ❑ Yes t I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that t noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �� (�^� y�.����� _. � ❑ Voluntary Disposal ❑ Other: ii r i v 3-SO 1-1 4(C) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to taw Cooled to Factors(Items 1-22) (Cont,) _41017/45°F Within 4 Houis. PROTECTION FROM CHEMICALS 3-501.15 Cowling Methods for PHFs 1=4 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 3-501.16(B) Cold PlIFs Maintained at or below Additives* — 590�004(F) 41°145'F" 302 14 Protection floor Una�TjjnL��� Mai 15 Poisonous or Toxic Substances s-,501,16(A) Hot PHFs; Maintained at or above — 140°F. * 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held 'Lit or above 130oF. 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separarion-Storaec —I _T501 19 Time as it Public Health Control* l 590.004(h) VariaDSE 7-202,11 Restriction-Presence and Use* 7-202.12 Conditions of I lse- T-201 IT- Toxic Cojnaiaers-_Frofiibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-ChenacAs" POPULATIONS 7 7-204.12 Cherrucals 71,11(A) — 21 3 8( 7 Unpasteurized Pre-packaged Juices and 7-204.14 D Crrt�iia� — Beverages with Warninv:Labels* i�� 3-80 LH(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 7-206T Restricted Use Pesticides, Criteria* 3-:901.110 Raw,or Partially Calked Animal Food and 7 —-I — Raw Seed Sprouts Not Served. -2067 Rodent Bait Stations�' So 1.11(C) Unopened Food Package Not Re-served. I C 7-206, Trackinc,Powders,Pest ontrol and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603,11 Consumer Advisory Posted for Consumption ol, Proper Cooking Temperatures for Animal Foords Fhat are Raw, Undercooked or 16 PHFs Not Otherwise Processed to Eliminate Pathog , P., -1.1001 3-401.1.1A(1)(2)A(L)(2) Egg�- 155'3F 15 Sec. gens. 3302.13 Pasteurized Eggs Substitute for Raw Shell Comminuted Fish, Mcats& Game Eggs* -- Animals- 155"F 15 sec. '" SPECIAL REQUIREMENTS 3-401.11(13)(1)(2) Pork and BcJ Roast - 136°F 121 min* 3-401.1'1(A)(2) Ratites. Injected Meats- 155`15 15 590.009(A)-(D) Violations of Section 590.009(A)-(D) in I sec. * catering. mobile food,temporary and 3-401.I I(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meal, debited under the appropriate sections Pouter or Ratites-165°F 15 sec. above if related to foodborne illness 3-401.11(C)(1)_(C)(i) wholc-nitocle,Intact Beef Steaks interventions and risk factors, Other — 145"F 590.009 violations relating to good retail 3-401.12 Raw Anonal Foods Cooked in a practices should Lie debited under#29- Microwave 165'F* — Special Requirements. 3-401,11(A)(1)(b) All Other PHFs-- 145'F 15 sec. * I 17 —Reheating for Hot Holding— VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&,(D) PHFs 165'F 15 see. * (Itenns;23-30) 3-403.118) Microwave- 165'F 2 Minute Standing Ctimal and non-critical violmirno, which do not orlan,to the Time* foodborne illness interventions and risk joctors listed above, can be 3-401.11(C) Courraorcialiv Voc"sed RTE Food- .found in tare following sections of the Food Code and 105(4412 140'F" 590.000. 3-403-1 Remai nine Unsficod Portions of Beef -it—em-1-cioad-AetaiFVroctices Inc 590.000 Roasts' 23. Mona cment aral Personnel------ FC-2 003 18 24, Food and Food Protection FC-3 004 Proper Cooling of PHFs; 25.______ Equipment and Utensils FC-4 005 3-501.14(,A) Cooling Cooked PHFs from 140, -F toWater.Plumbing and Waste FC-5 006 70°F Within" flours and From 70'F Y7__ Physicall Facility FC-6 .007 to 41'F/45'F Within 4 Hours. 28. Poisonous or Toxic Materials FC-7 .008 _3-501.14(B) Cooling PflFs Is4ade,From Ambient 000 Temperature Ingredients to 4 1'1/45'F 30, Other I Within I Hours* fron'&S eI rtrwi item in the i'xleokl 1999 Food Code or 105 CklR 596 000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'h Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name / L Date/ J Type ofADeration(s) Type of Inspection / © food Service AJ-Routine Address ,3Risk ❑ Retail ❑ Re-inspection Telephone Level ,,f ElResidential Kitchen Previous Inspection -7 /. DD 2 /'l ❑ Mobile Date: Ownerr HACCP Y/N El Temporary E] Pre-operation J e f a, irlWA C060d LA ❑ Caterer ❑ Suspect Illness Person In Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint Inspector t 13 Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT __ . _. _. ❑ 12. Prevention of Contamination from Hands E] 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH El 13. Handwash Facilities 941" - " "' a. PROTECTION FROM CHEMICALS El2. Reporting Of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals ' -`- --� `� -� .,w. ❑ 4. Food and Water from Approved Source TIME/TEMPERATURECONTROLS(Potentially Hazardous foods) ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION `" ` ` Y',- ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 1,REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) )j [110. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER.ADVISORy' . .am [:122. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 21. Physical Facility (Fc-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s:5 In9 ctFo,m 14.dw Inspector's Signatur • dw Print: 1 PIC's Signature: / Print: b e. 'O / Page of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assi runent of Res onp sibilLl 3-302.1 1(A)(1) Raw ,animal Foods Separated hum -590.003(B) I Damon str mor of Knowledge* Cooked and RIF Foods* ?,-103.1.1 Person in eh vge-dunec Contamination from Raw ingredients 3302.11(A)(2) j Raw Animal Foods Separated front Each EMPLOYEE HEALTH Othcr" 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(X) Food Protection* applicants* I. 3-302.1,5 Washine Fruits and Vegetables 590.003(F) Responsibility Of A Fooct Employee Or An 3-304.1.1 Food Contact with Equipment and Applicant To RepoliTo The Person In Utens(c i Char«e* Contamination from the Consumer 590.003(G) Reporting by Person rn Chance* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.0030) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-70t.1 t Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* .. 4 Food and Wafer From Regulated Sources Food Contact Surfaces 590.004(A-B) Compliance with Find Law* 4-501,111 Manual Warewashing-Hot Water 3-201,12 Food in a Hermetically Sealed Container* Sanitization ern erattues* 3-20Y.13 Fluid Milk and Milk Products* 4-501.1.12 Mechanical Warewashing-Hot Water 3-202.13 Shelf Eggs* Sanut9zation Iem�eramres* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pff, 3-20216 Ice Made From Potable Drinking Water'" concentration and hardness 5-1.01.11 Drinking Water from an Approved Svstem* 4-601.11(A) Equipment Food Contact Surfaces and 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 UUMS11S" Shellfish and Fish Froman Approved Source 4-70111 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caujit Molluscan Food Contact Surfaces of F ui tnent* 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 Regulatory Authority 2-301,11 Clean Condition-Hands and Arens" 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedule 590.004(C) Wild Mushrooms* 2-301.1.4 Wlneu to Wash* 3-201.17 Game Animal ` 11 Good Hygienic Practices 1-5 Receiving/Condition 2-401.11 Eating,Drinking or U.sin*Tobacco" 3202,11 PfIFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes.Nose and 3-202.15 Package Intcait * Mouth* 3-101.11 Food Safe and Unadulterated'w 3-301.12 Preventinc Contamination When Tustin * 6 Tags/Records:Sheilstock L12 Prevention of Contamination from Hands 3-202.13 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained' Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11. Parasite Destruction* Conveniently Located and Accesslbie 3-402.12 Records.Creation and Retention' 5-203.1.1 Numbers and.Opacities* 590.0040) Labeling of Ingredients' 5-204.11 Location and Placement= ry Conformance with Approved Procedures 5i 205.11 Accessibility,O eration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods,, Devices 3-502.12 Reduced oxy=en ackagin ,criteria (x301.11 Haudwashinc Cleanser.Availabilit 3-103.12 Conloxmance with A roved Procedures* 6-301.12 Hand Dryin,Provision „Denote critical item in the federal 1999 Food Code or 105 CMR 590,000. CITY OF SALEM BOARD OF HEALTH Establishment Name: LE NiQ c!°' Date. f'/ A3 Ary Page: of 2— Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R--Red Item Verified -._. PLEASE PRINT CLEARLY t3,§;7 Z&L A f Cd/511! 1 C lJt! Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure ..your food permit. /I 11 A i // ❑ Voluntary Disposal 0 Other: 3-50 L 14(7) PRFs Received ka Temperatures Violations Related to Foodborne illness Interventions and Risk According to Iaw Cooled to Factors(items 1-22) (Cont) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-SO1.I5 Cooling Methods for"HFs 79 14 Food or Color Additives PHF Hot and Cold Holding 3-202.12 Addnrve_'k 3-501.16(B) Cold PFIFbelow Maintained at or belo590.004(F) 4l`I45°F" 3-302.14 Protection from Unapproved Additives* 590.00 (F) Hot PHFs Maintained a[or above 15 Poisonous or Toxic Substances 40°F. 7-101.11 Identifying Info] -Original 3-501.16(A) I Roasts Held at or above 130'F. Containers* ?-102.11 Coin Name-Working Containers'" 20 Time as a Public Health Control 7-201.11 Se . tion-Stora e* 3-501_'19 Time as a Public�F1'ealih Control* 7-202.11 Restriction-Presence and Use 590.004(H) varianceRe uiretuent 7-202.12 Conditions of Use* 7-20111 'toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Smnitizer9.Criteria-Chemicals* POPULATIONS(HSP) 7-2041.2 Chemicals for Washin Prodace. Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.74 D •prig Agents.Criteria* Beverages with Warning Labels* 7-205.11 Incidental Food Contact, Lubricants* 3-801.11(6) Use of Pasteurized Eggs* 7-206.11. Restricted Use Pesticides.Criteria* 3-80111(D) Raw or Partially Cooked Animal Food and Raw Sced S routs Not Served.w 7-206.12 Rodent Bait Stations* 3-801.11(C') Unopened Rood Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods`That are Raw. Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate _ _ 3-401.L1A(1)(2) Eggs- 155'F 15 Sec. Pathogens.*`ria`'r""' ti es-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11 m (A)(2) Comminuted Fish,Meats&Game E=* Animals-155'F 15 sec. 'r 3-401.11(6)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats-155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3-40'1.11(A)(3) Poultry, Wild Game,Stuffed PIFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poulfir,or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11.(7)(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 f(29- Microwave 165'F* Special Requirements. 3-401.11(9)(1)(6) All Other PHFs- 145°F 15 sec 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACT/CES 3-403.11(A)&(I)) PHFs 165'F 15 see. . (Items 2330) 3403.11(B) Microwave-165'F2 Minute Standing Critical and rwn-critical violariont, which do not relate to the Time* foodborne 7iness interventiom and risk factors listed above, can be 3-403.11(C) Commercially Processed R'rE Food- found in the following.sections of the Food Code and 105 CMR 140'F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Bee[ Item Good Retail Practices _ FC 590.000 Maria ament and Pe Roasts* 23. rsonnel _ FC- 2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25. ___ E ui ment and Utensils FC 4 +._.005 P6 3-501.14(A) Cooling Cooked PHFs from 140°F to . Water, Plumbin and Waste FC 5 006 70°F Within 2 hours and From 70"F 27, Physical Facility FC- 6 I .007 to 41"F/45°F Within 4 Hours. * 28. Poisonous or Toxic MaterialsFC-7 .008 3-501.14(B) Cooling PliFs Made From Ambient 29. Special R quirements .009 Temperature Ingredients to 41°F/45°F 30 ___ -Other.__ ......__..._..--- Within 4 flours* ^' Denotes critical ilem in the(upend 1999 Food Code or 105 CNIR 590.000. I . . 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 TVDB of Ooeration(s) T e f Ins ection Ql1 d- A L Q e ❑v'�Food Service outine Address ? OQ , s"r Risk ❑ Retail ❑ Re-inspection TelephoneLevee} ElResidential Kitchen Previous Inspection "7y I• 601111112. / ' ❑ Mobile Date: Owner O96 f HACCP Y/N ❑ Temporary ❑ Pre-operation P 6 rwA 0404A ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) + ,, Time ElBed&Breakfast ElGeneral Complaint Inspector(I4tjt9 �r�� l�k! Out: Permit No. El0 herr 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 I ; , , `,. , ,_ , El12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities E EMPLOYEE HEALTH PROTECTION FROM CHEMICALS' ' ❑ 2. Reporting of Diseases by Food Employee and PIC E] 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE ,` ,- E] 15.Toxic Chemicals ' ` TIME/IEMPERATURE CONTROLS Potential) Hazardous Foods ❑ 4. Food and Water from Approved Source !; (Potentially ) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION r( , , ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control Food Contact Surfaces Cleaning and Sanitizing ',REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic PracticesCONSUMER 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): 1 of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofC ealNtI 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 6. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you tZ 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 FE29. Special Requirements (590.009) within 10 days of receipt of this order 30. Other DATE OF RE-INSPECTION: Ul{ S.5WMSP fFom -10.tl Aft Inspector's Signature;? Print: PIC's Signature: �9'Yl f1 n Prin[: Page /Of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT K - Cross-contaminator _ iI 590.003(4) Assignment of Res +visibility* 3-302-1 l(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge"' ( Cooked.and RTE Foods" 2-103.11 Person me -duties Contaminasorr from Raw ingredieras ' 3-302.11(4)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH _ Other 2 590.003(C) Responsibility of the person in charge to Contamination tmrn the Environment require reporting by rood employees and 3-302.11(A) H W, Protection" i plicants" 3-302.15 WashowFruits and Vestvtables 590.0037) Responsibility Of A Food Employee Or An 3-.304.1 I Food Contact wide Equipment and Applicant Tti Report'Io The Person In Utensils" Charge* Contamination from the Consumer 590.003(G) Re portirr by Person in Charge*� 3-306.14(4}(13} Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition o€Adulterated or Contaminated 590.(703(E) Removal o'f E elusions and Restrictions Fond 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCET Food" _ Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) 4-501,111 71anualWarewahing-Hot Water -cal Simt3zation Sem eratures* 3-207.12 Food in p Heuneti3lh Sealed Container* 3-201.13 Fluid Milkand Milk Product's* 4-501.112 Mechanical Warewashin.;Hot Water 3-202.13 Sheri lig-'s- Siaiuzation fcri ratures* 3-202.1.4 Eggs and Milk Products.Pasteurized" concentration Chemical Sanitization-temp.,plE 3-202.16 Ice Made F'roor potable Drinking Water`" concentration and hardness . 5-7.01.11 DrinkingWater from an A raved S stem* 4-601 A I(A) Equipment Food Contact Surfaces and Utensils Clean* i 590.006(4) Bottled Dunkin*Watcr* 4-602.11 C,lcanmg Frequency of Equipment Food- 590.006(S) Water Meets Standards in 310 C;MR 22.0* Cordact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-102.11 Frequency o1:Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment' Shellfish* 4-703.11 Methods of Sani(ization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Luted I Chemical* - Sources' 10 Proper,Adequate Handoeshing Came and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Re u!afo Authorit 7202.18 Sheilstoek Identification Present* 2-301.12 Cleaninv, Procedure" 590.004(C} Wild Mushrooms' 2-301.14 When to Wash* 3-2 1.77 C1ame Animals" 11 Good Hygienic Practices �, Receiving/Condition 2-401.11 Eating,Drinking or Using,Tobacco* 3-202.11 PHFs Received at Proper Temperatures 2-401.1.2 1 Discharges From the Lyes, i9osc';and 3-202.15 PackaQeLpteer3t * Month* 3-101.11 1 Food Safe and Iinaduitorated'* 3-3301.12 Pretientine Contamination When Tastin*" 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from Empl3-203.12 Sheilstock Identification Maintained)' Hand ash Tags/Records:Fish Products 33 Handwash Facilities 7402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records, Creation and Retention* 5-203.11 Numbers and C a parities* 590.004(.0 Labeling of Ingredients' 5-204.11 location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibilit Operation andNIaintenance IHACCP Plans Supplied with Soap and Nand Drying 3 Devices 502.11 S.ecialived Processing Methods* '3-502.1.2 Reducedox ' 'en packagina.criteria* 6-301.11 Handu=ashinp=Cleansor, AvailabIlit 8-103.12 Conformance with A. roved Procedures" 6-3(8.12 Hand Drying Provision "Delotescrifical ricin in the fed'a,,O 1999 Fwd Code or 105 CNIR 590000. CITY OF SALEM BOARD OF HEALTH Establishment Name: /�jJ/Q rfi n�IltS7Nl�L Date:_5VzG f®'f Page: Z of Item Code C-Critical Item DESCRIPTIONOF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 2 � /d J' ALL 0 s C 45,6A.90-0 P eW OZ CAC D s S .t.i d t , s Q !t � Discussion With Person in Charge: Corrective Action Required: ❑ 1No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction i inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure ,your food permit. % —�' ❑ Voluntary Disposal ❑ Other: I � 3-501.14(C) PHFs Received at'Cemperatures Violations Rotated to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'F(45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolin Methods for PHFs -- 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-50116(B) Cold PHFs Maintained at or below 590.004(F) 41°145'F' 3-30214 Protection from Unapproved Additives* 3-501..16(A) Hot PI-[Fs Maintained at or above 1.g Poisonous or Toxic Substances t40°F. .* 7-10'I.i l Ideotitying Information-Original -501.16(A) Roasts Held at or above 130"F. ;,:: Containers" 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.1.9 1 Time as a Public Health Controlx 7-20111 Restriction-Presence and J e* �- 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 "Toxic Containers-Prohibitions^' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204-12 Chemicals for Washing Produce.Critexia* 21 3-80I.I I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels* 3-801.t 1!B) Use of Pasteurised Eggs* 7-205.11 Incidental Food Contact, ,CruLubriet ial 3-301 11(D) Raw or Partially Cooked Animal Food and 7-2(Ih.it Restricted Use Pesticides.Criteria"� Raw Scrd 5 xouts Not Served " 7-206-12 Rodent Bait Stations* 3-801.11(C) Uno,cited Food Package Not Rc-served. 7-206.13 Tracking Powders,Pest Control and Monitoring" CONSUMER ADVISORY _ TIMErrEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods"That are Raw, Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs raonr 3-401.11A(1)(2) Eggs- 155".P 15 Sec. Pathogens fm as-Immediate Service 14:50F15scck 3-3(1213 Pasteurized F gs Substitute for Raw Shell 3-4011 I(A)(2) Comminuted Fish.Meats&Game Animals- 155'F 15 sec. * 3-401.11('B)(1)(2) Pork and Beef Roast- 130'F12lmirSPECIAL REQUIREMENTS 3-401A UA)(2) Ratites,Injected Meats- 155'F 15 590-009(A)-(I)) Violations of Section 590.009(A)-(ll)in sec. * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game. Scatted PHFs, residential kitchen operations should be Stuffing Coruaininag Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'1- 15 sec. * above if related to foodborne illness 1-401 11 Whole-muscle,Intact BeefSte.aks interventions and risk factors. Other 145'F s` 590.009 violations relating to good retail 3-401.12 Raw Animal FoWs Cooked in a practices should be debited under#629 - Microwave 165'F* Special Requirements. 3-401.,11(A)(1)(b) Ail Other PHFs-- 145'F 15 sec. I4 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-4011l(A)&(D) PflFs 165'F 15 sec. * (Items 23-30) 3-40A I(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Tune* foodborne illness interventions and risk factos listed above, can be 3-103.11(0) Commercially Processed RTE Fail- ,found in the following sections of the Food Code and 10.5 CUR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item I Good Retail Practices FC 590.000 1 Roasts* ,r-23 i Management and Personnel FC-2 .003 - 24 I Food and Food Proleciton FC 3 004 1L_Lg Proper Cooling of PHFs ,------ ------ - -- -- 25 �Erprrent and L+snails FC 4 005 3-501.14(A) C'otrhngCookcdPHPsfr<om140`Fto ---' 26 Water Plumbingand Waste FC-5 .006 70'F Within 2 Hours and From 70'F ' 27 � Ph sical Facilit _FC-6 7007i Yo 41 N'l45°F Within 4 Hours. [28 Poisonous or Toxic Materials FC 7 008 P - .3-501.14(B) Cooling PHFs Made From Ambient 29 Speaal Requirements 009 Temperature Ingredients tool F/4:5`F 30 Other - _- _-,,..,-----,- Within 4 Hours' *Dmotcs critical item in the'tederal 1999 Food C"3e or 105 CMR 590,000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date / Type of Operation(s) TyP6 of Inspection Ziwas P/ / vt2L o�'D?3-OY a Food Service 0 Routine Address Risk ❑ Retail ❑ Re-inspection 7 /V Yui S Level ❑ Residential Kitchen Previous Inspection Telephone9 . /_/j�j_ o��9 ❑ Mobile Date�-a'/-673 Owner / j HACCP Y/N El Temporary ❑ Pre-operation Ilva 6 p ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned/ /Duties 12. Prevention of Contamination from Hands ❑ ❑ 13. Handwash Facilities ''EMPLOYEE HEALTH i 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 FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals ; � _ ; i i ,` ,ti ❑ 4. Food and Water from Approved Source TIMErrEMPERATURE 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,'.! °' El 19. Hot and Cold Holding � ❑ 8. Separation/Segregation/Protection ❑ 20. Time As a Public Health Control W/9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) } 10. Proper Adequate Handwashing El 21: 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): I 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 ofCHeW,I 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils cited in this report may result in suspension or revocation of (FC-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)(590.0(16) 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:5901na aFcrm 14.do - e gn e. 7j,�y,�fG'dll, Print: PIC's Signature: Print.,�Os t p / Page 0 Pages J Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* Z 103.1'( Person in charge-dupes � Contamination from Raw Ingredients 3-302.11(A)(2) Raw Amunal Foods Separated from Each EMPLOYEE HEALTH _ Other" 2 590.00-T6 Responsibility of the person in charge to Contamination from the Environment require reporting by foot employees and 3-302.1 1(A) Food Protection* a rlicarm* 3-302.15 WashingFruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char*e' Contamination from the Consumer 590.003(G) Re)ortmg by Person in Charge* 3-306.14(A)(B) Returned Food and Reser%ice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 IIiscarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCEFood* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hof Wates 3-201.12 Fo(xf in it Hermetically Scaled Container* Sanitization Tem.eratures` 3?01.13 Fluid Milk and Milk Product's* 4-501.11.2 Mechanicat Warewxshinb Mot Water 3-202.13Shell Eggs* Sanitizailan Tem eratures* 3-202.14-501..114 Chemical SamBzation-temp"pH, .4 Eggs and Milk Products.Pasteutized'k 3-202.16 Ice Made From Potable Drinking Wafer* concentration and hardness. ,w 5-1,{11.11 Drinking Water from an Approved S stem* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean' 59().006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.01Contact 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-Ilot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Reoulefory Authortt 2-301.11 Clean Gandifion-Hands and Anne1` 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" ].1 Good Hygienic Practices s Receiving/Condition 2-401.11 Eating,Drinking or Using'robacc& 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges,From the Eyes, Nose and 3-202.15 Package Integrity- Mouth* 3-101.1 t Food Safe and Unadulterated* 3-301.12 1 Preventing Contamination When Tasting" 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-20118 Shellstock Identification* 590.004(1) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em levees* Tags/Records: Fish Products I3 Handwash Facilities 3-002.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records-Creation and Retentions` 5'03.11 Numbers and Capacities* 590M040) Labeling of Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205 11 Accessibibty. Operation and:Maintenance lHACCP Plans Supplied with Soap and Nand Drying ' 3-502.11 Specialized Processing Methods* Devices 3-502.12 Redticedoxygen packaging,criteria' 6-301.11 Flandwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Dryin,g Provision ^'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000- CITY OF SALEM BOARD OF HEALTH Establishment Name: G e/ / v z- Date: 2 2 3 c�' Page:� of 52 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R–Red Item Verified PLEASE PRINT CLEARLY 1AXZ4Et 92,121 ; O ,ow P A/r - p ifC � ;.e�/A;c ' ZS — T / .PGP n -f i l 4 �eLn!// /J .-P L P 7! ( //JJ P.,cr /C/ cif '..•- 'P /l' 1 ai� o f /n < _/ i C —Soe />a .P ivv / o s i 2C'/r f �V t ' r /A r, 4824o >j} / t Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes 1 have read this report,'have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. % ❑ Voluntary Disposal ❑ Other: jU � 3-501.14(C) PHFs Received at'remperatures Violations Retated to Foodborne Illness Interventions and Risk According to Law Cooled to I Factors(Items 1-22) (Cant) 41.'F/45'F Within 4 Hours, PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501-16(B) Cold PHFs Maintained it or below 3-202.12 Addttnes'° 590.004(F) 4'1'145°F* 3-302.14 Prrotectrot front Una roved Additivcs* 3-501.16(A) Hot PHFs Maintained at or above 5 Poisonous or Toxic Substances 140°F. * 7-101.1] Identifying,Inlonnation-Original Containers* 3-501.16(A)fi(A) Roasts Held at or above 130"F. 20 Time as a Public Health Control 7-102.11 Common l`Tame-Wcukina Containers"-' 7-201,11 Si: aratiou-Ston tee* 3-501.1.9 Time as a Public Health Control* 7-202.11 Restriction-Prcxnce and Ilse* 5)0.004(H) 'variance Recmrernent' 7-202.12 Conditions of Urex 7-203.1 I Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Stu id7.ers.Criteria-Chemicals'^ POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce.Criteria* 21. 3-80'1.11(A) Unpasteurized Pre-packaged.luices and 7-204.14 Drnn^A eats-Criteria' BeveraEes with Warning Labels* 7-20111 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized EanB* 7-206.1 t kestrreted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Conked Animal Food and Raw Seed Sprouts Not Served.,E: 7-206.12 Rodent Bait Stations* 3-801.1 1(C) Uno 7encct Food Package Not Re-served. 7-206.13 TrackinsT Powders,Pest Control and Monitorill" CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw. Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.11.A(1)(21 Epos 155-F 15 mmediatate Service 145"F15sec�r Sec Pathogens." ""'Pool 'Pool 1 � s immed3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.1 I(A)(2) Conuninuted Fish,Meats R.Game Eggs* ;'urinals- 155`''F 15 sec. ': SPECIAL REQUIREMENTS 3-401.11(23)(1)(2) Pork and Beet Roast- 130'F 121 mitis 3-401.11(A)(2) Ratites,Injected bleats- 155'F 15 590-009(A)-(D) Violations of Section 590.009(A)-(1'))in sec * catering, mobile food, temporary and 3-401.11(1(3) Poultry,Wild Game, Staffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'2 15 sec. ^ above if related to,foodborne illness 3-401911(C)(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145"F* 590.009 violations relating to good retail 3-401.12 Raw Animal Footis Cooked in a practices should be debited under#129- Mrcrowave I65°F* Special Requirements. 3-401.1l(A)(I)(b) Al Other I'Hf's - 145'2 15 sec. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-40'.1.1(A)&(D) PHFs 165'F 15 sec. v` (Reins 23-30) 3-403.1.1(,13) Microwave-165°F 2 Minute Standing Critical and non-cril'ieal violations, which do not relate to the Timer` foodborne illness isten,entions and risk facktrs listed above, can be 3-40311(C) Commercially Processed RTE Food- found in the following sections of the hood Code and 105 CMR - 140°F* 590.000. _ 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices -1 Fc-moo-0 Roasts* _23 _Management and Personnel FC-2 .003 24 Food and Food Protection FC-3 _004 18 ( ) b C, g q p___--_ -_ FC-4 005 Proper Cooling of PHFs t--qu 25 E w meat and Utensils 3-501.14 A Cooling Cooked PHFs from 140'F to Water Plumbing and Waste FC-5 -006 70'F Within 2 Hours and From 701, 27. Physical FacilityIFC-6 .007 to 4't'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 -- 3-5t)L14(B) Cooling PHFs Made From Ambient 29 SpecialRequirements 009 Temperature Ingedicnts to 41°F/45'2 30 Other „ Within 4 Hours"' snrC�cti�,�.zw: ------------ "DenoteF critical nein in the tederal 1999 Food Code or 105 CAR 590.000. v CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 NOTICE OF VIOLATION 105 CMR 590.021 The Salem Board of Health will be strictly enforcing the regulation stating that all openings to the outside shall be effectively protected against rodents, flies, cockroaches, and other insects. Included in this mailing is a copy of that notice. Recently, your establishment was conducting business in violation of the State Sanitary Code due to; Reason: DOOR OPEN TO ESTABLISHMENT Date: MAY 2, 2004 12:25 P.M. Please remedy this situation by keeping your doors and/or windows closed or by affixing appropriate protection to these outer openings. If you are seen violating this regulation again you will be issued a fine for each day the violation exists. THIS IS THE SECOND TIME DOOR IS OPEN. NO OTHER WARNING WILL BE ISSUED. THIS VIOLATION IS ALWAYS OCCURING AT THIS ESTABLISHMENT. Establishment: LENAS ORIGINAL SUBS Address: 134 NORTH ST. SALEM Reply to: Owner: JOSEPH 7 GINA COPPOLA DAVID GREENBAUM SANITARIAN j vvio-sc.wpd CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 NOTICE TO ALL FOOD SERVICE ESTABLISHMENTS Insect and Rodent Control The Salem Board of Health strictly enforces the Commonwealth of Massachusetts Regulation 590.021 : Insect and Rodent Control A) General. Effective measures shall be utilized to minimize the entry, presence, and propagation of rodents or of flies, cockroaches, and other insects. The premises shall be maintained in a condition that prevents the harborage or feeding of insects or rodents. B) Openings. Openings to the outside shall be effectively protected against the entry of rodents. Outside openings shall be protected against the entry of insects by tight-fitting, self-closing doors, closed windows, screening, controlled air currents, or other means. Screen doors shall be self-closing, and screens for windows, skylights, transoms, intake and exhaust air ducts, and other openings to the outside shall be tight-fitting and free of breaks. Screening material shall not be less than 16 mesh to the inch. Furthermore, if doors to your establishment are noticed open without the protection of a self- closing screen door or other effective means of protection you will be ordered to appear for a hearing before the city Health Agent and the Board of Health or be issued a fine. If you have any questions, please call us at (508) 741-1800. Reply to: jvscreen.wpd ------------- SENDER:ICOMPLETE THIS SECTION COMPLETE THIS SECTION . ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. 0 Agent ■ Print your name and address on the reverse X to dresses so that we can return the card to you. E flieceived y(Print ame) C. oat o)Delivery ■ Attach this card to the back of the mailpiece, yf g�r I or on the front if space permits. 3 G D. Is delivery address different from item 1? 0 Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No J & M Sandwich Shop Inc. d/b/a Lena's Original 134 North Street Salem, MA 01970 3. Service Type jp,Certified Mail ❑ Express Mail 0 Registered 0 Return Receipt for Merchandise ptp ❑ Insured Mail 0 C.O.D. 4. Restricted Delivery?(Extra Fee) 0 Yes 2. Article Number (Transfer from service label) 7003 1680 -0006 5995 9769. PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail USPS e 8 fees Paid Permit No.G-10 i • Sender: Please print your name, address, and ZIP+4 in this box• -- -BOARD OF HEALTH EM, MA 01970 [ ; FEB20204 U.S. Postal Service,. .� CERTIFIED MAILT. RECEIPT r- (Domestic Mail Oniy;No Insurance Coverage Provided) Ir Er Or } 7p-'.-g- s� Lrl M Certltled Fee O O Postmark Q Retum Reciept Fee Here (Endorsement Required) Restricted Delivery Fee (Endorsement Required) ..D ra Total Postage&Fees $ M O Sent To O " orroer,Rpt 7-Soallo. bio. city,State,21P+4 :rr ri CeHit des: ewanealzoozever'ooeew,o�sa ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mails or Priority Meile. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE-IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Retum Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSs postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT: Save this receipt andpresent it when making an Inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. o CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH x 120 WASHINGTON STREET, 4TH FLOOR a } o SALEM, MA O 1970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR -HEALTH AGENT February 17, 2004 J & M Sandwich Shop Inc. d/b/a Lena's Original 134 North Street Salem, MA 01970 Dear Mr. Joseph Coppola: On December 23, 2003 you were sent a letter regarding check#1295 dated November 21, 2003 that was returned to the City of Salem for insufficient funds. As of this date we have not received a check in the amount of$125.00 ($100.00 to cover the check and $25.00 for recovery fee). We received the Certified Mail card signed by you on December 29, 2003. Therefore you are operating with out a valid food permit. In order to remain open for business you must deliver a cashier's check for$125.00 to the Board of Health office, 120 Washington Street, 4"'floor before Monday, February 23, 2004 at 4:00 pm otherwise your establishment will be closed. If you have any questions, please call my office. Very truly yours, o'J anne Scott Health Agent J S/mfp CERTIFIED MAIL 7003 1680 0006 5995 9769 �� �'� �� i �� �`nl`¢ y ` PR' F . SENDER: COMPLETE THIS SECTION COMPLETE THIS DELIVERY ■ Complete items 1,2,and 3.Also Complete A. Received by(Please Print Clearly) �rQat oflivery 'item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse iso that we can return the card to you. C. Signature ■ Attach this card to the back of the mailpiece, X Agent or on the front if space permits. Addressee D. Is delivery ddress diffe item i? es 1. Article Addressed to: GIf YES,enter delivery address below: ❑ No J & M Sandwich Shop Inc. d/b/a Lena's Original 134 North Street Salem, MA .01970 3. Service Type Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise mp ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number(Copy from service label) PS Form 3811,July 1999 Domestic Return Receipt 102595-00-M-0952 UNITED STATES POSTAL SERVl@FW B First-Class Mail , -I,-ESSF4 Po tage&Fees Paid P M 3 YV P8 ..� t i 3„�Pbr M,No. y 0 2i DEC ` ;? • Sender: Please print ur �, ddress, an'Zl .1AM 5 :,Aca! a City of Salem ^'*I3 Health { 1 hington Street --4`h Floor DEC 312d03ale A 01970 Ca I Y OF SALEM ur TH li IM1 Ilm -' Ir U.S. Postal Service CERTIFIED MAIL RECEIR (Domestic Mail Only;No Insurance Coverige Provided) f� - Postage $ Certified Fee Postmark Q' Return Receipt Fee Here O (Endorsement Required) 1-3 Restricted Delivery Fee 17 (Entlorsement Required) O Total Postage&Fees O M Name(Please Print Clearly)(to be completed by mailer) tr Street APL No.;or Po Box No. Er • M1 Clry State,ZIP+4 •tt FUI*Tifiedj,M�ail Provides: Aailiceipt A unique identifier for yourmailpiece • A signature upon delivery ■ A record of delivery kept by the Postal Service for two years Important Reminders: • Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider insured or Registered Mail. ■ For an additional fee,a Return Receipt map be requested to provide,proof of delivery.To obtain Return Receipt service,please complete antl attach a Retum Receipt(PS Form 38111 to the article and add applicable postage to cover the fee.Endorse mailpiece Return Receipt Requested'.To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. • For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery'. ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Cerfifled'Maif receipt is not needed,detach and affix label with postage and mail, IMPORTANT:Save this receipt and present it when making an Inquiry. PS Form 3600,July 1999 inverse} 10.7595=99-10-2087 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH � s 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT December 23, 2003 J & M Sandwich Shop Inc. d/b/a Lena's Original 134 North Street Salem, MA 01970 Dear Mr. Joseph Coppola: Your check#1295 dated November 21, 2003 has been returned because of insufficient funds. Please send a money order or bank check for$125.00 ($100.00 to cover the check and $25.00 for recovery fee). If you have any questions, please call my office. Very truly yours, {/ �6nne Scott Health Agent JS/mfp CERTIFIED MAIL 7099 3400 0009 4078 9737 ADVICE FOR UNPAID DEPOSITED ITEMS Page 1 of 1 ' NT0312091-61 ACCT . NO. 9123881-0 12/09/2003 OFFICE/BRANCH: 520/520 ACCOUNT TYPE: MUNICIPAL INT CHKG THE FOLLOWING ITEMS HAVE KEEN RETURNED. WE ARE CHARGING YOUR ACCOUNT FOR ITEMS) $ ITEMS : 1 RETURNED UNPAID AS LISTED BELOW. AMOUNT: $100 . 00 FEES HAVE BEEN SENT TO ACCOUNT ANALYSIS . FEE: $0 . 00 TOTAL: $100 . 00 Reason: INSUFFICIENT 2nd TIME CITY OF SALEM EASTERN BANK GENERAL ACCOUNT - ZBA 195 MARKET ST C/O TREASURER' S OFFICE (�\ LYNN MA 01901-1380 PO BOX 528 1-800-EASTERN SALEM MA 01970-0528 Account No.: 9123881-0 Office/Branch:5201520 - -- -- - ---------- - - - C d6MSANOWICH SHOP INO. 129$ f1��i1JJ4ff}��i�,,IINWI]Ik - _ _ 9A OBA lENA90NIGINAL 11 Oayaa{�. ly nI '� fwo,q p �d%"iYdi�/'00 d2 006 >0113W93G - o re.e- `ol;`w.�l !MI Ilnti i eei 9 v O O si.<AY .a,�!°,xia�,$A-GE6/. G, 1.Cmxsrs Bnrix ' ;• .tlg l'1`s , i a0 r�'0 I 4 'op MOO l299a Cil W90499: 11309149 Se•fE '.•aooaB w000.' • I I i I ____ _____ ________ _____ _ _J ____ ___ __ _ _ _ _ __ ____-____ _____ _ _ _ __ __ _ __ _ ❑ 5ll—il, —1-114 d n I., S11 6 1kf— d I t I 1 1. (•, a 'J & M SANDWICH SHOP'INC 1295 /DBA LENA'S ORIGINAL 134 NORTH ST. ° r S.ALEM MA01970 ./� 1� t7/2110 DATA. 796 I� �" �"T Oy 1e t' - J _ pal � TOTHE 1 7 S�1 L�'.I Fl,�`��A�)� ! ` a �• r„ ..�k�"�1-�.� +r IP ',ORDER OF d UOLLA r ,/ �� CITIZENS.BANK ` 3 $s>g� e`n►+V Massachusetts\, � �`,�\\lS+r`\;\ fj,f 'l`/11J\tJ� , r`*� \t \1/ ; v\� \{ \ i\ � \ `.•: 1' .`,. r /,� >\ .� rJ� ( FOR` 01 u'0012,9511' 21l0701751' ` A3074�45 5ii';`f" " '/`r� <.• ti I100000i00001' oxwr CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR x SALEM, MA 01970 s TEL, 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws , to operate a Food Establishment in the City of Salem is hereby granted to: Owner ' s Name : Joseph & Gina Coppola Name of Establishment : Lena ' s Original Address of Establishment : 134 North Street Type of Establishment : FOOD SERVICE Application Date : 01/08/2003 Restrictions : Permit for Food Establishment 237-03 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 o CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR A r� c U SALEM, MA 01970 JAN U 2@03 '✓ TEL 978-741-1800 FAX 978-745-0343 GI i i {.. - L�xLEM STANLEYOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT t rS �r1 Oj t f1Cc�TEL)#'? �� ADDRESS OF ESTABLISHMENT 0 e `� {- S�L1�Jyj Ala 01q 7� MAILING ADDRESS (if different) �Tf OWNER'S NAME iG TEL# / 2 ADDR SS CITY . STATE ZIP- r CERTIFIED FOOD MANAGER'S NAME{S} A CERTIFICATE#(s)--CW G V204 q {required in an establishment where potentially hazardous food is prepared.} 17v_ ��o.G /1 EMERGENCY RESPONSE PERSON d_Oep �7JG� _HOME TEL##-X46'J 6 HOURS OF OPERATION: Mon1bY-Tu�e1QJWed.L0±Thu./0-q Fri.q-9 Sat.(A Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES (NO ) less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats 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 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 4W6e t nowledge a belief, �hja�v�e filed all state tax and paid all state taxes required under the law. 1/1j},E _a_,2 od, d res-ac' k"""'i -Signature /J� Date Social Security or Fede al— Ids entification Number ' ____' —_----------------_ ________------------- Revised 11/15/02 FOODAP2.adm Check#8 Date..... -O THE COMQMONVVEALTH 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 / Tyne of Operation(s) Type of Ins e0 ction GA- Food Service Ei Routine Address �--,- Risk ❑ Retail ElRe-inspection l Level4` [IResidential Kitchen Previous Inspection Telephone _ / /�� L �i /t�� El Mobile Date: Owner ''-�-�C (/ ( HACCP Y/N El Temporary ElPre-operation C� � ❑ Caterer ❑ Suspect Illness Person In Charge(PIC) t %�Sv V Time El Bed&Breakfast El General Complaint ', x..11-- In: ❑ HACCP Inspector` �l yr / /1 Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 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 El 17. Reheating El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding El8. 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 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: i Inspector's Signature: Print: /1 PIC'sSignature: -)7 „% ( Print Page/of Pages FORM 734A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION S Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from L_ 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Know ledge* 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 Y 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated f+3'' S90.003(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-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) I 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 Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 11 Good Hygienic Practices 2-401.11 Eating Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* ;'.'.12 Prevention of Contamination from Hands 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 71' 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. J CITY OF SALEM BOARD OF HEALTH Establishment Name: < � 21-2 _ S Date: /" Page: of _ Item Code` - _ C-Critical Item DESCRIPTION OF VIOLATION'/ PLAN OF CORRECTION Date : .. ,3 :, 5- - .„, Verified. No. . Reference F—Red Item PLEASE CLEARLY S, a Discussion With Person in Charge: Corrective Action Required: ❑No,: ❑Yes a I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to comply Exclusion e with all mandates of the Mass/Federal Food Code. I understand that noncompliance may C) Re-inspection Scheduled ❑ Emergency Suspension result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other FORM 7348 HOBBS &WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 41'F/45'F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives LL9 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41'F/450F* 1•:`15= Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140'F.* Containers* 3-501.16(A) Roasts Held at or above 130'E* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.1](A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying A encs,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw, Undercooked or -16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Effective 1/1/2001 3-401.11A(1)(2) Eggs- 155'F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145'F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155'F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D) in 3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 Min.* catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155'F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165'F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145'F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165'F* 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.1 l(A)&(D) PHFs 165'F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.1 l(B) Microwave- 165'F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140'F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. Water, Plumbing and Waste FC-5 .006 70'F Within 2 Hours and from 70'F 27. Physical Facility FC-6 .007 to 41'F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Sp ecial Requirements .009 Temperature Ingredients to 41'F/45'F F30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITy OF SALEWIMASSACWUSEITS 31s BOARD OF HEALTH M 120 WASHINGTON STREET, 4TH_FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOViCZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR - HEALTH AGENT COMt44NWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance. with regulations promulgated under authority of Chapter 94, Section 305A and Chapter ,IIZ, .Section 5 of the General Laws, to operate a Food Establishment .in the City of =Salem is hereby granted to: Owner's Name: Joseph & Gina Coppola Name of Establishment : Lena':s Original Address of EstablisBment ``134 ' 'North Street. Type ,of .Establishment : F00D SERVICE ApplicationADate 1"1'j28j200 Restrictions- " " Permit' for Food Establishment , w ...'a 50=02 a rr Frozen" Dessertd/ice Cream Permit',for the Sale of Tobacco,Products , " These Permits t Expire;December- 31.,,.2002 . 4., . 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 Cade, 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 r� u CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FUMY O FAX 978-745-0343 Q (t STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO jyUV 8 C�JiJ) MAYOR HEALTH AGENT CITY O SALEM HEALTH ,IDE,uT. 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT M S Y�(yWWO �� TEL#-I 1 A - 741'o1 IW D1d1fl 1�e1�S ADDRESS OF ESTABLISHMENT13LJ AI l) E h S+, SA- 119M MAILING ADDRESS (if different) C� OWNER'S NAME 1�Egullr I44-- TEL#91 0/�/ ADDRE S 131 If)e-- ') St S w I&,/)L" CITY T-- STATE j �I'�� ZIP CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATE#(s) 79L LL99-411,q (required in an establishment where potentially hazardous food is prepared.) Ytl EMERGENCY RESPONSE PERSON 'Y'A � h —� HOMETL# DAYS/HOURS OF OPERATION: Mo .la Tue. 6 Wed./o- Thu./a Fri. 17- Sat. A Sun.,�L-_9 TYPE OF ESTABLISHMENT /� FEE check only RETAIL STORE YES N SD-O;- $40 RESTAURANT YES0 BED& BREAKFAST YES NO 0 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES $5 TOBACCO VENDOR YES *N90 NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPT FORM Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my e tax returns and aid all state taxes required under the law. best knowledge belief, have filed all stat p q ignature Date Social Security or Federal Identification number ------------------------------]'- --------------------------------- Revised 11/1/01 foodapZadm Check#&Date !O9� 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 Type of Operation(s) Type of Inspection Food Service Routine Address / ( u /`\� L Rik Retail ❑ Re-inspection �t/44'G�7Level [I Residential Kitchen Previous Inspection Telephone O e y y ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person In Charge(PIC),__S�. "� Time ❑ Bed.B Breakfast ❑ General Complaint C� In: [:] HACCP Inspector i2a- ` Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) Violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS El2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 4. Food and Water from Approved Source El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements Up. Reheating ❑ 7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 9. Food Contact Surfaces Cleaning and Sanitizing ElEl 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP NSUMER ADVISORY ❑ 11. Good Hygienic Practices 2. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Print: PIC's Signature: Print: Page_/af Pages i n FORM 734A HOBBS&WARREN -BOSTON r- Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) 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 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3; 590.003(D) I 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 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-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* :10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 . Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* 12- Prevention of Contamination from Hands 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* F-13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(1) . Labeling of Ingredients* 5-205.11 Accessibility, Operation and Maintenance .V 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. a CITY OF SALEM 7� BOARD OF HEALTH Establishment Name: ���y/- S Date: �� �� Page: 2 of Item CodeC-critical Item , DESCRIPTION.OF VIOLATION / PLAN OF CORRECTION j Dae "NoAE , Verified S PRINT CLEARLY 2 C, SG �� u G y E 0,--2 07 J �, S$1v1 •1-n /3- Le -_Un 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 comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension result in daily fines of twenty-five dollars or suspension/revocation of your food permit. OEmbar o ❑ Emergency Closure e 9 9enc Y s ' r ❑ Voluntary Disposal ❑ Other F ` FORM 734B HOBBS &WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures ' Factors(Red Items 1-22) (Cont.) According to Law Cooled to 41*F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14" Food or Color Additives19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/450F* 15"" Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* -<10. Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS (HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21'. 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drving Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.' 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw, Undercooked or 16, Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs - Pathogens.* Enecfive 11v21" 3-401.11A(I)(2) Eggs- 155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145*F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D) in 3-401.1l(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 to 41°F/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(6) Cooling PHFs Made From Ambient 29. S ecial Requirements .009 Temperature Ingredients to 41°F/45*F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. i S } CITY OF SALEM r BOARD OF HEALTH F Establishment Name: Date: '/age: of .� Item; : Code C-Critical hem DESCRIPTION OF VIOLATION YPLAN OF CORRECTION $ Date Y No. Reference_ R—Red Item i+LEASE.ranrr CLEARLY c ' Verified } A S' ( vJ for 0/- Cot-1 cvi t � ti. r t Discussion With Person in Charge: Corrective Action R=equired: ` ❑ No ❑Yes a ${A I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled Li Emergency Suspension l result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other lg FORM 734B HOBBS &WARREN - BOSTON i Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures ` Factors(Red Items 1-22) (Cont.) According to Law Cooled to 41*F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(8) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* iL Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 1400F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* ' :20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* ';"'21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drvimt A encs,Criteria* Incidental Food Contact,Lubricants* 3-801.11(6) Use of Pasteurized Eggs* 7-205.1 I 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIMEITEMPERATURE CONTROLS Animal Foods that are Raw, Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Effective 1/112001 3-401.1IA(1)(2) Eggs- 155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.11(A)(2) Comminuted Fish, Meats&Game SPECIAL REQUIREMENTS Animals- 155*F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.1 l(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering,mobile food, temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodbome illness Poultry or Ratites- 165*F 15 Sec.* interventions and risk factors.Other 3-401.1l(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under 1129- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 '1n18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140*F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 to 41°F/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. l_ .v.- ......"..> �,:.-r,�;,V.oNrw. .....°.+atyTw.w.....'�+,•�•r ^..n^rT�f:a...rz�w. w�.a.k ... o- THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 9 North Street 4 Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 740-9705 Name / Date Type of:Operation(s) Tie of IIn_soecti�on f. Pi�Gr �f l//i /i7C// ._//j/d). Foody ServiceLl� Routine Address Risk�dl � �Ge Risk ElRetail El Re-inspection 7 Level ❑ Residential Kitchen Previous Inspection Telephone ,y y�_d�y �j� ❑ Mobile Date: ❑ Temporary ❑ Pre-operation Owner � e � ', �,O 4 lq 2HACCP Y/N El Caterer El Suspect Illness El Bed Eli` Char a PIC Bed&Breakfast General Complaint Person n/ 9 (PIC) /i ii Time ❑ HACCP Inspector- In: El Other •✓ 4_fr_ Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: RED Violations (1-22) Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E)❑ 590.009(F)❑ action as determined by the Board of Health. Local Law ❑ 7D PROTECTION MANAGEMENT [112. Prevention of Contamination from Hands 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time As a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY 1:111. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations (23-30) Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions El Immediately or within 10 days as determined by the Board and Risk Factors (RED Items 1-22): of Health. Non-critical (N)violations must be corrected immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C N 590.000/Federal Food Code.This report,when signed below 23. Management and Personnel (FC-2)(590.003) \ by a Board of Health member or its agent constitutes an ✓ order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004)3 5. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 25. Water, Plumbing and Waste (FC-5)(590.005) the food establishment permit and cessation of food establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:Mmn roc 14 d Inspector's Signature: Print: 7 PIC's Signature: Print: Page o@^ Pages Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) c PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT ;_8. Cross-contamination [11 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* F2_° 590.003(C) Responsibility of the person in charge to Contamination from the Environment �. require reporting by food employees and 3-302.11(A) Food Protection* _ applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Chare* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 1,3 .1 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003E Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4° Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness* 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensilsand Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by (_10 Proper,Adequate Handwashing Regulatory Authority 2-301.11 Clean Condition- Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices .r5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges from the Eyes,Nose and 3-202.15 Packa a Inte rit * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* f"6- Tags/Records:Shellstock 112 °. Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products F-13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* ;t7` Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 1 Hand Drying Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: PnG` `s ��or�'r�/ Date: oe /ice'//,Z Page: .;Zof -2- f item '= Code ' ' C—Critieal,ltam, DESCRIPTION OF VIOLATION•/ PLAN OF CORRECTION , ° " ' ' Date' No. Reference, -R—Red Item ,_ r.,,. PLEASE.PRIRr CLEARLY Verified =... } t U u i 0 ti i 6 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 comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may 1-1 Re-inspection Scheduled L) Emergency Suspension result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure 4 ❑ Voluntary Disposal ❑ Other FORM 734B HOBBS &WARREN - BOSTON - Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 41'F/45'F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41'F/45'F* Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140'F.* Containers* 3-501.16(A) Roasts Held at or above 130'F.* 7-102.11 Common Name-Working Containers* " Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS (HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21`- 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* "'' Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 - Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIMEITEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16;... Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Eeecl'a rnt200r 3-401.1IA(1)(2) Eggs- 155'F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145'F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155'F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D) in 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 Min.* catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats-1557 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165'F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 1450F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165'F* 3-401.I1(A)(1)(b) All Other PHFs- 145'F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17'f Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165'F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165'F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 1400F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140'17 to 26. Water, Plumbing and Waste FC-5 .006 70'F Within 2 Hours and from 70'F 27. Physical Facility FC-6 .007 to 41'F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41'F/45'F 30. Other Within 4 Hours* *Cenotes critical item in the federal 1999 Food Code or 105 CMR 590.000. !I i Massachusetts Department of Public Health 120 W Board S Health Division 9 Sals Sal Wof Food and Dru Board Street,4 Floor em, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name D e I T e of 0 eration s Tvoe of Inspection Food Service ❑ Routine Address sk ❑ Retail e-inspection Level ElResidential Kitchen Previous Inspection Telephone a ❑ Mobile Date: Cf ,� I Q Owner HACCP YIN El Temporary ❑ Pre-o��ration ❑ Caterer ❑ Suspect Illness Person in Charge(PIC)� / Time ❑ Bed&Breakfast El General HACCP Complaint VI In: 3;o� Inspector Out: Permit No. ❑Other Each violation ch-e6keb req ires 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 „ a.a.,„ ,a. , „� , ,m""'- ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTHI` i PROTECTION FROM CHEMICALS f ❑ 2. Reporting of Diseases by Food ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals p is e r. au � �-g •a t9 -;+ FOOD FROM APPROVED SOURCE.,,:;`: ,_- ,: ,a,r ..p "TIMEfrEMRERATURE CONTROLS(Potentially Hazardous Foods) °` " ❑ 4. Food and Water from Approved Source f ❑ 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`- ,,, ,� , El 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 (CONSUMER',ADVISORY'. ,.•__ ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-a)(590.0so.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S SXM,OF�14.d. in ro, . =) 9 0,,��,,�_/I& I Inspector's Signature: Print: PIC's Signature: Print: Paget of Pages G w- --'-Cl G ez it Violations Related to Foodborne Illness r _. interventions and Risk Factors(items 1-22) j PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Cross-contamination 1 590.003(A) Assignmentof Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from -r590.003(B�emonstration of Knowledge* Cooked and RTE Foods* 2-703,71 Person in char e-dut Is Contamination from Raw Ingredients 3-302A I(A)(2) Raw Atrium]Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3302.15 WashingFruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-3(A.1 I Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char e* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Resetvice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Contamer* Sanitization Temperatures?, 3-201.13 Flui d Mi lk and Milk Products* 4-501.112 MechanicalWarewashino ilotWater 3-202.1.3Shell Eggs* Sanitization Temperatures*Eggs gs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Poconcentration and hardness. 5-101.11 Drink n Water from an roved System* 4-601-11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 4-602.71 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.01' 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 Regulatoty Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Packa e ante it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting" 6 Tags/Records:Shellstock 1.2 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* - Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.0040) Labeling of Ingredients' S-21)4.11 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance F7 e /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. Handwashing Cleanser,Availabilit 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision •Denotes critical item in the federal 1999 Foal Cade or 105 CMR 590.000. j 1 CITY OF SALEM 1 �t BOARD OF HEALTH Establishment Name: >�✓l l/1 rhe .. �.1I !c� 13 Date:/a_/-l::�_1 Page: of Item Code C-Critical Item v DESCRIPTION OF VIOLATION/PLAN OF CORRECTIONDate No. Reference :R-Red Item' _ Verified" PLEASE PRINT CLEARLY rc L I t t Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ } inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension } comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure i your food permit. ^A vl 0 n ❑ Voluntary Disposal ❑ Other: i SOI74(CT PHR Received at r perat to Violations Related to Foodborne illness Interventions and Risk Accordiintol-aw Cooledto Factors(lifents 1-22) (Cont) 4 1'17/45"F Within 4 Hoturs, PROTECTION FROM CHEMICALS Coalitu,lyf�,Lhods for PI-fFs 19 PRF Rot and Cold Holding 1=4 Food or Color Additives 3-50'1 16(B) Cold PHFs Mintitained at or bekliv 3-20-2Y2 3-302,14 Protectiou jol!2 590.004F) 110/45°F- nti --ov'� ----4! 3-501.16(A) Hot PHFs Maioned at or ab 15 I Poisonous or Toxic Substances 140'F -7-t 5 1.1­l-t Identifying fritolinalron 1-5ol 16 � ) (A) RiNisis Held at or above 130'F, Connor 102,11 Comanon Nioue -WorkLn 20 Time as a Public Health Control — 7 - Timms as a Public I th cunuol�� 2iTt.i I S�pza a6vat-Storage, 7-202.11 R'ntriclonl--pacscncr and 'v e ----- 7-202.12 Conditions of?lye* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 7-204.11 allio7tv"(7riterui -olefflic4ts 7-120�7�-- —Ow—micids for Was Criteria* 21 3-801A 1(A) Uapatcunzotl PrepackagedRaces wid 77 204.14 Di1j!jE�ALcuu,.._Cri—.. Bevera2es with±'Ll Naming 7-205,11 7-206,11 11(D) Raw or PirijaIN CookedAilimil F-oild and Raw,St t'd sprouts Not Served 7,206.12 Rixiew Bart Stauillm 3-90l 11 c Unopened Fooill Package Not Re server'- ,-206,13 '1 racking P,mderi, Pi Cootiol and Monimlin"', CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 3. FF1- 11 Consumer Advisory Posted for Consumption 0; Proper Cooking Temperatures for Animal Foods'Mat are Raw.Undercooked t;, PHFs I Not Olhcr .ise Pox:essed to Eliminate 3-=401.13 1(I t(-.} Fgg,- 155�F 15 Sec. Patfio-n' Em,s Inarnedialle Serviuc 145F i 5sec, 3-301 13 P-stozatz,ail Eaie,.Subsunrie for Paw Comminuted Fish, Mews&Gaine SPECIAL REQUIREMENTS 401A1 �1)0) (8) _PP06 and lint Roast - 130',F 121 nii0 3-401.11(A)f2) liatira', Injecictif %lzats-- 155+ 15 sec. cateringmobile food, tomporail;and 1.11(A)i3) Poultry,WiFd Berne, Statfeci fli4rs, residential kitchen operations should he stuffing corllaininla Fish,bleat, debited under the appropriate sectuNIS Poultrvol, alxwc if related to foodborne illness 40L 11(C)(3) 1Yhole-mm0e, Intact Beef Sliads interventions and risk factors. Other 145"T 590,009 violations relatino' to good retail pi actices should he debitedunder#29 - i-401.12 Raw Aninud Fixais in a .................M.icrowikW 165'F Special Requirenrants. 3-401AUA)(1)(b) Al,Ot aei I>Iff--s-- 145"17 15 sec- i7 cci7 Reheating tot Hot Holding VIOLATIONS RELATED TO 0000 RETAIL PRACTICES 3-463,11(AA(1?) {Items23-30) -403.1}(B) -'Microwave- 165'F 2 Mulct,!Standing Criurell and non-(roirail which do not relate to lite, Time" ftiodborne illness ouret ventiorry and liskjaciors livoJ above, ran be d03 1 J(C) Cotrariemtdv firta:essed RTF.F,mid fiallid in the ft4lolvingle,-tions q/tris Foad Code and.105(WIR 3-463.7!(E) Remaining ulehced Radom of licef 23 _M nagfneLt ndPer sonnel FC 2 1 003 24� Food and Food Protection FC 3 004 18 Proper Cooling of PHFs -- --------------- 25, E lig qu _ln_Tt_trtd Fr--4 O(Y5 -------------- = 26, 1 Water,PilaTibinjand Waste I FC-5 1 OW cooliagcook"atfifil-'s from l4i'F, , d 701;Within 2 flour<and From 74'111 7� Physictil Fac. ifity FC-6 007 to 4 1'F/45'F Within 4 Hours. 26 Cooling PHFs Madc From Arribi it S. adc From Arribiet 1 i .009 TemperatureIngredientsul41��1S`F30, OtherrTs01.14(F3} 4, Within 4 Harry' 1)oioes mlai i acia ia live 1cderal 1999 Food G*cr 104(klk 590 our, Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4`" Floor p. g Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 NameDa Type of Operation(s) Tvoe of Insoection f-c _ W Food Service Routine Address I 3.4 f Ris Ll Retail Re-inspection Level ❑ Residential Kitchen Previous I spegtion Telephone - �,% El El Date: Temporary ❑ PrAration Owner HACCP Y/h El(� r, C ' ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) J­ C ( Time EI Bed&Breakfast El General Complaint El Inspector Out: In. :I L Permit No. ❑ O herr- ( Each violation checked re uires.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) ❑ 1 -_action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT r, "I -„„ -, ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties k EMPLOYEE HEALTH w€ El 13. Handwash Facilities PROTECTION FROM CHEMICALS El 2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives C] 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals f L FOOD FROM APPROVED SOURCE ^�, 's ,` TIME/TEMPERATURE CONTROLS PoteMiall Hazardous Foods ' ❑ 4. Food and Water from Approved Source (Potentially ) ❑ 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�) `'' ""'T J8.'9 Hot and Cold Holding El 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ("..REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(MSP) .f El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices `CONSt1MER ADVISORY r „` al '" ,m �-� w i �a�« �:..� , �-, x ..,�, a.+ ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions 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. w 590.000/federal Food Code. This report,when signed below N ' by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food , 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other / DATE OF RE-INSPECTION: (, f ��� S:SXMm etFmm 14.d. I ' TID\ Inspector's Signature: �, ll / Print: PIC's Signature: I nntS0 S r! O Page of Pages i U Violations Related to Foodborne Illness .* Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* � 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Fond Protection* applicants* 3-302.1.5 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-3(4.11 Food Contact with Equipment and - Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.(X)3(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food` 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water Sanitization Temperatures* 3-201.1Food in il Hermetically Sealed Container* 4- . ecancaWarewashing 3-20'(.133 501112 Mechanical -Hot Water Fluid Milk and Milk Products* d 3-202.13 Shell Eggs* Sanitization Temperatures* li 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5401.1.1 Drinking Water from an Approved System 4-601.11(A) Equipment Food Contact Surfaces and A> Bottled tiled Drinkin Water* Utensils Clean` 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Sheimsh and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-20114 Fish and Recreationally Caught Molluscan Food Contact Stu-faces 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 Regulatoty Authority 2-301.1.1. Clean Condition-Hands and Arms* 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 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and 3-202.1.5 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tastin * 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to yces* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 5-203.11 Numbers and Capacities* acities* 3-402.12 attd Creation and Retention* 5-204.1.1 location and Placement* 590.004(1) Labeling of Ingredients' 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Handwashirnz Cleanser, Availability 8-103.12 Conformance with Approved Procedures* 6-301..12 Hand Drying Provision *Denotes critical item in the Federal 1999 FN J Code or 105 CMR 590.000. CITY OF SALEM } BOARD OF HEALTH Establishment Name: {- (Y,i l r:< (.� �r _.� Date: q --) �n Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference R—Red Item f - Verified PLEASE PRINT CLEARLY >r _ � iv- I1 M C I n — I Lg' ( 1 � / alnlvek— ll 11 I 12 1 n _.2, i C 10 0.n �.�. A ) ) 1 Discussion With Person in Charge: Corrective Action Required:k ❑ No Yes } I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency closure youk food permit. i ❑ Voluntary Disposal ❑ Other: v � i J 4(C) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk I According to La" Cooled to Factors(livirs 1-22) {Cont) 4 I'P/4.S,,F Wilkin 4 Hiaug, (",-1 ; -C(K)l i m,M�'.thod s irs PHFs Maintained at or beh, PROTECTION FROM CHEMICALS F-14 [_L9 PHF Hot and Gol�ldinq Food or Color Additives 01.1()(B) 63-1155f, 590,0040F) 41°f45"F� 3-301 ILj2roaec Poisonous or Toxic Substances 3-50 1,INA} flol PHFs, Maintained aiTr­above 140'F. ing Intu inalit 76(A) Roasts Held at or above 130°F. 7-102,11 Cka-ruon"Narro -Workin!L(Imaaini�c�* LIAL_ Time as a Public Health Control 1-50i 19 'rimc as a putdic 7-201., S=pat non st T3ealih Control= I Vat ianceRcqmreinent ,20111 Restriction - U�o' 7-202.12 Conditiow of Uso. 7-103.U Toxic Criplameo,-prolubmion04 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE F7-204.11 Sariifizerv,Criteria-Che.jaicaW POPUL, 10!4§; '7-2174.12 inisiaeurizeA flrc-pa6 igcd Jincs and Chemical&foi %,efi CircnO 21 3-801.1 I(A) L, 7-204,14 L fieveraves with 'WariniLl ILIIls� 3-801,11(B) Use of Pa�tokL 5 26,�,I I Incidental Food�'onwt,Lulyicantil il-�11—I-— 1-801.1 1()) R,re,or Partialiv CkK)K(,dAtnuad lrex,,dziud Rc,�tricfed L,w Critcna* -I-- - I Raw St rd Sproats Nt)t Served. 7 206 11 RodiW Bml Staaons 3-801.1](C) 5acking Control and coed Ila Ise c(L CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-00 (1 Consunsct �deisots Pe ted for f-onsnrnpation at -ed cr Prow Cooking Temperatures for Annual Fx)& that are Raw. Linderwok Not Other wi�e Pro�c�"ed�o Eliminate PHFs )(7— J, at I.i FL (55'F 15 - rvn 3-3(1 13 PzstearrzM Egg, SlAbstitulv to,,Raw ShOl 3-401.1I(_ )(2) 451fl 5sec- cumnanitted FM,Mcats&Gail)v Animals 1�,l 1, 15 1 --- SPECIAL REOUIREMENTS Port, and fleet Roast - 1301` 121 win* 590�0(0(A)-J)) Vi(aajjojj��or Section 590.W)9(A)-(1.)) in 3_401_I I(A)(2) Ratac�, bijecicd %Ieka� - 155,F 15 $cc. catering_rbohfltfilod,teinfarrai'v and romdenbal kitchen operations diould bc LI I(A)(3; Pouln.'Wild Gaine,Sla17fe(F1;TfE', qnrifing Confainint, Fish.Meat, debited under the appropriatesTc-11011S Pnitre or Ratites-165°F` tS sec. �, I Axwe if related to ftiodho, 401ADC)'(3) Whole-naisciclivact Btef Steaks inteiventionsaird risk factori. OLh(-r 145`F* g 590.009 Violations relating to otx] retail 3-401,12 Raw Annual Foods Co,)ked in a laactices ,hould be debited under#29 - 'Microwav=e 10.5'F Special Reqitirenrents- 7145 " 15 we Ai7 Othei PiFf, —1 (T7 Reheating for Hot Holding VIOLATIONSPELATED TO GOOD RETAIL PRACTICES 3-403.1 j(AT&-(5) P1 IF, 165"t' 15 sec. (Items 23-30) 403.F3(b) Nficrovave- 165'F2 Minute StandingC)hiralaml non-crilwai viotabons, which do am relate m the Tin et' ----I foodhorne dlne.n nuerventlons find riAjii,fors liwed above, (an be -7403 11(C) Commercial1v Picte�sedirlt-,Fecd- fiaind in thejnilowng se(trr)to of the Food Code(wd 105 CUR 140'F it—em Good Retail Practices PC 590,000 I(E) Remaining uneljctd Portion's of Beel, 23, N4 and flat onnial Roasf,* --- -— - L----L.-L-00-3-1-- 24. Food and Food Prolection FC 3 004 Proper Cooling of PHFs qu7,�mLt an rn 005 CMinF Ctx)kcd,PfWs bolu 1,4)'F to ------ 26, Wat0f,PfUalbin(Land W"to 70'f;Wit1hin 2 1 foun wid From 711 FC 6 007 z to 4 1 1-/45F Withi a 4 Flow s, CWit olin g PHFs Made From Ambi"a T,raperatorc lagredicra�i,�4101`/45,F ------