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FANTASY ISLAND RESTAURANT - ESTABLISHMENTS FANTASY ISLAND RESTAURANT 516 LO RING AVENUE I SL } o . o e. o o City of Salem Board of Health r'FOOD ESTABLISHMENT INSPECTION REPORT 120 Washington Street, 4th Floor, Salem, MA 01970 Tel (978)741-1800 Fax.(978)745-0343 Name FANTASY ISLAND / Deborah Lam Date 11/16/2016 �Tvoe of Ooeration(s) Type of Inspection Food Service:>99 ❑ Routine ld Re-Inspection Address 516 Loring Avenue Risk Level: 1 Previous Inspection Permit No. FM-16-32 Date: Telephone 745-1700 HACCP: 0 ❑ Preoperation ❑ SuspectIllness Owner Fantasy Island Restaurant Time ❑ General Complaint Person in Charge(PIC) In: 2:49:11 PM ❑ HACCP ❑ Temporary Event Inspector Jeffrey Barosy Out: 3:09:44 PM ❑ Other Each violation noted requires an explanation on the narrrative page(s)and a citation of specific provision(s)violated. Non-compliance with: (Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) (Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health (FOOD PROTECTION MANAGEMENT I I 12.PREVENTION OF CONTAMINATION FROM HANDS 01.FOOD PROTECTION&MANAGEMENT I I 13.HANDWASH FACILITIES (EMPLOYEE HEALTH I (PROTECTION FROM CHEMICALS 02.REPORTING OF DISEASES I 14.FOOD OR COLOR ADDITIVES 03 PERSONNEL WITH INFECTIONS I I 15 POISONOUS OR TOXIC SUBSTANCES (FOOD FROM APPROVED SOURCE I ITIMEITEMPERATURE CONTROLS 04.FOOD&WATER FROM REGULATED SOURCES I I 16.PROPER COOKING TEMPERATURES FOR PHFs 05.RECEIVING/CONDITION I I 17 REHEATING FOR HOT HOLDING 06.TAGS/RECORDSSHELLSTOCK I I 18.PROPER COOLING OF PHFs 07.CONFORMANCE WITH APPROVED PROCEDURES/ I I 19 PHF HOT&COLD HOLDING HACCP PLANS I 20.TIME AS A PUBLIC HEALTH CONTROL (PROTECTION FROM CONTAMINATION I (REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 08 CROSS-CONTAMINATION I 21.REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS 09.FOOD CONTACT SURFACES - - - - ADVISORY 10.PROPER,ADEQUATE HANDWASHING 22.+I (CONSUMER CONSUMER ADVISORY 11.GOOD HYGIENIC PRACTICES I Violations Related to Good Retail Practices(Blue Items) Number of Violated Provisions Related To Critical(C)violations marked must be corrected immediately orwithin 10 days Foodborne Illnesses Interventions and Risk Fo as determined by the Board of Health.Noncritical(N)violations must be Factors(Red Items 1-22): corrected immediately or within 90 days as determined by the Board of Health Official Order for Correction: Based on an inspection today,the items 23.MANAGEMENT&PERSONNEL I checked indicate violations of 105 CMR 590.000/federal Food Code.This report,when signed below by a Board of Health member or its agent N 24. FOOD& FOOD PROTECTION I constitutes an order of the Board of Health Failure to correct violations cited in this report may result in suspension or revocation of the food establishment 25. EQUIPMENT& UTENSILS I permit and cessation of food establishment operations If aggrieved by this order,you have a right to a hearing Your request must be in writing and 26.WATER, PLUMBING&WASTE I submitted to the Board of Health at the above address within 10 days of receipt of this order. N 27. PHYSICAL FACILITY 28. POISONOUS OR TOXIC MATERIALS 29.SPECIAL REQUIREMENTS N 30. OTHER S 5901nspectF a 6014 dm DATE OF RE-INSPECTION: INSPECTOR' /�� PERSON IN CHARGE 014-1 ( Signature Signature City of Salem Board of Health J FOOD ESTABLISHMENT INSPECTION REPORT 120 Washington Street, 4th Floor, Salem, MA 01970 Tel (978)741-1800 Fax.(978)745-0343 Address : 516 LORING AVENUE Permit Number FM-16-32 Applicant: FANTASY ISLAND / Deborah Lam Inspector : JBarosy Inspection Type Inspection Description Status Comment 24. FOOD 8 FOOD PROTECTION 3-305.11 Contamination from Premises: PASS Marinade found in in steel cauldrons in Food Storage reare basement area with flies flying about. Lids were not securely fastened to prevent insect infestation. Provide a food safe impervious cover for marinade or store marinade in a food safe container that is impervious to rodents and insects. Corrected On Site 27. PHYSICAL FACILITY 6-501.12 Premises/Fixtures: Cleaning, FAIL On the stainless steel shelves behind the Frequency/Restrictions cooking line there are black and brown colored bowls and cups that are covered in grease. Clean and sanitize these utensils and cleaned and sanitize the shelves to prevent attracting insects and rodents. 30. OTHER Other PASS NOTE:All violations from the 10/20/2016 routine inspection have been corrected. NOTE: PIC informed the inspector that the Allergy Awareness Certificate and the Food Safety Manager Certificate is to be delivered to the establishment. Inspector instructed her to deliver copies of both certificates to the Salem Board of Health as soon as the establishment receives them. Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4th Floor Salem, MA 01970-3523 Tel. (978)741-1800 Fax (978) 745-0343 City/Town of _ .YL len, Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Namerr Date Ty ofOperation(s) TTyge-ofInspection FQ n �n C _Clc A JZ/�/2Q I LTJ Food Service (URoutine AddressS1/ : A Risk ❑ Retail ❑Re-inspection 1bo Level ❑ Residential Kitchen Previous Inspection Telephonen q /�^rN -t 7(nJS^l ❑ Mobile Date: OwnerHACCP YIN ❑ Temporary El Pre-operation DoJmrn I ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) n Time ❑ Bed 8 Breakfast ❑General Complaint verl Inspector )ejCrp yyafn Out1 Q9wm, Permit No. ❑Other Each violation checked tequires�explanation on the narrative pade(s)and a citation of specific provision(s)violated. Non-compllance with: Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD PROTECTION MANAGEMENT ❑ 12 Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13.Handwash Facilities EMPLOYEE HEALTH "T ON FROM CHEMICALS [12. Reporting of Diseases by Food Employee and PIC PROTE ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded E] 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMEREMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Aocuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ,❑ 11`8•Cooling PROTECTION FROM CONTAMINATION 0'19.19.Hot and Cold Holding d8.Separation/Segregation/Protection [120.Time as a Public Health Control 2(9.Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSUSCEPTIBLE-POPULATIONS(HSP) ❑ 10. Proper Adequate Handwashing ❑21.Food and Food Preparation for HSP ❑ 11.Good Hygienic Practices CONSUMER ADVISORY ❑22.Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. 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 t f Health. 590.000/federal Food Code.This report,when signed below c N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2x590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3)(5go.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 (FO-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)(5eo.0oe) 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 REINSPECTION: ,m,,, Novr 31 2©j_� Inspector's Signature: Print: PICS Signature: / Print: b - Vt 1 l ' Page./ oil Pages III F Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination I FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Fonds Separated from I 1 590.003(A) Assignment of Responsibility* I Cooked and RTE_Foods* 590.003(B) Demonstration of Knowledge* I I Contamination from Raw Ingredients I 12-103.11 Person in charge-duties I 3-302 11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH I Contamination from the Environment I 2 590.003(C) Responsibility of the person in charge to 13-302 11(A) Food Protection* I require reporting by food employees and 13-302.15 Washing Fruits and Vegetables I applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An I Utensils* Applicant To Report To The Person In I Contamination from the Consumer I Charge* 13-306 14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* I I Disposition of Adulterated or Contaminated 13 590M03(D) Exclusions and Restrictions* I Food 590.003(E) Removal of Exclusions arid Restrictions I 3-701 11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 19 Food Contact Surfaces 4 Food and Water From Regulated Sources I 4-501.111 Manual Warewashing-Hol Water 590.004(A-13) Compliance with Food I.aw* I Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* I 14-501.112 Mechanical Warewasbmg-Hol Water 3-201.13 Fluid Milk and Milk Products* I Sanitization Temperatures* 3.202.13 Shell Eggs* 4-501.114 Chemical Sanilizaron-temp.,pH, � I concentration and hardness. * 3-202.14 Eggs and Milk Products,Pasteurized* I 14-601.11(A) Equipment Food Contact Surfaces and 3-202.16 Ice Made From Potable Drinking Water* I utensils Clean* 5-101.11 Drinking Water from alt Approved System* I 14.602,I 1 Cleaning Frequency of Equipment Food- 590.006(A) Bottled Drinking Water* I Contact Surfaces and Utensils* 590.006(13) Water Meets Standards in 310 CMR 22.0* I 14.702.11 Frequency of Sanitization of Utensils and Shellfish and Fish From an Approved Source I Food Contact Surfaces of Equipment* 3-201 14 Fish and Recreationally Caught Molluscan I 14.703 11 Methods of Sanitization-Hot Water and Shellfish* Chemical* 3-201.15 Molluscan Shellfish from NSSP Listed I I tgI Proper,Adequate Handwashing I Sources* 2-301 11 Clean Condition-Hands and Arms* I Game and Wild Mushrooms Approved by Regulatory Authority 12-301.12 Cleaning Procedure* I 13-202.18 Shellstock Identification]'resent* I 2-301.14 When to Wash* I 1590.004(0) Wild Mushrooms* I if Good Hygienic Practices i 3-201.17 Game Animals* I 2-401.11 Eating,Drinking or Using Tobacco* ISI ReceivinglCondition ( 12-401.12 Discharges From the Eyes,Nose and 3-202.11 Plc Fs Received at Proper TemMouth* peratures* 3-202.15 Package Integrity* 13-301.12 Preventing Contamination When Tasting* 1 � 3-101 A I Food Safe and Unadulterated112 I I Prevention of Contamination from Hands 6 Tags/Records:Shellstock I 590.004(E) Preventing Contamination from 3-202.18 Employees* Shellstock Identification * I 113 I I Handwash Facilities 3-2113.12 Shellstock Identification Maintained* I I Conveniently Located and Accessible Tags/Records: Fish Products I 3-402.11 Parasite Destruction* 15-203.11 I Numbers and Capacities* 5-204.11 Location and Placement* 3-402.12 Records.Creation mid Retention* 1 I I 5-205 11 I Accessibility,Operation arid Maintenance 590 004(J) Labeling of Ingredients' 7 Supplied with Soap and Hand Drying Conformance with Approved Procedures I I Devices IHACCP Plans I Device 1I 16-301.11 I Hing andwashCleanser,Availability Specialized Processing Methods* G301.12 gland Drying I 13-502.12 Reduced oxygen packaging,criteria* I I I Provision I 18-103 12 Conformance with Approved Procedures* I *Denote,crucal item in the federal 1999 Food Code or 105 CMR 590.000 CITY OF SALEM BOARD OF HEALTH Establishment Name: F",6 t .zs/aJ Date: J_0/ 1Y,2,zZ6 Page: Z of Rem Code C-Cmtcal nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. I Relerenoe I R-Red nem Verified 1 PLEASE PRINTCL ABLY f r�r J 77 r n Y� rDv[•lh2 rvi fF'.L'C�76h L,.aS Cnrlr vGT_ e- o .lDwlnq W,,, Yin'' G en✓ Frnn� Piar /Irv✓' i r r✓ix„,� Cor r'orl 1e r r r , r 2 0 ' �SorMe t1y �wtLSh.nn Srn� S or-�oper //Srgr7a4e,, rrn/ltl¢ 0._ - 1174 C �,.mrna Sf r1,; ��70YllF�' t- CLW1aVfrIlI,I nY IV,' rcoYreltWl f'T'•f1�77� i-IS'DeGf•/Oh � II - I (�IJrShWCLcVIr�Oyha{' rnn. 't'rnn� r Y � � - II r o n // r r ` Sa _4,,.,J, rr (b TPMDPYa JU/p- SC hnw. 9of �— l 1 hop.6- PTC 1✓n-c r�4 v vr_ a T n SAY - � U for �Q / I L 1 r . l I W*4 r-AIcoilj_'rr�-.P.Ir 'Lr� C©!m e.hj Cl1 P, d- X120.7 SaNr�QTrO I n ThP rY120.n R-tmo. 3-3 G s 4orei' Love 5;_50p- rnl.e - cr rNQ b C.r TEJ bre vvyl'� Lrocr- t^�h"Inr»rnr�T/n N, I I J I Discussion With Person in Charge: Corrective Action Required: I ❑ No M--' les I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction r violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or spension/revocation of o Embargo ❑ Emergency Closure your food permit. A ❑ Voluntary Disposal 0 Other: I Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) (Cont.) 13-501.15 Cooling Methods for PHFs I I 119 I PHF Hot and Cold Holding PROTECTION FROM CHEMICALS 3-501.16(6) Cold PITFs Maintained at or below F 114 Food or Color Additives 590.004(F) 41 0/450 F* 3-202.12 I Additives` I 13-501.16(A) Hot PHFs Maintained at or above > 3-302.14 Protection from Unapproved Additives` 1400F. ' t 15 Poisonous or Toxic Substances 13-501.16(A) Roasts Held at or above 130°F. ` 7-101.11 I Identifying Information-Original 120 Time as a Public Health Control S Containers* 13-501.19 Time as a Public Health Control* 7-102.11 + Common Name-Working Containers* 1590.004(14) Variance Requirement 7-201.11 I Separation-Storage` r, 17-202.11 I Restriction-Presence and Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-202.12 I Conditions of Use* I POPULATIONS(HSP) 7-203.11 I ToxicCoivaincrs-Prohibitions* I 121 3-90LII(A) Unpasteurized Pre-packaged Juices and 7-204.11 I Sanilizers,Criteria-Chemicals* I Beverages with Warning Labels* 7-204 12 I Chemicals for Washing Produce,Criteria* I 3-801.11(B) Use of Pasteurized Eggs* I 7-204.14 I Drying Agems,Criteria* I 13-801.11(D) Raw or Partially Cooked Animal Food and 7-205.11 I Incidental Food Contact,Lubricants* I Raw Seed Sprouts Not Served. 2 � 7-206.11 Restricted Use Pesticides,Criteria" I 13-801.11(C) Unopened Food Package Not Re- 7 7-206.12 Rodent Bait Stations* 17-206.13 Tracking Powders,Pest Control and I CONSUMER ADVISORY ,< Monitoring 22 3-60.1 I 1 Consumer Advisory Posted for Consumption of i Animal Foods That are Raw,Undercooked or ? TIME/TEMPERATURE CONTROLS Not Otherwise Processed to Eliminate 16 Proper Cooking Temperatures for Pathogens.*Em'rnrzm, PHFs I 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* m 3-401.11A(1)(2) Eggs- 155°F 15 Sec. j Eggs-Immediate Service 145'FI5sec* SPECIAL REQUIREMENTS 3-401 11(A)(2) Comminuted Fish,Meats&Game590.009(A)-(D) Violations of Section 590.009(A)-(D) in Animals- 155°F 15 sec ` I catering,mobile food,temporary and 3-401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 min* I residential kitchen operations should be i 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec., * debited under the appropriate sections 3-401.11(A)(3) Poultry,Wild Game,Stiffed PHFs, above if related to foodborne illness Stuffing Contahhing fish,Meal, interventions and risk factors. Other Poultry or Ratites-165°F 15 sec. * 590.009 violations relating to good retail j 3-401.1 I(C)(3) Whole-muscle,Intact Beef Steaks I practices should be debited under 429- 145°F* Special Requirements. `t 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* I VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-401.11(A)(1)(b) All Other PI-IFs- 145117 IS sec.• I (Items 23-30) 17 I Reheating for Hot Holding I Critical and non-critical violations, which do not relate to the foodborne illness iniervention.c and rick factors listed above, can he 3-403.11(A)&(D) PHFs 165°F 15 sec. * I found in thefollowing sections of the Food Code and 105 CMR ` 3-403.11(6) Microwave- 165°F 2 Minute Standing 590.000. f Time* I I Item Good Retail Practices FC 590.000 I 4 I 3-403.11(C) Commercially Processed RTE Food- 1 23. Management and Personnel FC-2 003 I 140°F* I 1 24. Food and Food Protection FC-3 .004 I r 13-403.11(E) Remaining Unshced Portions of Beef 1 25. Equipment and Utensils FC-4 .005 I a Roasts* 1 26 Water,Plumbing and Waste FC-5 006 ' 118 Proper Cooling of PHFs 127 Physical Facility FC-6 007 I t 1 28. Poisonous or Toxic Materials FC-7 .008 I ! 3-501.14(A) Cooling Cooked PI-IFs front 140°F to 129 I Special Requirements .009 I 70°F Within 2 Hours and From 70°F to 130. 1 Other I r 41°F/45°F Within 4 Hours.* sssau�e.eao e� 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41'F/45'17 Within 4 Hours* 3-501 14(C) PIiFs Received at Tempemnues According to Law Cooled to 410F/450F Within 4 Hours. Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. t CITY OF SALEM BOARD OF HEALTH �7 Establishment Name: FO -cy ms� Date: �s�20/2D26 Page: 3 of / Rem Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dat tVo. Relerem* R-Red item Verified PLEASE PRINT CLEARLY t I I r✓ 1 /PAi ardsnmi�iz>-T rr�Wir� gown oL, IIt1kj I v-� / 3-S I S'( 2 P wet S, A a7,f f r vn o v w ° irnh✓bwn av✓'�. Keret,9✓a�DrS DescLf�✓� Covl2c�et of �imv. mic ih� c41,0n. 6- k n r SW" d';V _ �S y-5't77J..21 rQ,� So i+ �rovi�ps c,,.,�,d or licca uilz s�inn. k i nnLac S T ` r an III Dlscussion With Person in Charge: J Corrective Action Required: I ❑ No ar Yes I have read this report, have had the opportunity to ask questions and agree to correct all o Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled [3Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollar orsion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk 13-501.15 Cooling Methods for PHI's Factors(Items 1-22) (Cont.) I 19 PHF Hot and Cold Holding PROTECTION FRO N CHEMICALS 3-501.1603) Cold PlfFs Maintained at or below ti 114 Food or Color Additives I 590.004(F) 410/450 P` 3-202.12 Additives* I 3-501.16(A) Hol PH Fs Maintained at or above 3-302.14 Protection from Unapproved Additives* I I 140°F.* 115 Poisonous or Toxic Substances I 3-501 A(i(A) Roasts Held at or above 130°F. * I 7-101.11 Identifying Information-Original 120 Time as a Public Health Control Containers* 13-501.19 Time as a Public Health Control* I 17-102.11 Common Name-Working Containers* I 1590.004(H) Variance Requirement I • 17-201.11 Separation-Storage* 17-202.11 Restriction-Presence and Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-202.12 Conditions of Use* I POPULATIONS(HSP) 17-203.11 Toxid Containers-Prohibitions* I 21 3-801.11(A) Unpasteurized Pre-packaged.Juices and 17-204.11 Sanitizers,Criteria-Chemicals* I Beverages with Warning Labels* �• ( 7-204.12 Chemicals for Washing Produce,Criteria* I 3-801.11(B) Use of Pasteurized Eggs* > 17-204.14 Drying AFents,Criteria* I 3-801.11(1)) Raw or Partially Cooked Animal Food and 17-205 11 Incidental Food Contact, Lubricants* I I Raw Seed Sprouts Not Served. 17-206.11 Restricted Use Pesticides,Criteria* I 13-801.11(C) Unopened Food Package Not Re-served.` I 17-206.12 Rodent Bait Stafions* I 7-206.13 Tracking Powders,Pest Control and I CONSUMER ADVISORY Monitoring* 22 3-603.11 1 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or TIMEITEMPERaTURE CONTROLS Not Otherwise Processed to Eliminate 16 Proper Cooking Temperatures for I Pathogens.*E""" PHFs 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* I 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Eggs-Immediate Service 145°F15sec* SPECIAL REQUIREMENTS 3-401.11(A)(2) Comminuted Fish,Meats&Game I 590.009(A)-(D) Violations of Section 590.009(A)-(D) in Animals- 155°F 15 sec. * catering,mobile food, temporary and ." 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* I residential kitchen operations should be 3-401.11(A)(2) Ratites,Injected Meals-155°F 15 sec. ( debited under the appropriate sections above if related to foodborne illness 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, Stuffing Containing Fish,Meat, interventions and risk factors. Other Poultry or Ratites-165°F 15 sec. * 590.009 violations relating to good retail 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks practices should be debited under#29- 145°F* Special Requirements. 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* I VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-401.11 A 1 (Items 23-30) - ( )( )(b) All Other PHI's- 1Hold I S sec. * I Critical and non-critical violations,which do nor relate to the 117 I Reheating for Hot Holding I foodborne illness interventions and ri.ckfacio ry listed above,can he 3-403.11(A)&(D) PRFs 165°F I S sec. ` I found in rhe following sections(?f the Food Code and 105 CMR 3-403.11(B) Microwave- 165°F 2 Mmule Standing I 590.000. Time* Item Good Retail Practices FC 590.000 -2 I 3-403.11(C) Commercially Processed RTE Food- 123. Management and Personnel FC .003 I 140°F* I 1 24 Food and Food Protection FC-3 .004 'k 3-403.11(E) Remaining Unsliced Portions of Beef 125. Equipment and Utensils FC-4 .005 I Roasts, I 26. Water,Plumbing and Waste FC-5 006 27. Physical Facility FC-6 I .007 I 118 I Proper Cooling of PHFs I 128. Poisonous or Toxic Materials FC-7 .008 3-501.14(A) Cooling Cooked PHFs from 140°I'to 129 I Special Requirements .009 I I Ir 70°F Within 2 Hours and From 70°F to 130 1 Other I 41°F/450I' Within 4 Hour., s &e 3-501.14(B) Cooling PHFs Made From Ambient 'Temperature Ingredients to 41°F45°I' Within 4 Hours* 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45°1- Within 4 (lours. "Denotes cmical Item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH n Establishment Name: Fa SianJ Date: U12o12r�� Page: of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Rem PLEASE PRINT CLEARLY Verified 4xlll64e, "M '/ reLcpeeoAnr ha c CrrVmbS CA-011 L64 delrf'r pm j:WO-g-kdT 1,1101. qA �"+4'opw j C so S r I o. rr f-aLn rn�Y viwt-•�-•nc rvr c� 1{ ,nt ave. k,1 rhea Se— lirrr.! �i 14 S �cLrrnc rno� l�e_ C�rl�S i�� cLmd e r IP1 Sre/d P, spf.r/p' uiraerL Cry I re jqe4en�f 11, i r Bci r r O 2 (J��- �r r,K I1�iGrnwrye Ls +nnd r�'crr.^�ine nw� yPasgq2� m4p �1r e a4 t eoyeire. r"rea y1�ca^oi„rnve cn ! FIS d rem nJ J,L- s ( il1 jr S - I �/ I F _ _ 2S '- �Q?�12 — T a i ern - rnd-ajI cay,T . o/p,ep (-1rr�y S �tU/P/�DQ-2.v1� P�, 1�1a[a woad. I�Pmf r✓I�FJ cI-nmQ_—S0.• Ct7Y1 T/a inrrS' ICoYYPLt� ! IrLt�l ri,2 ri1- r h c�c;G•�'rnrn�� I � , I Discussion With Person in Charge: A Corrective Action Required:1 CI No ILK Yes j I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction J inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled Cl 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 Dispose) ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) (Cont.) 3-501.15 Cooling Methods for PHFs PHF Hot and Cold Holding PROTECTION FRO d CHEMICALS 119 3-501.16(13) Cold PI-IFs Maintained at or below p 1 14 I Food or Color Additives 590.004(F) 410/450 F* 3-202.12 Additives* 3-501.16(A) Hol PRFs Maintained at or above s 3-302.14 Protection from Unapproved Additives* I 140°F 1 15 Poisonous or Toxic Substances { 7-101.11 Identifying Infomtation-Original 13-501.16(A) Roasts Held at above 130 * ;a' Containers* 120 I Time as a Public c Health Control I 7-102.11 Common Name-Working Containers* 13-501.19 Time as a Public Health Control* `y 17-201.11 Separation-Storage* 590.004Qi) Variance Requirement t 17-202.11 Restriction-Presence and Use" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-202.12 Conditions of Use* POPULATIONS(HSP) 7-203.11 Toxic Containers-Prohibitions* I 121 3-801.11(A) Unpasteurized Pre-packaged Juices and ;r I7-204.11 Sanitizers,Criteria-Chemicals* I Beverages with Wamin�Labels* 7-204.12 Chemicals for Washing Produce,Criterta* I 3-801.11(B) Use of Pasteurized Eggs* 7-204.14 Drying Agents,Criteria* I 3-901.11(D) Raw or Partially Cooked Animal Food and 7-205.11 Incidental Food Contact,Lubricants* I I Raw Seed Sprouts Not Served. * 7-206.11 Restricted Use Pesticides,Crilena* I 13-801.11(C) Unopened Food Package Not Re-served. 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders,Pest Control and I CONSUMER ADVISORY Monitoring* 22 3-60111 1 Consumer Advisory Posted for Consumption of Anima(Foods That are Raw,Undercooked or TIMEITEMPERaTURE CONTROLS Not Otherwise Processed to Eliminate 16 Proper Cooking Temperatures for Pathogens.*Errant*'nrzoo' PHFs 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 1 3-401.11A(l)(2) Eggs- 155°F 15 Sec. Eggs-Immediate Service 145°PlSsec" SPECIAL REQUIREMENTS 3-401.11(A)(2) Comminuted Fish,Meats&Game I 590.009(A)-(D) Violations of Section 590.009(A)-(D) in Animals- 155°F 15 sec. * catering,mobile food, temporary and 3-401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 min* residential kitchen operations should be 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec. debited under the appropriate sections above if related to foodbome illness 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, interventions and risk factors. Other Stuffing Containing Fish,Meat, Poultry or Ratites-165°F 15 sec. * 590.009 violations relating to good retail 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks ( practices should be debited under 429- 145`F* Special Requirements. 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* I VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-401.11(A)(1)(b) All Other PRFs- 145°F 15 sec. * I (Items 23-30) Critical and non-crincal violations, which do not relate to the 1 17 Reheating for Hot Holding I foodborne illness interventions and risk.facias listed above, can he 3-403.11(A)&(D) PHFs 165°F I S sec. " found in the following secnonv of the Fond Code and 105 CMR 3-403.1 I(B) Microwave- 165°F 2 Minute Standing 590.000. Time* I Item Good Retail Practices FC590.000 1 3-403.11(C) Commercially Processed RTE Food- I 1 23. Management and Personnel FC-2 .003 I 140°F* 1 24. Food and Food Protection FC-3 .004 I 3-403.11(E) Remaining Unsliced Portions of Beef 1 25. Equipment and Utensils FC-4 .005 1 1 Roasts* I 1 26. Water,Plumbing and Waste FC-5 I .006 I 18 Proper Cooling of PHFs I 1 27. Physical Facility FC-6 .007 1 3-501 14(A) CoolingCooked PHFs from 140OF to 1 26' Poisonous or Toxic Materials FC-7 .008 1 129 Special Requirements .009 I 70°F Within 2 flours and From 70°F to 1 30 Other l 1 41°F/45°F Within 4 Hours. * ssmr�e�wmc 3-501.14(13) Cooling PHFs Made From Ambient -temperature Ingredients to 41017/45017 Within 4 Hours* 3-501.14(0) PRFs Received at Temperatures Accor durg to Law Cooled to 4 PF/45°F Within 4 flours. *Denotes critical nem to the federal 1999 Food Code or 105 CMR 590.000. ti CITY OF SALEM r BOARD OF HEALTH �" Establishment Name: Fa✓t'jnSy ZSdn_VJ Date: ©fa-0�2o26 Page: J of 7 Rem Code C-Critical Item / DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dery No. Reference R-Red Item Verified PLEASE PRINT CLEARLY I I b 501.- \7y-,,,P_a w` y , ' v rce r Tor-, e, n visd IJ Rn SP.rnv�1� Frr�D�� I�f)2"YX_ PreJ1.Ik,�r; r r r r 2 r, C r d11- Irv. nnn('.d'I rNPr 1117 6-50t 1-2, - r_ eek n drr� ' r r c.c� r A IrL 90,_ 111af t r 1 I`I 42nr -{�rc hor,rlw rn� oink. L bS 6 G r 2 n e, r�Se. ('r))rV-"r4 M C s rd- n �e,r�rC r r nTaraH7'. I Discussion With Person in Charge: Corrective Action Required: I ❑ No V Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction inspection, to observe all conditions as described, and to Exclusion violations before the next ins p 13 Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo Cr- Emergency Closure your food permit. O �l /t—�- ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk li 15 C 501 3- . 00u I Factors(Items 1.22) (Cont.) I g Methods for PHFs PROTECTION FRO w CHEMICALS 119 PHF Hot and Cold Holding 1 3-501.16(6) Cold PHFs Maintained at or below 114 I Food or Color Additives I 590.004(F) 41°/45°F* 3-202.12 Additives' I 3-501.16(A) Hot PHFs Maintained at or above 3-302.14 Protection from Unapproved Additives' I I 140°F * 115 Poisonous or Toxic Substances 13-501.16(A) Roasts Held at or above 130°F. 7-101.11 Identifying Information-Original 120 I Time as a Public Health Control Containers* I 3-501. Time aa Public Health Control* 7-102.11 Common Name-Working Containers* I 1 1 7-201.11 Separation-Storage` I 1590.0044((I I) Variance Requirement 17-202 11 Restriction-Presence and Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-202.12 Conditions of Use* I POPULATIONS(HSP) 7-203.11 Toxic Containers-Prohibitions` I 21 3-801.11(A) Unpasteurized)'re-packaged.fincesand 17-204.11 Sanilizers,Criteria-Chemicals* I BevcvaVs with Warning Labels' ` 17-204.12 Chemicals for Washing Produce,Criteria* I 3-801.11(13) Use of Pasteurized Eggs` 17-204.14 Drying Agents,Criteria* I 3-801.11(D) Raw or Partially Cooked Animal Food and 7-205 11 Incidental Food Contact,Lubricants* I Raw Seed Sprouts Not Served. 17-206.11 Restricted Use Pesticides,Criteria* I 3-801.11(C) Unopened Food Package Not Re-served' I 17-206.12 Rodent Batt Stations* I 7-206 13 Tracking Powders,Pest Control and I CONSUMER ADVISORY Monitoring* 22 3-603.11 1 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or I TIME/TEMPER\TURE CONTROLS Not Otherwise Processed to Eliminate 16 Proper Cooking Temperatures for Pathogens.*'"°'"' PHFs I 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* I 3-401.1IA(1)(2) Eggs- 155°F 15 Sec. i Eggs-Immediate Service 145°F15sec* SPECIAL REQUIREMENTS 3-401.1 I(A)(2) Comminuted Fish,Meats&Game I 590.009(A)-(D) Violations of Section 590.009(A)-(D) in Animals- 155°F 15 sec. ° 3-401.11(6)(1)(2) Pork and Beef Roast- 130°F 121 min* I catering; mobile food, temporary and residential kitchen operations should be 3-401.11(A)(2) Ratites, Injected Meats-155°F 15 sec I debited under the appropriate sections 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, above if related to foodborne illness Stuffing Containing Fish,Meat, interventions and risk factors. Other E ' Poultry or Ratites-IGS°F 15 sec. , 590.009 violations relating to good retail Ij t 13-401 11(C)(3) 'Agtole-muscle,Intact Beef Steaks I practices should be debited under#29- 145°F• Special Requirements, 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* I VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-401.11(A)(1)(b) All Other PHFs- 1450I' 15 sec. " (Items 23-30) 17 Reheating for Hot Holding I Critical and non-critical violations,which do not relate to the foodborne illness interventions and risk,lactorr listed above, can be 3-403.11(A)&(D) PHFs 165°F 15 sec. * found in the follmving sections of the Fond Code and 105 CMN 3-403.11(B) Microwave- 165°F 2 Minute Standing I 590.000. Time* I Item I Good Retail Practices FC 1 590.000 1 3-403.11(C) Commercially Processed RTE Food- 1 23, 1 Management and Personnel FC-2 1 .003 1 140°F" I 124. Food and Food Protection FC-3 1 .004 1 i 3-403.11(17) Remaining Unsliced Portions of Beef I 25. Equipment and Utensils FC-4 1 .005 1 Roasts` 1 26. Water,Plumbing and Waste FC-5 .006 i ( 28. Poisonous or Toxic Materials FC-7 .008 27. Physical Facility FC-6 .007 I 18 Proper Cooling of PHFs 3-501.14(A) Cooling Cooked I'IiFs from 140°I'l0 1 29. Special Requirements .009 I 70°F Widtil 2 Hours and Front 71 to 130. Other I ` 41*F/45°F Within Hours. * S3Wft­mas2 da 3-501.14(13) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°1' Within 4 Hours* 3-501 14(C) PHFs Received at Temperatures According to Law Cooled to 41°F/45°F Within 4 Hours t *Denotes entical item in the federal 1999 Food Code or 105 CMR 590-000. k CITY OF SALEM t BOARD OF HEALTH Establishment Name: &A-sv :2l1 a�l Date: 1J)/20/2Zd_C Page: of 7 Rom Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Referents R-Red Rem PLEASE PRINT CLEARLY verified Rea,— U CP f-,04 A I - 12_r7 6.�4112 akVY0_3 ' C rrc'oyer � / -C'54'2�1'd G / /e'a sank so4 I'S 1ie6 J 2 S� �-5b11L --Side_ wz;J k i h is rA Lk iofm rYLf2 40 4e. 6P_ 1ina I / !�4 -3tx,2ZLl 'A, e Ip e_s- ar crankerf Or i)ve- I n a 3 3o2,LL R s as t s to 113 G-3oa.Z2 � sb�p � � ` Crl, o �� ^hronf- ties�c Y10.S I'C� Scar fp v7 f�aw� nrl Cot.h�: S�nrei S'r_ pp_ t ire- L,.;A l",fl e. Z1CGbSe� or r'n n_-�,`rl -{�Na"E' 'Jzii Lots- •"r-� raarrha �CAr�'f-rd a�i'41'me oft s'Oec.�'inn,, I I I Discussion With Person in Charge: Corrective Action Required: I ❑ No Jes 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 dollarsAr suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: r� y Violations Related to Foodborne Illness Interventions and Risk j Factors(Items 1-22) (Cont.) I 3-501.15 Cooling Methods for PI IFs 19 PHF Hot and Cold Holding PROTECTION FROM CHEMICALS 3-501.16(B) Cold PHFs Maintained at or below 114 Food or Color Additives I 1590.004(F) 410/450 F* 3-202.12 Additives* I 3-501.16(A) Hot PHFs Maintained at or above 3-302.14 Protection from Unapproved Additives* I I 140°F. 1 115 Poisonous or Toxic Substances 3-501.16(A) Roasts Held at or above 130°P. * I 7-101.11 Identifying Information-Original Containers* � 20 ' Time as a Public Health Control I 3-501.19 Time as a Public Health Control* 7-102.11 Common Name-Working Containers" 1 7-201.11 Separation-Storage* 1590.004(H) Variance Requirement 17-202.11 Restriction-Presence and Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-202.12 Conditions of Use* POPULATIONS(HSP) 7-203.11 Toxic Containers-Prohibitions* ` 21 3-801.11(A) Unpasteurized Pre-packaged.Juices and 7-204.11 Sanitrr.ers,Criteria-Chemicals" I Beverages with Warning Labels* 17-204.12 I Chemicals for Washing Produce,Criteria* 3-801.1 I(B) Use of Pasteurized Eggs" 7-204.14 Drying Agents,Criteria* I 13-801.11(1)) Raw or Partially Cooked Animal Fond and i 7-205.11 Incidental Food Contact,Lubricants* I Raw Seed Sprouts Not Served. 7-206.11 I Restricted Use Pesticides,Criteria* I 13-801.11(C) Unopened Food Package Not Re-served. 7-206.12 I Rodent Bail Stations" 7-206.13 Tracking Powders,Pest Control and CONSUMER ADVISORY Monitoring* 22 3-603,11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw, Undercooked or TIME/TEMPER�TURE CONTROLS Not Otherwise Processed to Eliminate 16 Proper Cooking Temperatures for Pathogens.*Fe .,aaoo, PHFs 3-302 13 Pasteurized Eggs Substitute for Raw Shell Eggs" 3-401.1 IA(1)(2) Eggs- 155°F 15 Sec. Eggs-hmnediate Service 14501`15sec" SPECIAL REQUIREMENTS 3-401.11(A)(2) Comminuted Fish,Meats&Game 590 009(A)-(D) Violations of Section 590.009(A)-(D) in Animals- 155°F 15 sec. * catering,mobile food, lemporary and 3-401.1 l(B)(1)(2) Pork and Beef Roast- 130°F 121 min* residential kitchen operations should be 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec. debited under the appropriate sections 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, above if related to foodbome illness Stuffing Containing Fish,Meat, interventions mrd risk factors. Other Poultryor Ratites-165°F 15 see * 590.009 violations relating to good retail 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks practices should be debited under#29- 145°F* Special Requirements. 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 sec " (Items 23-30) .I 17 Reheating for Hot Holding Critical and non-critical violations, which do not relate to the foodborne illness interventions and rick factors listed above, can be 3-403.11(A)&(D) PHFs 165°F 15 sec. * found in rhe following sections of the Food Code mid 105 CMR 3-403.11(11) Microwave- 165°F 2 Minute Standing 590.000. Time* Item Good Retail Practices FC 590.000 1 3-403.11(C) Commercially Processed RTE Food- 123 Management and Personnel FC-2 003 I 140°F* 1 24 Food and Food Protection FC-3 004 I 3-403.11(E) Remaining Unsliced Portions of Beef 1 25. Equ omenl and Utensils FC-4 .005 I Roasts* 126. Water,Plumbing and Waste FC-5 .006 1 18 Proper Cooling of PHFs 27. Physical Facility FC-6 007 1 1 28. Poisonous or Toxic Materials FC-7 .008 I 3-501.14(A) Cooling Cooked PHFs from 140°I'to 29. Special Requirements .009 I 70°F Within 2 Hours and From 70°F to 30 Other 41°F/45°F Within HOmJ.* 559U.bxi42da 3-501.1403) Cooling PHI's Made From Ambient Temperature Ingredients to 41°F/45012 Within 4 Hours* 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41017/450F Within 4 Hours. * Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000 CITY OF SALEM BOARD OF HEALTH r7 Establishment Name: F.:0asy Date: &12o12/'L1-,e Page: of / Item Code C-Critical ttem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Deft No. Reference R-Red ttem Vert led oLense PRINT cl.eaaLr 276 SOS2 ��. 4 / r Q OA. .%P r 1 � X AA / G raaS'e�� rt ms•t � rv��� �n.✓ basis m r.rf �P_ w,.� � rma� Irv_.,-}�X 2.9 594 9 - 1� � 11 !t , 1 eI —�— (.l nneTcenr �'h� on 'ih� GririrSP ant ac TNe- cer- -i'd'- LcA flrl r1 r^�vi �Yl i r.i ie)"S n d'Oix 'V/9'�TLe { h2 PIC c Ua- Ae- e_r�Lb r5,n MnyN-{. s ja je-4 - - sa er-Pr a jtF �nyr i i i Discussion With Person in Charge: I Corrective Action Required: I o Not�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 El Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of t�enty-fiv dollar or pension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk 3-501 15 Cooling Methods for PHFs Factors(Items 1.22) (Cont.) I 1 9 PHF Hot and Cold Holding PROTECTION FROM CHEMICALS 3-501.16(6) Cold PITFs Maintained at or below r 114 Food or Color Additives 590.004(F) 410/45017* 3-202.12 Additives* 3-501.16(A) Hot PHFs Maintained at or above 3-302.14 Protection from Unapproved Additives* I 140°F , 15 Poisonous or Toxic Substances 13-501.16(A) Roasts Held at or above 130°F 7-101.11 Identifying Information-Original 120 Time as a Public Health Control Containers* 3-501.19 Time as a Public Health Control* 7-102 11 Common Name-Working Containers* 1 1590.004(1{) Variance Requirement 7-201.11 Separation-Storage* 7-202.11 Restriction-Presence and Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-202.12 Conditions of Use* POPULATIONS(HSP) 7-203.11 Toxic Containers-Prohibitions* 121 3-801.11(A) Unpasteurized Pre-packaged.luices and 7-204 11 Sanihzers,Criteria-Chemicals* t Beverages with Warning Labels* 7-204.12 Chemicals for Washing Produce,Criteria* 3-801.11(8) Use of Pasteurized Eggs* I 17-204.14 Drying Agents,Critena* 13-801.11(D) Raw or Parially Cooked Animal Food and 7-205.11 Incidenlal Food Contact, Lubricants* Raw Seed Sprouts Not Served. 17-206.11 Restricted Use Pesticides,Criteria* 3-801.11(C) Unopened Food Package Not Re-served ` 7-206.12 Rodent Bait Stations* r 17-206 13 Tracking Powders,Pest Control and CONSUMER ADVISORY Monitoring* 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or TIMEITEMPERIATURE CONTROLS Not Otherwise Processed to Eliminate t 116 Proper Cooking Temperatures for I Pathogens* PHFs 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs 3-401.11A(1)(2) Eggs- 155°F 15 Sec. ? Eggs-Immediate Service 145°F15sec* SPECIAL REQUIREMENTS 3-401.11(-4)(2) Animals- 1d 'F 1 Meats&Game I 590.009(A)-(D) Violations of Section 590.009(A)-(D) in Animals- 155°F IS sec. * 1 catering, mobile food, temporary and 3-401.11(6)(1)(2) Pork and Beef Roast- 130°P 121 min* residential kitchen operations should be ' 3-401.11(A)(2) Ratites, Injected Meats-155°F 15 sec debited under the appropriate sections 3-401.11(A)(3) Poultry,Wild Game,Stunted PI-117s, above if related to foodborne illness Stuffing Containing Fish,Meat, interventions and risk factors. Other Poultry or Ratites-165°F 15 sec. * 590.009 violations relating to good retail yam" 3-401 11(C)(3) Whole-muscle,Intact Beef Steaks practices should be debited under#29- - 145°F* Special Requirements. 1 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES I 3-401.11(A)(1)(b) All Other P14Fs- 145°F 15 sec. * (Items 23-30) 117 Reheating for Hot Holding I Critical and non-critical violations, u/rich do not relate to the foodborne illness interventions and ri.sk/aclors!ivied above, can be 3-403 11(A)&-(D) PHFs 165°F 15 sec. * /onnd in rhe following sections of the Fond Cade and 105 CMR 3-403.11(6) Microwave- 165°F 2 Minute Standing I 590.000 Time* I Item Good Retail Practices FC 590.000 I 3-403.11 C Commercial) Processed RTE Food- ( ) Y 23. Management and Personnel FC-2 .003 I 1400I7* 124. Food and Food Protection FC-3 .004 3-403.11(E) Remaining Unslieed Portions of Beef 1 25. Equipment and Utensils FC-4 __ .005 Roasts, 26. Water,Plumbing and Waste FC-5 .006 I 1 27. Physical Facility FC-6 .007 I IIS Proper Cooling of PHFs I 1 28. Poisonous or Toxic Materials FC-7 .008 i 3-501.14(A) Cooling Cooked PHFs from 14001-'Io 1 29. Special Requirements .009 I 700I7 Within 2 hours and From 70°F to 30. Other 41°F/450F Within 4 Hours. * sesor�.as:as 3-501.14(6) Cori PHFs Made From Ambient Temperature Ingredients to 41°1745°I' Within 411ours* 3-501 14(C) PI-JFs Received at I'emperamres Accordine to Law Cooled to 410F/450F Within 4 (lours. *Denotes critical item in the ledeml 1999 Food Code or 105 CMR 590.000. I+ City of Salem, Massachusetts IV { , + Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PhUCHP.aI�I health@salem.com Prevent. Promote. Protect. Kimberley Driscoll Larry Ramdin, MPH, REHS, CHO Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2017 Permit Number: FM-16-508 Permit Type: Food Establishment>99 seats Goods& Services: I Food Service: >99 Name of License Holder: FANTASY ISLAND / Deborah Lam Name of Food Establishment Fantasy Island Restaurant Address of Food Establishment 516 Loring Avenue Salem MA 01970 Restrictions: This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2017 unless sooner suspended or revoked. Permit Fee: $0.00 Effective: 1216/2016 Larry Ramdin, MPH, REHS, CHO Health Agent r CITY OF SALEM, 10 MASSACHUSETTS txeatch BOARD OF HEALTFI •,••'�,.••�,• ••,•" 120 WASHINGTON SIREET,4TH Ft,00R KIMBERLEY DRISCOLL TFL.(978)741-1800 FAx(978)745-0343 LARRY RANIDIN,RS/RENS,CHQ,CPd+S MAYOR health@salem.com Hr ALTH AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: P -m-s ! �T/ v*'V 19 � ✓ ! A�iL�''J� 2) Establishment Address: -1 � k7l /'fJ 6 A V r-- 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: d [ ' /�'�� -7 0 0 5) Applicant Name&Title: D 0 6) Applicant Address: I S-- � �/j�M I /vs TeyL � {{�/1�rjLC� �� /y,+D 1 q Yid 7 Applicant Telephone o: 3 l �b y3 24 Hour EmergencyNo: �6 �3 EmaP '6 D LSI PP P Q Ml. r OM 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address mor oration r� An individual Pu A partnership I n I Other legal entity 12) Person Directly Responsible 7�For .Daily nOperations(Owner, Person in Charge, Supervisor,Manager,etc.) Name&Title: D c�O ,v�l L 'p`V vv rfi-6�" I 7 A , Address: "I 7M //� S�L�, r J M �7� n gra i r z kl9 ` -- Telephone No: 1& 1-7 e-�Lf67.3, /Fax: Email: l/�+J 1� � � &C6 i1 h Emergency Telephone No: I ( I 7 � 6 3 -1 S- 1-�,3 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: "I Date: (�1 v �/4 Amount, q� dv Food Establishment Information 14) Water Source: G( 7 y 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) G( T y c . hnn —/12o MoN--CµurZ It - sem —1 ( 5L) 16) Days and Hours of Operation: Ft-L ,k-7 17) No.of Food Employees: Z 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): &-Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) Dge tall( Sq. Ft) ❑Caterer ,. a manent Structure LT I-ood Service—( Seats) ❑ Frozen Dessert Manufacturer Mobile O Food Service—Takeout O Residential Kitchen for Retail Sale O Food Service—Institution ❑ Residential Kitchen for Bed and ( MealslDay) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: ---------------------------------------------------------•-______ ___ Breakfast Establishrnents_......-____._-_,,,-- (check one) RETAIL STORE RESTAURANT Annual ❑ Less than 1000sq.ft. $70 ❑Less than 25 seats $140 Seasonal/Dates: 0 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑More than 10,000sq.ft. $420 ❑25-99 seats $280 ire than 99 seats $420 Temporary/DatesMme: ❑B-ed- --8---B-----reak-t---as-U---------------Childcare Se--S"erv--ices---------/Nursing H-...-----------om----e....------------ .............. .---------------- $..100---....... ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF—potentially hazardous food(time/temperature controls required) Non-PHFs—non-potentially hazardous food(no time/temperature controls required) (check all that apply): RTE—ready-to-eat foods(Ex.sandwiches,salads,muffins which need no further orocessing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill l Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs I Juice Manufactured and Packaged for I Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 0 ��b ( i /C 26) Signature of Individual or Corporate Name: ell QUESTIONAIRE -GREASE TRAPS 2013 1. NAME OF ESTABLISHMENT: '�y �S } °J F-f-SlAmm"JI 2. ADDRESS OF ESTABLISHMENT: �5 /Mb 1� 7 v 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? / G i 4. WHAT SIZE GREASE Tr DOES YOUR ESTABLISHMENT HAVE? � ( 720Z� CAPACITY IN GALLONS /O (o &A-L��A-) o-,�- S. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? •7R`( q), �S ✓( G� G' uM / ' j6- f �t'�'f �1 �O NL 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? The Commonwealth of Massachusetts Printfoi i,':4 Department of Industrial Accidents Office of Investigations 91 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information ,, n '' Please Print Leeibly r,rr Business/Organization Name: �►' tOA`-y Address: 7/ LA h4 /J lD AV 'L City/State/Zip: S Q�/(/C K1 Pr_0 I9_ Phone#: q7bp 7 'T S- 7 Aree yo an employer? Check the appropriate box: Business Type(required): 1.�Q I am a employer with employees(full and 5. El Retail orpart-time).* 6. estaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp. insurance required] $• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers'comp.insurance required]** 11.❑ Health Care 4.E] We are a non-profit organization, staffed by volunteers, with no employees. [No workers'comp.insurance req.] 1211 Other *Any applicant that checks box#1 most also fill out the section below showing thein workers'compensation policy mfomration. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that isproviding workers'compensation insurance for my employees Below is the policy information. Insurance Company Name: krL 6Z�I/L 1� 0"f7!1_7 ( o k) 1-0 S Lp Insurer's Address: [ f 0 12 L 20 W A] C 0 L 0 4) y /.7 /2 City/State/Zip: ()--ti.-/O C__y k A— 0 L"" `j — q [ 7 � Policy#or Self-ins.Lic.# b rt4 1 3 p 0 I Expiration Date: 0 b I d 1 7 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify,under the pains and p allies ofperjury that the information provided above is true and correct. Simature: 01_L�t/'-r 'iDate: II Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple permit/icense applications in any given year,need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Foran Revised 7/2010 f ` Arbella Protection Insurance Company 1100 Crown Colony Drive, Quincy, MA 02269-9174 A R B E L L A° PROiECiION INSY Rq HCE CONP/,NV '4rORKERS COMPENSATION AND EMPLOYER'S LIABILITY POLICY INFORMATION PAGE 1; Policy Number-- -- -- -- er . Transact- -ion Effective Date Bill Type 4220054138 01 RENEWAL 06/01/2016 Direct Bill 1. Ned Insured ana Mailing Address J' Agent JAgent - ----am _ -- -- _ __1 28-697 FANTASY ISLAND RESTAURANT HUB INTERNATIONAL NEW ENGLAND LLC 516 LORING AVE 299 BALLARDVALE ST SALEM, MA 01970 WILMINGTON, MA 01887 Phone #978-657-5100 All workplaces are shown on an attached schedule. 2. Policy Period at 12:01 A.M. Standard at Address of Named Insured From: 06/01/2016 To: 06/01/2017 Form of Business •Business Description Corporation RESTAURANT 3. A. Workers Compensation Insurance: q $, -Part One of the policy applies to the Workers Compensation Law of the states listed here: rr Massachusetts 3. _13—Employer's Liability Insurance: Part Two`of—the-policy applies to work in each state listed in Item 3:A. The limits of our Liability under Part Two are: Bodily Injury by Accident $500,000 a Each Accident �~ Bodily Injury by Disease $500,000 Each Employee Bodily Injury by Disease $1,000,000 Policy Limit 3. C. Other States Insured: Part Three of the policy applies to the states, if any;listed here: . Connecticut New Hampshire Rhode Island J 3. D., This policy includes these endorsements and schedules: J, r WC000000C WC000406A WC 00 04 14 WC000422B WC 20 03 01 WC200302A WC200303D WC 20 04 05 WC 20 06 01 A 4. -- The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans:t" All information required on the attached Information Page Extension n is subject to verification`and change by audit. Minimum Premium Total Estimated Premium J $294 $5,592 HUB international New England, LLC Countersigned by By:_ r a Date 68 AP 1021 01 16 4220054138 01 05/03/2016 Page 1 V,. -" ,�A�i' ''��a Y,,,� y_ ,a�•`�Y � ,?���:v;6 ago[ Y ��V': r�r�t� - .l- 4x'f : ,,.• 4 r ',A'r'ti+ t�., +M. 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'. ,;�. :.'1!,,Lt I� 3 CITY OF SALEM, MASSACHUSETTS Mnm BOARD OF HEALTH • KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4"FLOOR MAYOR TEL.(978)741-1800 FAx(978)745-0343 LARRY RAMO N,RS/REHS,CHO,CP-FS LRAMDIN(0)SALEM.COM HEALTH AGENT COMPLAINT INTAKE FORM Date: Iv I I l I I Time: Received By: Complaint Number: 1959 Complainant /AO nIln SU 'N') Address: F-"t4a'`S —1-5IGn Phone: ��� GrG IlCAhGre�A k-�T� w . • /� Investigated By: J"ev �5�✓AW Date: C I Property Owner/Occupant Name Telephone #: FOOA I P nspec'L'totjo r for 101D Z0-tb� Ql� l )avinU� • COND12���J City of Salem, Massachusetts lu Board of Health 3 9 120 Washington Street, 4th Floor, Salem, MA 01970 T,A'nC a.F D Pie Tel. (978) 741-1800 Fax. (978) 745-0343 PublicHealth Iramdin@salem.com Prevent. Promote, Protect. Kimberley Driscoll Larry Ramdin, MPH, REHS, CHO Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2016 Permit Number: FM-16-32 Permit Type: Food Establishment>99 seats Goods&Services: I Food Service: >99 Name of License Holder: Fantasy Island- Deborah Lam Name of Food Establishment Fantasy Island Restaurant Address of Food Establishment 516 Loring Avenue Salem MA 01970 Restrictions: This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2016 unless sooner suspended or revoked. Permit Fee: $420.00 Issued: 1/1/2016 CITY OF SALEM, MASSACHUSETTS I�,bttoHeatcb BOARD OF Hum,PFI 120 WAS]IINGPON S'11UT1 r,4m FLnoR KIDIBERLEY DRISCOLI, Thr.(978)741-1800 Fns(978)745-0343 L\I1RY HAMI)IN,HS/RF I IS,Cttc I,Ch-I'S MAYOR IramdinOsalernxom HIS,\I;1'I-I AGFNI' Food Establishment Permit Application (Application must be submitted at'least /30 days�before the planned opening date) 1) Establishment Name: /�/ 7 X/ 2) Establishment Address: 7 tP t--0 ��(0 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: t-7 C/ -7 1 -70 Q 5) Applicant Name&Title: ©r_hI,I— I,-,t UI r tz / I-D 1� 6) Applicant Address: '( Ss3 �(s�6z3 lot ? 3 PzlSTlGfl�l �.co 7) Applicant Telephone o: 24 Hour Emergency o: Email: 8) Owner Name&Title(if different from applicant): J 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. aarra-ssociation Name Title Home Address A individual it OA4q G� P/Zc (S �1/`//NS ��K An individual VVG� A partnership Other legal entity 1� 12) Person Directly Responsible For Daily Operations(Owner, Person in Charge, Supervisor,Manager,etc.) ( Name&Title: I Address: I��'Ili✓p �7 (Mfi/ucSTp Telephone No: 6 I / 0 ?7���rZ3 Fax: l -` I v�mail:D� Emergency Telephone No: I 7 9--3 1( 5 6 Z3 I13) District or Regional Supervisor(if applicable) Name&Title: Address: 1� Telephone No: Fax: Email: ; Check#: 1k- N Date: I vI IIS Amount Y _ Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) C,[ Ty kto )- � Y7u y!+ r (r 10 16) Days and Hours of Operation: St4kl / Y&-D i13v 17) No. of Food Employees: 16) Name of Person in Charge Certified in Food Protection Management: (,(qyv(y `/ON L—P-0 NG­rti 7-0 6"(0 0� Required as of 101112001 in accordance with 105 CMR 590.003(A) ��fly�o 44( („*M �, 2-0 6G 7�j�'r 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): FfYes No 20) Location: 22) Establishment Type(check all that apply) (check one) O Retail( Sq. Ft) ❑ Caterer t4ve'rmanent Structure E ood Service-( Seats) ❑ Frozen Dessert Manufacturer Mobile food Service-Takeout 17 Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home LyFrfod Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: -----------------------------------•--------------------------------...-. .Breakfast Est__a_b__I_i_shm_ ents... ............,...... RETAIL STORE RESTAURANT (check one) 13 Less than 1000sq.ft. $70 ❑Less than 25 seats $140 n131000-10,000sq.ft. $260 ❑Residential Kitchens $140 Seasonal/Dates: ❑More than 10,000sq.ft. $420 ❑25-99 seats $260 La-More than 99 seats $420 Temporary/Dates/Time: - ---- --- --- ---- -- -- -- ----- ------------------- -------------------------------------------------------------------- ❑ Bed 8 BreakfastlChildcare Services(Nursing Home $100 --------------------------------------------............................ ...... ............... ....... -------------- ......-- ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT' $25 `Including, church kitchens, state funded childcare 8 Drivate club 23) Food Operations: Definitions: PHF-potentially hazardous food(t/meltemperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperatum controls required) (check all that apply): RTE-ready-to-eat foods(Ex.sandwich,s,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly 1 Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially I Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs I Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be comoleled by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A,I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law... 25) Social Security Number or Federal ID: o `Il , (° s Q q 26) Signature of Individual or Corporate Name: T)�J v Client#: 1747 FANTASYISL ACORD. CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDIYYYY) 05/06/16 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Certificate Desk HUB International New England LLC jaICD."No.Eat/ 978 657-5100 (AIAc,Ncl. 866 475-7959 299 Ballardvale Street E-MAIL ss: nee.certificates@hubinternational.com Wilmington, MA 01887 978 657-5100 INSURERS)AFFORDING COVERAGE NAIC0 INsuRERA:Arbella Protection Ins.Co. INSURED INSURER B: Fantasy Island Restaurant Debbie Lam INSURER C: 516 Loring Avenue (INSURER D: Salem,MA 01970 INSURER E: INSURER F: 1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED 3Y PAID CLAIMS. IILTRR TYPE OF INSURANCE (NSB MD POLICY NUMBER fBR MMID0Y�1 1POLICY VLDDY�I LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PAEMISES(Ea NTEental $ CLAIMS-MADE u OCCUR MED EXP(Any one person) $ PERSONALS ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPL�IES PER (PRODUCTS-COMPIOP AGG $ 1 POLICYIPE T ILOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT IS — fEa scarcer, ANY AUTO BODILY INJURY(Per person) Is ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ( I HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Peracutlenp $ $ UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS UAB H CLAIMS-MADE AGGREGATE $ OED RETENTION$ $ WORKERS COMPENSATION TORY IAM TSI �RH AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE❑ IEC EACH ACCIDENT Is OFFICERIMEMBER EXCLUDED'! NIA (Ma clatory in NH) I E.L DISEASE-EA EMPLOYEEI$ If yes,describe order DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT I S A Liquor Liability 8500064167 5/06/16 05/06/17 Each Occur$1,000,000 Coverage Aggregate $2,000,000 DESCRIPTION OOF OPERATIONS I LOItTI6W1JM Y[ES� tt ORD 101,Additional Remarks Schedule,if more apace is required) Evidencin Li uor Liabili sC e I antas Island Restaurant located at 516 Loring,Avenue, Salem,MA 01970. JUN 02 2016 v1- 80ARUI OI- HtALTH CERTIFICATE HOLDER CANCELLATION Town of Salem,MA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington Street ACCORDANCE WITH THE POLICY PROVISIONS. 3rd Floor Salem,MA 01970 AUTHORIZED REPRESENTATIVE I ._ F ';�).. @ 1988.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1621309/M1621307 JE001 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. q,1� � (I � (j Name Date - ^ ype • Operafion(s) Type of Inspection n f ' ' LU"Food Service ❑ Routine Address` ( tN rsk ❑ Retail Me-inspection Telephone �q Level ❑ Residential Kitchen Previous Inspection R o7) ❑ Mobile Date: h' ^^^ ❑ Temporary ❑Pre-operation Owner I '.Y ' HACCP YIN C 171/1 n I ❑ Caterer [I Suspect Illness Person-in-Charge(PIC) 1 � � Timer ❑ Bed&Breakfast [I General Complaint 1, ❑ HACCP Inspector 11, �t r.� I^ Permit No. ❑Other ach violation checked requir 'ss�an explanation on the narrative page(s)and a citation of specific provision(s)violated. V Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ �. ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD PROTECTION MANAGEMENT q13. . Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/Duties Handwash Facilities EMPLOYEE HEALTH F-12. Reporting of Diseases by Food Employee and PIC ECTION FROWCHEMICALS El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives ❑ 15.Toxic Chemicals FOOD'FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS Potentially Hazardous Foods ❑ 4. Food and Water from Approved Source ( ) ❑ 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 ❑ Health Con r I 8. Separation/Segregation/Protection El20. Time as a Public ea t o ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPULATIONS'.(HSP): 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP ❑ ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions Immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.0001federal Food Code.This report,when signed below FC-N by a Board of Health member or its agent constitutes an 24. Food and Food Protection l 23. Management and Personnel (FC-2X590.0 4)) order of the Board of Health. Failure to correct violations (FCcited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-4(590.00)(sao oo5) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (r-cs)(59o.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590 007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receiat of this order. 30. Other DATE OF REINSPECTION: ^' _�/1 Inspector's Signature: - Print: mil X/I PICsSignatures I Print: t'�'j) Pagelof4ages Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(.A)(]) Raw Animal Foods Separated from I 1 590,003(A) Assignment of Responsibility* I Cooked and RTE Foods" 590.003(Bl I Demonstration of KmwJedge" i Contamination from Raw Ingredients ( 2-103.11 I Person in charge-dimes 1-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of"the person to charge to 3-30111(A) Food Protection" require reportutg by thisd employees and 3-302( IS Washing Fruits and Vegetables i applic:antc* 3-304.11 Food Contact with Equipment and 590.003(1`) Responsibility Of A Food L•mployee Or An I Utensils* Applicant To ReportTo 7lie Person In Contamination from the Consumer Cporti 5 j 3-306.141 A)(B) Returned Foal and Reservice of Food* cH)fN)3(G) Reporting by Person n Charge* Disposition ofAdulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* I Food 590.003(F) I Removal of P.aclusions and Reatrictions ( 3-701.1 I Disearding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fond 41 I Food and Water From Regulated Sources I 19 I 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" 14-501.1 12 Mechanical Warewashing-(lot Water 3-202.13- - - Shell Eggs* I Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurim& I 4-501,114 Chemical Sanitization-teutp.,pH, concentration and hardness. r 3-202.16 Ice Made Front Potable Drinking Water" 4-601,11(A) Equipment Foul Contact Surfaces and 5-101.11 Drinking Waterhurn an Approved System' Utensils Cleats 590.006(A) Bottled DrinkingWater" I 14-602.11 Cleaning Frequency of Equipment Fund- 1590.00o(B) 1Vater Meets Stvui;ude in 31D�b1R 22.1)" Contact Surfaces and Utensils* Shellfish and Fish From an Approved Sourc^ 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 l kaod Chemical* Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by j Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* I 3-202.1 Shellstock Identification Present* i 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* i 2-101.14 When to Wash* 3-201.17 Game Animals* j I it Good Hygienic Practices S j Receiving/Condition i '2-401.1 1 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures" l 2401,12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* - Mouth* 3-101.11 Food Sate and Unadulterated ,. 3-301.1^_ Preventing Contamination When Tasting* I � I 16 I Tags/Records:Shellstock 112 Prevention of Contamination from Hands 13-202.14 Shellstock Identification* I 590.004t,E) Preventing Contamination from 3-203.12 Shellstock identification Maintained* Employees* TagstRecords: Fish Products I ( 13 I Handwash Facilities 3-402.11 I Parasite Destruction* Convenlenhy Located and Accessible 3-402.12 Records,Creation,and Retention* 15-203.11 Numbers and Capacities* i 590.004(,0 Labeling of Ingredlents' j 15-204.11 location and Placement* i 7 Conformance with Approved Procedures I j 5-205.11 Accessibility,Operation and Maintenance I IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging.criteria* 16-301.11 Handwashing Cleanser,Availability I 18-103.12 Conformance with Approved Procedures* 16-301 12 Hat) Drying Provision r Denotes critirai item in the federal 099 Foid Code ur 105 CNIR 590.000. CITY OF SALEM � nn BOARD OF HEALTH / Establishment Name: Date: Page: of C{J Item Code C-Critical Item lJ DESCRIPTION OF VIOLATION/PLAN OF CORRECTION �^ Date -- No. Reference R-Red Item 1,JJ .rye verified PLEASE PRINT CLEARLY _ _ oL_C��t� � �+�,Q It V�- F Ia M /� I%1/ In_ /t //11S� Lr .Uf ° d1C-� 66I IL. rjv l�X/M /O.vt a 1 On� 1C9�16� a �n lire � A .. An C�` 1 C �<o�U2�1,6 �IYX t,[ _PtA L 0',rn, A OV- tn1 O'Ll . Av 4y1 ;�` ( A/Y �. Skim QO 4 n/ .CSD I ✓ CO I v 4. (1n .Alibi I t�CJ7/�_/ - /7(/ LW, \ k/ a- 6?17 1 0-CX A l I V t r ®/L Discussion With Person in Charge: C7ective Action Required: I ❑ No IUY fes I have read this report, have had the opportunity to ask questions and agree to correct all ary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and toExclusion P :o/e'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 susp ,ion/revocation of ❑ Embargo ❑ Emergency Closure .your food permit. Wn 0 X / /{ LlVoluntary Disposal 0 Other: 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodborne Illness,IntemenHons and Risk According to law Cooled to Factors(Items 1-22) (Cont.) 41°F145°F Within 4 Hours. PROTECTION FROM CHEMICALS I 3-501.15 Cooling Methods for PHFs I 114 I Food or Color Additives I 119 PHF Not and Cold Holding I 3-501.16(B) Cold PHFs Maintained at or below 13-202.12 Additives* , 590.004(F) 4101450 F* 3-302.14 Protection from Uoapnrmed Additives* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 1 1400E * 1 7-101.11 Identifying Information-Original 13-501.16(.4) Roasts Held at or above 130`F. " I Containers* ( 20 Time as s Public Health Control 17-102.11 Common Name-Working Containers* 1 3-501.t9 Time as a Public HealthHealth Control* 1 77-201.11 Separation-Storage* j { 7-202.11 Restriction-Presence and Use* 1 590.004(H) Variance Requirement i 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 17-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.1' Sanitizers.Criteria-Chemicals* * i 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.1_ Chemicals for Washing Produce,Criteria Beverages with Wanting Labels* 7-204.14 Drvina Agents.Criteria* 3-801.21tB) Use raPasteurized Eggs" I 7-205.11 Incidental Food Contact,Lubricants* j 3-801.11(D} Raw or Partially Cooked Aninud Food and 7-206.1 t Restricted Use Pesticides,Criteria* I Raw Seed Sprouts Not Served. 7-206.12 Rodent Bair Stations* 1 3-801.11(C) Unopened Food Package Not Re-served. i 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEtIEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 I Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked m' PHFs Not Otherwise Processed to Eliminate 3-401.I1A(t)(2) B 155`F 15 Sec. Pathogens.*FL .'moor Eggs-Immediate Service 145°FISsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&.Game Bgzs* Animals-155°F 15 sec.* SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A){D) Violations of Section 590.009(A)-(D)in 3401.11(A)(2) Ratites,injected Meats-155°F 15 sec. catering,mobile food,temporary and 3401.1 t(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * I above if related to foodborne illness 3403.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F m 1 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Conked in a practices should be debited under#29- Microwave 165°F* I Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145F 15 sec:.* 17 Reheating for Hot Holding VIOLATIONS R iLATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165°F 15 sec.* I (Items 23-30) 3403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do nor relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°P'P 590.1100. 3403.11(E) Remaining Unsliced Portions of Beef 1, Rom i Good Retail Pracdces I FC 1580.000 Roasts* 123. Manaoement and Personnel I FC-2 .003 118 Proper Cooling of PHFs 1 24. Food and Food Protection FC-3 .004 1 25. Equioment and Utensils FC-4 005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water.Plumbum and waste i FC-5 .006 70°F Within 2 Hours and Front 700E 27, Physical Fac ltv FC-6007. ; to 41°F/45'F Within 4 Hours. * 1 28. Poisonous or Tock Materials ' FC-7 � .008 j 3-501.14(B) Cooling PHFs Made From Ambient ( 29. Special Requirements ' 009 Temperature Ingredients to 41°F/45°F 1 30' Other 1 Within 4 Hours* *motes critical item in the federal 1999 Fcad Code or 103 0NIR 590.(()1. CITY OF SALEM n n BOARD OF HEALTH Establishment Name: Date: Page: of Item Code ' C-CHI]Cal Item (� _ _. DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified c�\ LEASE PAINT CLEARLY C ` _ ,o K10 (AZ&3,z_,P D. nit a 0 ! I I V P Y14�m..4 /f� - , amm Z—"W' Ci,Lc�l�� _ M iQ v r A �TSl�PM�lOnt.�' � �pQ�_.U/1. �1,� b , Q,o�` ♦i� - — I �l I I Discussion With Person in Charge: Corrective Action Required: No I t] 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 under a d that noncompliance may result in daily fines of twent -five d ars or ension/revocation of I ❑ Embargo ❑ Emergency Closure your food permit. �vj' ❑ Voluntary Disposal ❑ Other: ry I _ 3-i()1.14(0 PHFs Received at Temperatures Violations Related to Foodborne illness.Interventions and Risk According to Law Cooled to Factors(ftnis t-22) (Cont.) 41°F(45°F Within 4 Hours. PROTECTION FROM CHEMICALS { 3-501.15 Cooline MethtxLs for PHFs 14 ( Food or Color Additives { ( 19 PHP Not and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below ( 3-202.12 Additives* ( 5g0,004(F 43°145°F* 3-302.14 Protection from Unapproved Additives* i 3-501.16(Al Hot PHFs Maintained at or above f ( 15 Poisonous or Toxic Substances 140°F * i 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Field at or above 130°F. Containers* ( 20 Time as a Public Health Control ( 7-102.11 Common Name-Working Containers* 1 01.11 Separation-Storage" { 3-501.590.004(4(Hi Variance Requirement as a Public Health Control* r { 4 7-202.11 Restriction-Presence and Use* I ( 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ( 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) ( 7-204.11 Sanitizers.Criteria-Chemicals' ( 11( 21 3-801. .4} Unpasteurized Pre-packaged Juices and ( 7-204.12 Chemicals for Washing Produce,Criteria' i Beverages with Warning labels" ( 7-204.14 Ihring Agents-Criteria, i 3-801.11(B) Use of Pasteurized Egn* ( 7-205.11 Restricted tedal Fddd Contact, .Criteria* 3-801.11(0) Raw or Partially Cooked Animal Food and ( 7-206.11 RestriMed Use Pesticides.Criteria* ( Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* , ( 3-801.1)(C) Unopened Food Packam Not Re-served. 7-206.13 Tracking Powders,Pest Control and `f Momton»a CONSUMER ADVISORY 7IMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Aminal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3401.11A(t)(2) Eggs- 155°F 15 Sec. I Pathogens,' Eggs-Immediate Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game { Egxs* Animals-155°F 15 sec. f SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 3-401.1 l(A)(2) Ratites,Injected Meats- 155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in scc.* catering,mobile food,temporary and 3.401.1 t(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3-403.11(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 Foals Cooked in a practices should be debited under#29 - Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PAFs-145°F 15 sec, ( 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165°F 15 sec.* (Items 23.30) 3-403.11(6) Microwave- I65°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.I i(E) Remaining Unshood Portions of Beef float I Good Retail Practices I FC 1590.000 1 Roasts* 1 23. Manacement and Personnel FC-2 .003 I j 18 Proper Cooling of PHFs { { 24. Foal and Food Protection FC-3 .004 ! 25. I Eguipmam and Utepsifs ( FC-4 .005 i 3-501.14(A) Codling Cooked PRFs from 140°F to 126. Water.Phrmbino and Waste i FC-5 .006 70°F Within 2 Hours and Front 70°F 27. Phvsical Facility FC-6 .007 to 410F/45T Within 4 Hours. * i 28. Poisonous or Toxic Materials `, FC-7 008 i 3-501.14(B) Cooling PRFs Made From Ambient 29. ( Special Requirements 009 I Temperature Ingredients to 41°F/45°F I X I Other Within 4 Hours* rXnotus crhical item in the federal 1999 Fend Cale or 105 CMR 590A)0. CITY OF SALEM 4 p BOARD OF HEALTH 'f Establishment Name: Date: `d - .�1) (.� Page: of Y— Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY d Q n9ad 4 Cr v - A,( len A�p I 0 '4 0,6 � 5\A ,p��. a.,.� mil 47 �y 19 AA Discussion With Person in Charge: Corrective Action Required: I ❑ No ❑L fes f 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 finetwenty-five dollars or sus p /revocation of ❑ Embargo ❑ Emergency Closure .your food permit. I(�V / ❑ Voluntary Disposal ❑ Other: l i --- .r .,�,.... � �' � -.. • i n'rti.��_ ."w^'Yxa Jr Ya^Y ti.-..r - -a.,rte, �.- "� , r��+_'Y,�a- _.. I . 3-501.14(C) PHFs Received at Temperatures Violations Relater!to Foodborne Illness interventions and Risk According to Law Cooled to Factors prams 1-221 (Cart.) 41°F/45°F Within 4 Hours, 3-501.15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS 1 19 PHF Hot and Cold Holding 4 Food or Calor Additives 3-501.36(B) Cold PHFs Maintained at or below 3-202.12 Additives* j 590.004(F) 410145'F* 3-302-14 Protection from Unanproved Additives* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances I 14U`F. 7-101,11 Identifying Information-Original 3-501.16(.9) Roasts Held at or above13WR Containers* ( lA rime as a Public Health Control 7-102.11 Common Name-Working Containers* 3-501.19 Time as a Public Health Control* i 201.11 Separation-Storage* 590.U04(H) VarianceRegnrement 7-202.11 Restriction-Presence and Use* Z 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* , POPULATIONS(HSP) 7.204.11 Sanitize".Criteria-Chemicals* 21 3-80I.11(A) Unpasteurized Pre-packaged Juices and 7-204.13 Chemicals for Washing Produce,Criteria* i Beverages with Warning labels* 7-204.14 Drying Agents.Criteria* 3-801.1 I(B) Use of Pastemized Eggs* 7-205.11 Incidental Foal Contam lubricants* ( 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206,11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served. J 7-206.12 Rodent Bait Stations* t 3-801A I(C) unopened Food Package Not Rc-served. 7-206.13 Tracking Powders,Pest Control and Momtonng'* CONSUMER ADVISORY TIME[TEMPERATURE CONTROLS 22 3-603.11. Consumer Advisory Posted for Consumption of 16 i Proper Caok9ng Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.*`"°""°'"2°01 3-401.11A(i)(2) Eggs- 155°F 15 See. Eggs-Immediate Service 1450FlSsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 3-401.11(A)(2) Comminuted Fish.Meats&Creme Animals-755°F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Park and Beef Roast- 13"121 min* 3401.11(A)(2) Ratites,Injected Meats-155'F 15 590.OU9(A)-(D) Violations of Section temporary and in sec. * catering,mobile food,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, ! residential kitchen operations should be Stuffing Containing Fish,Meat, J debited under the appropriate sections Poultry or Ratites-1650F 15 sec. * f above if related to foodborne illness 3-101 rll(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 Corked in a practices should be debited under#29- Microwave 165°F s Special Requirements. 3401.11(A)(1)(b) All Other PRFs-145°F 15 sec. 17 Reheating for Hot Holding I VIOLATIONS R 5LATED TO GOOD RETAIL PRACTICES 3403•!I(A)&(D) PRFs I65°F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 1 3-403A I(C) Commercially Processed RTE Foul- found in the follnndng sections of the Food Code and 105 CMR 1400F* 590.000, 3403.11(E) Remaining Unsticed Portions of Beef 1 Hem i Goad Retail Practices FC 590.000 j Roasts` 23, 1 ManNemant and Personnel FC-2 .043 18 Proper Cooling of PHFs t i, 24, j Food and Ford Protection FC-3 .004 125. j Equiament and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. 1 Water.Plumbing and Waste i F0_5 ow f 70°F Within 2 Homs and From 70°F 27, ( Physical Fac6v 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 i 29. ( Special Requirements 009 Temperature Ingredients to 41'P/45°F ! 30. 1 Other 1 Within 4 Hours* rhncxes critical irzm in the federal 1999 Fwd Cate ai 1W CMR:90.(X)0. �, peND$ City of Salem, Massachusetts 3 Board of Health AP9 120 Washington Street, 4th Floor, Salem, MA 01970 e pe Tel. (978) 741-1800 Fax. (978) 745-0343 PabhCHealth Iramdin@salem.com Prevent. Promote. Protect. Kimberley Driscoll Larry Ramdin RS/RENS, CHO, CP-FS Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM-15-30 Permit Type: Food Establishment>99 seats Goods&Services: IFood Service: >99 Name of License Holder: Fantasy Island- Deborah Lam Name of Food Establishment Fantasy Island Restaurant Address of Food Establishment 516 Loring Avenue Salem MA 01970 Restrictions: This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: $420.00 Issued: 1/1/2015 ' CITY OF SALEM, MASSACHUSETTS FHam, BOARD or Hew.Ttl P111 ", P-M.I. • •" 120 WASI'IINGfON S'ni1?C'r,4T11FLooit KIMBERLEY DRISCOLL Tra..(978)741-1800 FAX(978)745-0343 LARRY R\NIDIN,RS/RISI IS,CI IO,CP-FS MAYOR ImnadmGsalem.com HGAI:n4 AC FNP Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: L-PrV /' 9,6�7/�Ug-q� 2) Establishment Address: ✓`� L� �Ii// � S p 1 i M 3) Establishment Mailing Address(if different): �1 4) Establishment Telephone No: / L�S I -7 d L 5) Applicant Name&Title: h 7-� D a* 4 f h'✓� S Applicant Address: (� iA) T�'��b �n M A-n � v 7) Applicant Telepho/a No241-iour 7*/3 Email: /6n L LG�11yc� rr!Jt 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address �a vidual 9 oR-� Ik 1 PR-vsI a;,f 1 / / 5�✓�S/"'IAIS fin �i� Apartnership I A*tz-6 t"04T-AO He Other legal entity I / 12) Person Directly Responsible For Daily Operations(Owner, ,P,errson in Charge,Supervisor,Manager,etc.) Name&Title: f� �ikitJa4O �-" /n� q,r Address: I 77 �I I N s / �2 (Z10 /� ' '4}it�[moi l✓, M Telephone No: ) � 1-7- 91 L4�'U ,; FaxI%/ -J L CO q-1 ZI Email: / d L" Emergency Telephone No: � (7 cK-3 Lf n -2' 3 13) District or Regional Supervisor(if applicable) l c ��®>.� Name&Title: DEC ^ Z) ,,1014 Address: Bnar• -'n,' Telephone No: Fax: Email: Check#: 17 60 Dale: (y f V � � r Amount: '! 7,0 • a—) 1 w Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) 5&a V I G Pu M P//Jv 16) Days and Hours of Operation: §W + (Ful`iQ Ay gvvD -U30 17) No. of Food Employees: 7/J 18) Name of Person in Charge Certified in Food Protection Management: C? pt1�A Ik L/p✓� y Zo q 1�t y S _ Required as of 10/1/2001 In accordance with 105 CMR 590.003(A) r(.p N A- V kl)l GHr11.Y7 h cif_o 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): Ll'es No 20) Location: 22) Establishment Type(check all that apply) (check one) 13 Retail( Sq.,F,t�) ❑Caterer L�rmanent Structure od oService-( n�o l Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑Residential Kitchen for Retail Sale E0015-od Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: _Breakfast Establishments -...................... ........................... (check one) RETAIL STORE RESTAURANT LA ual ❑ Less than 1000sq.ft. $70 ❑Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑More than 10,000sq.ft. $420 ❑25-99 seats $280 9WA6­re than 99 seats $420 Temporary/Dates/Time: - - ---- -- ----------------------------------------------------------------------- ❑ Bed&BreakfasVChildcare Services(Nursing Home $100 ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT" $25 "Including, church kitchens, state funded childcare&private club 23) Food Operations: Definitions: PHF—potentially hazardous food(timeffemperature controls required) Non-PHFs—non-potentially hazardous food(no time/temperature controls required) (check all that apply): RTE—ready-to-eat foods(Ex.sandwich a,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs ✓ for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Ser46 Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods.Only Preparationof Non�HFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be comnleted by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. - 24) Signature of Applicant: lY — Pursuant to MGL Ch.62C,sec.49A,I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: d 7��2 to 5_5 ( q /;Q,�1 � 26) Signature of Individual or Corporate Name: 4— Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"'Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax(978) 745-0343 City/Town of1..Qrw� Address: FOOD ESTABLISHMENT[INSPECTION REPORT Tel. Rng Name P#te Typ Operation(s) Type o spection ' 1� nod Service utine Addres 1 o J Risk Retail Re-inspection Telephone Y -, I �0 Level ❑ Residential Kitchen Previous Inspection p /I� l J ❑ Mobile Date: OwnerIN ❑ Temporary [IPre-operationHACCP Y 1 ❑ Caterer ❑Suspect Illness Person-in-CP ge I ) to Time ❑ Bed&Breakfast 0 HACCP General Complaint !r ' In: Inspector `R r, >rt OutjPermit No. ❑.Other �1 F Each violation checked requires ane pI ation on the narrative p ge(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ y p q Allergen Awareness 590.009(G) Elcorrective action as determined by the Board of Health. 1XV rFF DPROTECTICN MANAGEMENT 2. Prevention of Contamination from Hands 1. PIC Assigned/Knowledgeable/Duties N-LEMPL_OYEE HEALTH ) ❑13. Handwash Facilities E] 2. Reporting of Diseases by Food Employee and PIC LROTECTION_FROM'CHEMICALS ❑ 14.Approved Food or Color Additives F13. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals LF000_FROMAPPROVED SOURCE ) �TN7lJTEMP.ERATURECONTROLS(L_?o_te_n_tlalryHazardo_usFoods)I ❑ 4. Food and Water from Approved Source _- _- __ ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling PROTECTION FROM CONTAMINATION 9. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time as a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing LREQUIREMENT,S FOR HIGNLYSUSCEPTIBLE--POPULATtONS'(NSP)�] Q 221. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices ICOySUMERADVISORY Jgi2 . Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1.22): of Health. Noncritical(N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N / 23Management and Personnel (FC-2X590.003) by a Board of Health member or its agent constitutes an � . 24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc-4X590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food C/ 26. Water, Plumbing and Waste (FC-5X590.006) establishment operations. If aggrieved by this order,you L, 27. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of)his o**tag 30. Other DAT .OFRE-INSPECTION: LIL� Inspector's Signature: Print: r-�,, �J PICS Signature: Print: VT6J Y�(]� / m es 1 I r � �, v� 1111 l j -•VV•' �. ._--i-�'..•-� -..- �.-.�. -'- ��-�...•a..w-..... .•..+...`_V y.'-`f fi�y 1iY�».. rte..-.`�` � e -' �- , - .. Violations Related to Foodbome Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT I S I Cross-contamination I 1 590.003(A) Assignment of Responsibility* I 13-302.11(A)(1) Raw Animal Foods Separated from f Cooked and RTE Foods* 1 590.003(6) Demonstration of Knowledge" I I I Contamination from Raw Ingredients 12-103.11 Person in charge-duties I 13-302.1 I(A)(2) I Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* Contamination from the Environment ( 2 590.003(C) Responsibility of the person in charge to I I 1 I 3-302.1 t(A) I Food Protection' require reporting by food employees and 3-302.15 1 Washing Fruits and Vegetables applicants* 3-304.11 ( Food Contact with Equipment and I 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To ReportTo The Person In I I Contamination from the Consumer Charge* 3-306.14(A)(B) I Returned Food and Reservice of Food* 590 003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 13 590.003(D) Exclusions and Restriction;* � Food 590.003(E) Removal of Exclusions and Restrictions 3.70 1.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 I Food and Water From Regulated Sources I i 9 I Food Contact Surfaces j 590.004(A-B) I Compliance with Food Law* I 4-501 111 Manual Warewashing-Hot Water 13-201.12 I Food in a Hermetically Sealed Container* ( Sanitization Temperatures* 3-201.13 I Fluid Milk and Milk Products* I 14-501.112 Mechanical Warewashing-Hot Water 13-202.13 I Shell Eats* I Sanitization Temperatures* l 3-202.14 I Eggs mid Milk Products, N.steuri7e0 I 14-501.113 I Chemical Sanitization-temp.,pH, i 3-202.16 Iee Made From Potable Drinking Water* I concentration and hardness. 5-101.111 Drinking Water from an Approved System* I 14-601.11(A) I Equipment Food Contact Surfaces and I 5M.006tA) Bottled Drinking Water* I Utensils Clean* J 4-602 11 I Cleaning Frequency of Equipment Food- 590.D06(B) I Water Meets standards;.a A 1 r CMR 22ce Contact Surfaces and Utensils'� Sish ash and Fish From an Approved Satre I 14-702 11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreatianaily C'sup..ht Molluscan Food Contact Surfaces of Equipment* SIre1Mollusca 14-703.11 ( Methods of Sanitization-Hot Water and 3 201.15 Sources* Shellfish from uSSF listed f Chemical* Sources" I 1 I I Game and Wild10 Proper,Adequate Handwashing Mushrooms Approved by ' ) RequlatoryAuthorlty 12-301.11 1 Clean Condition-Hands and Arms* J 13-202.18 I Sheltstock Identification Present' I 12-301.12 I Cleaning Procedure* 1590.004(C) Wild Mushrooms* I 12-301.14 ( When to Wash* 3-201.17 I Game Animals'' 1 111 I I Good Hygienic Practices 3 I Receiving/Condition 12401.11 1 Eating,Drinking or Using Tobacco* 1 3-202.11' 1 PRFs Received at Proper Tcmperatutes* I 2-401,12 Discharges From the Eyes,Nose and 13-202.15 I Package Integrity" I I y I Mouth* 3-101.11 I Food Safe and Unadulterated" I 13-301.12 I Preventing Contamination When Tasting* I 16 Togs/Records:Shelistock I 112 t Prevention of Contamination from Hands 3-202.18 Shetlstock Identification* I 590.004(E) Preventing Contamination from 1 3-203.12 Shellsiock Identification Maintained* 1 Employees* 1 Tags/Records;Fish Products 113 I i Handwash Facilities 1 3402.11 Parasite Destrucuor.,* I i Conveniently Located and Accessible I I 13-402.12 Records.Creation and Retention" I 15-203.11 I Numbers and Capacities* 1590.004(1) Labeling of Ingredients' I 15-204.11 I Location and Placement* 7 I I Conformance with Approved Procedures I 15-205.11 I Accessibility,Operation and Maintenance /HACCP Plans I I Supplied with Soap and Hand Drying 3-502.11 Specializzd Processing.Methods* I Devices 3-502.12 Reduced oxygen packaging,criteria" 16-301.11 I Handwashing Cleanser,Availability f 8-103.12 Conformance with Approved Procedures* 16-301.12 I Hand Drying Provision 1 °Denotes critical iter in the feral 1999 Food Code or 105 CMR 59U 000. ao�� t CITY OF SALEM BOARD OF HEALTH I Establishment Name:rf 'Pt . -_n '1 ivl Date: 3 ^ °�— ILfi Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION _ Date. No. Reference R-Red Item '��' Verified PLEASE PRINT CLEARLY I M'2U) AQA_1M,4 I (AL i —(�P P e l+OAIL, I I I✓L,� 7n n vrn l t 114 ( � — r�� � UA oivi / J � ._S�r' 1Y�'� iO C-O�� �Pi (/4U W)a a/yq 0 Jam- q A A M,.n, 4 OIt /! I/r .f,(✓<, 4 �.Q//1 0 _ r17_1j,S,s _.(d1C\VIlk1J.21� $Pc-aci—sicussion3- 01, V, � � ,� ' "With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I 1 have read this report, have had the opportunity to ask questions and agree to correct all n v ary Compliance ❑ Employee Restriction/ I' violations before the next inspection, to observe all conditions as described, and to Exclusion P C3 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. 0 Voluntary Disposal 0 Other: 3-501.14(0) PHFS Received at Temperatures Violations Related to Foodbarne illness lnteraenffons and Risk _ According to taw Cooled m Factors(items 1-22) (Cont.) 41'F/45'F Within 4 Hours. CHEMICALS { 3-501.15 Cooling Methods for PHFS PROTECTION FROM CHEM 14 ( Food orICAL Color Additives { 19 PHF Not and Cold Holding 3-501.16(B) Cold PHFS Maintained at or below r 3-202.12 Additives* � 590.004(F) 4101450 F* t 3-302.14 Protection from Unapproved Additives' _ 3-501.16(A) Hot PHFS Maintained at or above ( 15 Poisonous or Toxic Substances 110'17. * 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. ' { Containers* i 20 - Time as a Public Health Control { 7-102.11 Common Name-Working Containers* { ( { 3-501.19 Time as a Public Health Cnntrtzi* 7-201.11 Separation-Storage* 590.004(H) Variance 7-202.11 .Restriction-Presence and Use* ( e Requirement { 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEP11BLE 7-203.11 I Toxic Container;-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitize".Criteria-Chemicals* 7-204.12 Chemicals for trashing Produce,Criteria* ( � 21 3-801.11(A) Unpasteurized Pte-packaged Juices and { { Beverages with Wattling Labels*7-204.14 Drying Agents.Criteria* 3-801.1 I(B) Use of Pasteurized Eggs* { ( 7-205.11 Incidental Foot Contact.Lubricants* { 13-801.11(D) Raw or Partially Cooked Animal Food and { 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprains Not Served ( 7-206.12 Rodent Bait Stations* ( { 3-801A I(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 1 22 3-603.11 Consumer Advisory Pasted for Consumption of TIMEIPEMPER4TURE CONTROLS Animal Foods That are Raw.Undercooked or ' 16 Proper Cooking Temperatures for Not Otherwise.Processed to Eliminate PHFS mx,.e,nzxn 3-40tAIA(i)(2j Eggs- 155F 15 Sec. P O1 '* Eggs-Immediate Service 145'F15see* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-441.11(A)(2) Comminuted Fish.Meats&Game * Animals-155'F 15 sec.* { SPECIAL REQUIREMENTS { 3401.I1(B)(1)(2) Pork and Beef Roast-130°F 121 min* i ( 3-401.11(A)(2) Ratites,Injected Meats- 155'F 15 590.O0 5(A)-(6) Violations of Section 590.009(A)-(D)in t sec.* I catering, mobile food,temporary-and 3-401.1 I(A)(3) Poultry,Wild Game,Sniffed PHFS, i residential kitchen operations should be Stuffing Containing Fish,Meat. 1 debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to Foodborne illness 3-401.11(C)(3) Whole-muscle,inmet Beef Steaks interventions and risk factors. tither 1450F* 590.009 violations relating to gond retail ' , 3-401.12 Raw Animal Faxis Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFS- 145'1715 sec. { 19 Retreating for Hot Holding VIOLATIONS R:LATER TO GOOD RETAIL PRAC77CES 3403.1 I(A)&(D) PHFS 165'1715 sec.* (Items 23-30) 3-403.11(B) Microwave- 1650 F 2 Minute Standing Critical and non-critical violations,which do not reloe to the 1 Time" foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commerda]ly Processed RTE Food- found in the follon=ing sections of the Food Cade and 105 CMR i 1400F* 590.Q00. 3403.11(E) Remaining Unsliced Portions of Beef ( item f Good Retail PreWces ( FC 590.090 i Roasts` 1 23. 1 Management and Personnel FC-2 .003 18 { Proper Cooling of PHFSf 24. i Food and Foci Protection ( FC-3 .004 ! f 25. 1 Equipment and Utensils FC-4 eW I 3-501.14(A) Cooling Cooked PRFs from 140`F to ( 1 2, ! Water.Ptumbinq and waste FC-S 006 70°F Within 2 Hours and From 70°17 127. 1 Phvsical Facility FC-6 .007 to 41`F/45°F Within 4 Hours.* 1 28. Poisonous or Toxic Materials FC=7 .008 i 3-501.14(6) Cooling PHFS Made From Ambient 129. Special Requirements .009 _1 Temperature Ingredients to 41'F/45°F 30, 1 Other ! Within 4 Hotus* Denotes critical twin in the federal 1999 Food Code or 105 C-MR 590.000. CITY OF SALEM G BOARD OF HEALTH Establishment Name: V /–VMfO,�Z"k 0_ ., Datm r j� Page: of Rem Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION ' Date No. Reference R—Red item VerifiedPLEASE PRINT CLEARLY ;tel r f2- -- Ivo X10 I 'V�cx ZI — SL S 1�1r ter— . -bP C_V 0 I I I I 1 I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ 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. — 0 Voluntary Disposal 0 Other: 3-501.144C) PHFs Received at Tempemtmes j Vio[arlons Related to Foodborne[lines&Interventions and Risk According to Law Cooled to Fa#ors{items 1-22) (Cont.) 4t'F/45`F Within 4 Hans. PROTECTION FROM CHEMICALS 3'501.15 Cooling Methods for PHFs 14 ( Food or Color Additives 19 PHF Hot and Cold Holding 3-50 L 16(B) Cold PILFs Maintained at or below 3-202.12 Additives*' 590.004(F1 4101450 F* 3-302.14 I Protection from Un proved Additives[ i 9>64ences 3-501,i6(X) Hot PHFs Maintained at or above 15 Poisonous or Toxic Su 140s 7-101.11 identifying Information-Original Cnntamers• � 3-501.16(A) Roasts Heid at or above 130°F.* 20 Time as a Public Health Control + 7-102.11 Common Name-Working Containers* t f 3-501.19 Time as a Public L{eatth Control* 7-201.11 Separation-Storage* j ' ! 7-202.11 Restriction-Presence and Use* ' 590.004(H) Variance Requirement y 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 1 7.203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) {'t 7-204.11 Sanitizers.Criteria-Chemicals* ' 21 )-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 I Chemicals for Washing Produce,Criteria' Beverages with Warning Labels* 7-201.14 Drying Agents.Criteria* 1 . 3-$01.118) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact.Lubricants* ( 3-801.11(D) Raw or Partially Cooked Animal Food and 1 7-206.11 Restricted Use Pesticides,Cri[erin* ( Raw Seed Sprouts Not Served. * I J 7-206.12 Roden Bait Stations* ( 3-$01.11(C) Unopened Foul Package Not Re-served. 7-206.13 Tracking Powders, Pest Control and Monitoring" CONSUMER ADVISORY TIME(i EMPER4TURE CONTROLS 22 3-603.11 Consumer Advisory Pasted fur Consumption of Animal Foods That are Raw,Undercooked or 16 Proper'Cooking Temperatures for PHFs Not Otherwise Ptoeessed to Eliminate 3-401.11A(1)(2) Eggs- 155'F 15 Sec. Pathogens.*ePb °'nom' Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell f' 3-401.1I(A)(2) Comminuted Fish.Meats&Game Eggs- Animals-155'F 15 sec. 4 3.40LI1(B)(I)(2) Port:and Beef Roast-130'F121 min* SPECIAL REQUIREMENTS y 3-401.11(A)(2) Ratites,Injected Meats- 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in i Sec.* catering, mobile food,temporary and 340I.1I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F t5 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1 145'F°' 590.009 violations relating to good retail d 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-40LI1(A)(1)(b) All Other PIFs- 145`F 15 sec.* y17 Reheating for Hot Holding WOLA77ONS R;4TED TO GOOD RETAIL PRAC77CES 3403.11(A)&(D) PHFs 165-F 15 sec. * (Items 23-30) t 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the n Time* foodborne illness interventions and risk factors listed above, can be 1 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef I Item ; Good Retail Practices FC 590.0tf0 i Roasts* 1 23, 1 Manaoament and Personnel ! FC-2 .003 I ' 18 Proper Gaoling of PHFs , 24. Food and Food Protection I FC-3 .004 ! 1 25. Equipment and Utensils , FC-4 .005 , 3-501.14(A) Cooling Cooked PHFs from 140'F to 26, Water.Plumbing and Waste i FC-5 906 70'F Within 2 Hours and Front 70'F 27. Plivstcal FacntiN FC-6 .007 to 41`F/45'F Within 4 Hours.* 1 29. Poisonous or Toxic Materials FC=7 .008 3-501.14(B) Cooling PHFs Made From Ambient 129. Special Requirements .009 i Temperature Ingredients to 41'F/45'F 30. Other Within 4 Hours* s,u:,,rro:rtxn j ^Demter critical iiam in the L^deral 1999 Fuad Code ui 105 CMR 590.000. CITY OF SALEM f " p �, BOARD OF HEALTH r Establishment Name: �7pAoa_ 3C a""'s-, Date:'_3_ (— t- Page: � of Item Code C-Critical Item _ DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY Trb-�' t=: ,- , . - _ Dn v - �. 47, �c al itis_ C!/ A_a4 .—_r A^, _ I DAA x N.Er �7�1 n I CC /FYIra- h� (�- OA P !0 An JI I Discussion With Person in Charge: Corrects a Action Required: I ❑ No Yes l 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 R �Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that E H �S I y noncompliance may result in daily fines Af twenty-five dollarss—uspension/revocation of ❑' ' m argo u Emergency Closure •I your food permit. V/ /, /N�� — — ]NV L�-�l ❑ Voluntary Disposal ❑ Other: 3-547.14(C) PHFs Received at Temperatures y Violations Related to Foodbarne illness interventions and Risk According to Law Cooled to fS Factors{Items 1-22) (Cont.) 1 41*FJ45°F Within 4 Hours. 3-501.15 Cocline.Methods for PHFs PROTECTION FROM CHEMICALS j j j 19 PHF Hot and Cold Holding 14 Food or Color Additives j 7 j 3-501-16(B) Cold PHFs Maintained at or below 3-202.12 Additives*' 590.004(F) 41°145°F* 3-302.14 Protection from USgDroved Additives* j 13-541.16(A) Hot PRFs Maintained at or above j 15 Poisonous or Toxic Substances � ° * 7-101.11 Identifying Information-Original 140 F. 3-501.16(A) Roasts Held at or above 230'F. Containers* " j 1 20 Time as a Public Health Control j 7-102.11 Common Name-Working Canminerc* 3-501.19 j TimeVariance Requirement as a Public Health Control* 7-101.11 Separation-Storage* 590.(104(H) j 7-202.11 Restriction-Presence and Use* j Varij 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizes.Criteria-Chemiesis' j 7-204.12 Chemicals for Washing Produce,Criteria* j 2] 3-841.l l(A) BeveragesUnpasteurized t Pre-packaged Juices and j .Beverages with Wanting Labels* J 7-204.14 Drying Agents.Criteria* 3-801.1 I(B) Use of Pasteurized Eggs* j 7-205.11 Incidents]Food Gonias Lubricants* j 3-801.11(D) Raw or Partially Cooked Animal Food and j 7-206.11 Restricted Use Pesticides,Criteria* j Raw Seed Sprouts Not Served. j 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders,Pest Control and ( j 3-801.11(C) Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMEt1 EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 ! Proper Cooidng Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3 401.I1A(i)(2) Eggs- t55°F 15 Sec. Pathogens.*s ..rn,2oct Eegs-immediate Service 145°Fl5sec+ 3-342.13 Pasteurized Eggs Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game Ems* Animals-155°F 15 sec. " SPECIAL REQUIREMENTS j 340LlI(B)(I)(2) Pork and Beef Roast- 130°F 121 min* ' 3-401.11(A)(2) Ratites, Injected Meats-155`F 15 590'004(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile ford,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Most. debited under the appropriate sections Poultry or Rat9tes 165°F 15 sec, * above if related to foodborne illness i 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 Fools Cooked in a practices should be debited under 3129- Microwave 165°F* Special Requirements. : 3401.1 I(A)(1)(b) All Other PHFs- 145°F 15 sec. j i7 Reheating for Hot Folding j VIOLA7701YS R LATED TO GOOD RETAIL PRAC77CES 3443.11(A)&(D) PHFs 165°F 15 see.* (Items 23-30) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can be 3-443.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400P 590.000. 3-403.11(E) Remaining Unslicetl Pinions of Beef Item I Good Retail Practices FC 1 590.000 Roasts* A 23. 1 Management and Personnel FG-2 .003 f, 18 Proper Cooling of PHles 1 24. Food and Foci Protection l FC-3 .004 1 25. Eqt pmem and Utensils FC-4 .005 j 3-501.14(A) Cooling Cooked PHFs from 140`F to 1 2& 1 Water.Piumbnq and waste ; FC-5 .006 i 70°F Within 2 Hours and From 70`F 127. i Physical Facility 1 FC-6 .007 i to 41`F/45°F Within 4 Hours. * 1 28. ! Pasoncus or Toric Materials FC-7 .008 j 3-501.14(6) Cooling PHFs Made From Ambient ! i 29. 1Spittal Requirements 1 .009 1 , Temperature ingredients to 41°F/45°F II( 1 30. 1 Other I 1 Within 4 Hous* 'Denote,uitical tem in the fed cal 7'/99 Feat Cade 01 105 C.MR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:oa� . Date: . �—�— (1/ Page: J of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified • PLEASE PRINT CLEARLY C4 44 �,,,t�l o n lro-.,? , 3 ✓CNty 7Mo V-1-11_1) Ian elm.. ��liVt�"inn ltp-ol In,A 0,0 �} (a&00 C) I ��m r 00 r i 91-o 00 i A Discussion With Person in Charge: I Correct ve Action Required: I ❑ No�fes I have read this report, have had the opportunity to ask questions and agree to correct all 4r' Voluntary Compliance ❑ Employee Restriction � Exclusion violations before the next inspection, to observe all conditions as described, and to `tom e-inspection Schedul ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that I��}-�/J noncompliance may result in daily fines 9� twenty-fW'e dollars or uspension/revocation of 0 7 batgo��S ❑ Emergency Closure • your food permit. �// �1/�" - � /v ❑ Voluntary Disposal ❑ Other: ') 3-501.14(C)4(C) PHFs Received at Temperatures Violations Related to Foodborne illness lntementlons ana Risk According to law Cooled to t Factors films 1-22) (Cant.) 4t`F145`F W idem 4 Hairs. PROTECTION FROM CHEMICALS { 3-501.15 Cooling Methods for PHFs { 14 { { 19 PHF Hot and Cold Holding { Food or Color Additives ! 3-50L 16(B) Cold PHFs Maintained at or below r { 3-202.12 Additives* 590.004(F) 41'145`F* i ( 3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hot PHFs Maintained at or above ( 15 Poisonous or Toxic Substances 7-101,11 Identifying Information-Original I40�. * „ Containers* � 3-501.16(A) Roasts Held at or above. 130'F. { { 20 Time as a Public Health Control 7-102.11 Common Name-Working Containers* 3-501.14 Time as a Public Health Control* { 1_201.11 Separation-Storage* { { 590.004(590,004(H) Variance Requirement 7-202.11 .Restriction-Presence and Use* { { 1 7-202.12 Conditions of Use+ { REQUIREMENTS FOR HIGHLY SUSCEPTIBLE f i 7-203.11 Toxic Containers-Prohibitions* ! POPULA71ONS(HSP) 1 { 7-204.11 Samtizers,Criteria-Chemicals* 21801.11(A) Unpasteurized Pre-packaged Juices and { 7-204.12 Chemicals for Washing Produce,Criteria* 1 Beverages with Warning Labels" { 7-204.14 Drying Agents.Criteria* ( mlii 11(B) Use of Pasteurized Eggs* ! 7-205.11 bicidental Food Contact.Lubricants* j 3-801.11(D) Raw or Partially Cooked Animal Food and i 17-206.11 Restricted Use Pesticides;Criteria* Rea Seed Sprouts Not Sewed * i { 7-206.12 [rodent Bair Stations* { { 3-801.11(C) Unopened Food Package Not Ro-served. " 1 7-106.13 Tracking Powders, Pest Control and Monitoringv CONSUMER ADVISORY TIMEii EMPER4TURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of r ( 16 ( Proper Cooking Tempet'utrtres for Animal Foods Thai are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 4Execm u+rAMr -40f.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.* Eggs-immediate Service 145`Fl5sec• 3-302.13 Pasteurized Eggs Substitute for Raw Shell 7 3.401.11(A)(2) Comminuted Fish.Meats&Game Ems. i Animals-155'F 15 sec. Z SPECIAL REQUIREMENTS 3-401.11(3)(1)(2) Port:and Beef Roast-130`F 121 min* � 590.009(0)-(D) Violations of Section 3-40IA I(A)(2) Ratites,Injected Meats-155`F 15 ! .590.009(A)-(D)in sec. * J catering, mobile ford,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness t 3-401.11(0)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 1650F* Special Requirements. 340131(A)(1)(b) All Other PHFs- 145'F 15 sec.* { { 17 Reheating for Hot Holding { WOLA77ONS R-LATED TO GOOD RETAIL PRACTICES i 3-103.11(A)&(D)' PHFs 165"F 15 sec.* { (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing 1 Critical and non-critical violations,which do not relate to the 5 Time* ` foodborne illness interventions and risk factors listed above, can he ' 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3-40331(E) Remaining Unsliced Portions of Beef + Rom ; Good Retail Pracdces 1 FC 590.000 i ,: 1 23. 1 Management and Personnel FC-2 .003 1 Roasts { 18 { Proper Cooling of PHFs i 24. 1 Footi and Food Protection I FC-3 .004 ! 1 25. 1 Equipment and Utensils ! FC-4 .005 i 3-50L M(A) Cooling Cooked PHFs from 140`F to 1 26. 1 Water.Piumbinq and Waste i FC-6 006 700F Within 2 Homs and From 70°F ( 27. 1 Physical Facility FC-6 .007 to 41`F/450F Within 4 Hours.* 128. i Poisonous or Toxic Materials FC=7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 1 Temperature Ingredients to 4 PF/45oF 30, 1 Other Within 1 Hours* i TM DznOtw critical ism in the federal 1999 FooA Cade ur 105 GvtR 590.000. v4M oFMassachqse--fts—,1-N,­'- '2- A7 .. �T-7 ,120 Washington Ht 1,9970 W, Y 44- 'A! ......i"%i .4f, �WT -M, 41, 4M PRINTED T D, - 12/12/2013' - I zr V6 0x' IASTABLISIIWNTNAME vantas _y.-IslandRestaurant-5�­ z-�-4­- V" g-,516--Ldrifig:Ali6iiu File Number:BHF 2004-000138 LOCATEDATs- 05.16,LOR�ING,�AVENUE-i�s .. . ........ If SALEM,' An itk�l A t If, tmiplre Regfridlons/Notes Permit Type i. PetinitN6:,r.-,,.�,Permit issuea---P4�x�mi s Fee l.f E BHP-20144055; FWDSERVIC 31 2014 z:ESTABLISIMENT 44 51 WP $42000*1�-' �` V, }Total Fees. V nkIC le, If 4 1 4 N v Boarclof llealthy'. If V:jk4 gb s:." 59 At 1 If J 7 4 �,-, _�", � , j This Permit-i must be reissned-upoweliange of.owners hij or locatiah.The permit must posted. _v- -in a prominent location in Establishment. x AN- 0, Sanitary Code WiAred In atcordance with the State Said 'aby�r—e*o-n,ation-s,-Iimpr'ovemen�-isI or equipmen6chinges,'a-irema e, -A -all plans for such must be subliultf'6�di_to aiidapjiriv- �,b h Salem BeardnMe 6 ed y-t i Paget "0. F FI / ' CITY OF SALEM, IV MASSACHUSETTS � E G® u, BOARD cw H1iN:rH ^-'e® `G 120 W VSHINGTON S'11WET,4M FI. (&!-V KINIBERLEY DRISCOLL TIa..(978)741-1800 FAX(978)74 j4N%RY"RANIDIN,RS/RUNS,(1110,CP-FS MAYOR Immdin0salem.com �C Q HISN:rfI AGENT or s pyjN Food Establishment Permit / Akation (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: r —T kt S\� T� L- I " _ F O 77� �R-\)7 2) Establishment Address: S/ G t/r0 h—/ !O T��, 5N M , M�} 'D /9 7 0 r 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: q 7 r , I�'7 � � � ( 7 o oU�� 15) Applicant Name&Title: h 9��,/1,D ,�A4 Ir 471 �, lkc y 1/ 12 t 771 -) 7 c ,III 8) Applicant Address: 157 W C 5/117 MI�S 7rn- 17�� . M�/� "rr ' �� / &A'U 7) Applicant Tele; ni No 3 Lt ` 24 Hour Em Ige/ncy No: 816 Y3 Email: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address t-rcorporation An individual �/i(SI/tQAI��Po✓I PP;lDL'r07 15-1 /AUA)S Lit- W A partnership I M Other legal entibr r,Iqfj 12) Person Directly Responsible For Daily Operations(Owner, Person in Charge,Supervisor,Manager,etc.) Name&Title: Address: lri� I_�JZ�S�N l N �l Yi2 !`�✓ �/2 ���( , �/�OIXJ Telephone No: p 63 1 �(jC(�J Fax:R?�/ 7O YD t /y/Email: Emergency Telephone No: 4017 �3 Y b L L 3 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: ! 7 'P / Date: 1 vI t t 3 Amount: Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) L i Tv MON I(' 3L) 1(30 )%n-1 Sel i(' bo- (/n^I /-2/< 16) Days and Hours of Operation:SµU/}p L1 17-0-0 1 f.:?D 17) No.of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: y/orv6- A*&I(r Pg/V fs tr�,Av&lrb pas Required as of 101112001 in accordance with 105 CMR 590.003(A) Z I W g 11 L/ Qo 9414 - Lgwt, �L �-✓'�YGYY� 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): _�Z Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) 13Retail( Sq. Ft) 13Caterer I� mt eanent Structure Dfo-od Service-( y(t L Seats) ❑Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length OF Permit: .- Breakfast EstabHshments----•---------••••-•- _.. RETAIL STORE �ual(check one) RESTAURANT Permit: .... Less than 1000sq.ft. $70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑1000-10,OOOsq.ft $280 ❑ Residential Kitchens $140 ❑More than 10,OOOsq.ft. $420 ❑25- 9 seats $280 61-more than 99 seats $420 Temporary/DatesRme: ❑Bed& BreakfasUChildcare Services/Nursing Home $100 - ------------------------------------------------------------------------------------------------------ ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare B private club 23) Food Operations: Definitions: PHF-potentially hazardous food(time(temperature controls required) Non-PRFs-non-potentially hazardous food(no dme(temperature controls required) (check all that apply): RTE-ready-to-eat foods(Ex.sandwich=s,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Ord r Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs _7 for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF In Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: W/-f n Pursuant to MGL Ch.62C, sec.49A,I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Numberor Federal ID: OV Z-69y/994'� 26) Signature of Individual or Corporate Name: / lAe� � �" 'Commonwealth of Massachusetts - F F✓. - F _ � 6-s City of Salem # s . s_ Board ofxealtn - Kimberley Dnseou. k k .� q 120 Washington Street,4th Floor h MByar SALEM;MA '01970, _ Food_/Retail Establishment frPermitir "trf DATE PRINTED: 12/11/2012 x s - - ESTABLISHMENT NAME: Fantasy Island Restaurant i. x File Number:BHF-2004-000138 - - 516 LoringAvenue ( t a� 9 { Salem e MA, 01970 3 LOCATED AT: ;0516 CORING AVENUE ' SALEM,MA-_01970 M _" Permit Type Permit No. , .+ Permit Issued Permit Expires - .-. Fee Restrictions./Notes ' FOOD SERVICE BHP-2013-0106 Jan 1,2013 Dec 31,2013 $420.00 -`, ESTABLISHMENT " - - a � ,r . Total Fees:--- .,- $420.00 + V 3 t �4 k PERMIT EXPIRES December 31, 2013 Board of Health :a 1 7 + - This Permit is not transferable and must be reissued upon change of ownership or locations The permit must be posted in a prominent location in the Establishment: -" y In accordance with the State Sanitary Code,beofre any revonations,improvements;`or equipment changes are made, 1 all plans for such must be submitted to and approved by the Salem Board of Health.-, x < Page i z ` CITY OF SALEM, �1 MASSACHUSETTS RECEIV >t > Iieatth BOARD OF HFAIa'I-1 .,, "` 120 WASI IING FON Slta-icr,4°1 FWOIt KIMBERLEY DRISCOLL Tml (978)741-1800 Fns(978)745-0343 DLC MAYOR liamdin(i).salem.com LARRY R\bIDIN,R5/REIIS,(J 10,CT-FS CI i v JI= SALEM BOARD OF HEALTH Food Establishment Permit Application (Application must t�lb�e\\submitted at least t330 days beforethe planned opening date) 1) Establishment Name: ��,Iv-/+Sy T-5 t' '/ 6' /f v` 'vfT' 7- 2) Establishment Address: L4 h'v N od/, i /1— 0 17 6 3) Establishment Mailing Address(if different): /� 4) Establishment Telephone No: -I � 9 -11 � 1 -70 -0 5) Appiicant Name&Title: S/Gg D p-i-(. L-4" ��/� 'S'f`'9 ,A �y I 6) Applicant Address: 1S W�}v y llj- Tee � A0 /vl /♦/L� ��T � � /��7y 7) Applicant Telephone o 3 o ��3 24 Hour Em rgency N� / �� Email: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 16) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address ).A corporation r An individual 1/1170 A partnership Other legal entity I t 12) Person Directly Responsible For Daily Operations,(Owner, Person in Charge, Supervisor,Manager,etc.) Name&Titie: Address: Telephone No: ��� '1�� t'7� � FaVb � ILI Email: Emergency Telephone No: f 7 J 1 2 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: S 6 Date: PZAZ.I Amount:y� Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) ' -30 16) Days lnditu�rs of Operation: 17) No. of Food Employees: ZS 18) Name of Person in Charge Certified in Food Protection Management: / Required as of 101112001 in accordance with 105 CMR 590.003(A) GJ3OILf1 (( L+4-1 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): Ids No 20) Location: 22)establishment Type(check all that apply) Y3 Retail(6 DT" Sq. Ft) ❑ Caterer ermanent Structure , ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer Mobi e ❑ Food Service-Ta eout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: ------------------------------------------------------------------- ---------Breakfast Establishments-------------------- check one) RETAIL STORE RESTAURANT nual ❑ Less than 1000sq.ft. $70 ❑ Less than 25 seats $140 Seasonal/Dates: 13 1000-10,OOOsq.ft. $280 17 Residential Kitchens $140 More than 10,000sq.ft. $420 1125-99 seats $280 93,1121bre than 99 seats $420 Temporary/Dates/Time: ---------------r- -- - -------- ----.----- -e--- - s-in -------- ------------------------------ ❑ Bed &BreakfasUChildcare Servics/Nursing Home $100 - --------N ---- ---------------------------------- ------- -------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare&private clubs) 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs-non-potentially hazardous food(no timeltemperature controls required) (check all that apply): RTE-ready-to-eat foods(Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. - 24) Signature of Applicant: �/ ✓^v—ul. Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. c 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: Masbachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street;0 Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name I Date Type of Operation(s) Type of Insoection M. Food Service ❑ Routine Address /'1/z isk ❑ Retail ElRe-inspection aLevel El Residential Kitchen Previous Inspection Telephone (a(� II � ❑ Mobile Date:wQ Owner HACCP YM Temporary El Pr e-operation qif�rGv � O<a� , ❑ Caterer El Suspect Illness Person in Charge(PIC) /lrl�CjMI Time El Bed 8 Breakfast ❑ General Complaint In: El HACCP inspector �` nfi I P_Cr Out: I Permit No. ❑Other Each violation checked requires an enation 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 T bace Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) 90.009 o(I4,0 action as determined by the Board of Health. /141j�i-n FOOD PROTECTION MANAGEMENT" "' _ ' - _ I ❑ 12. Prevention of Contamination fro'6ro/l ds ❑ 1. PIC Assigned/Knowledgeable/Duties v1I 't �uQP13. Handwash Facilities EMPLOYEE HEA,-TH - PROTEION - I [12. Reporting of Diseases by Food Employee and PIC L_�__CT__ _.FROM CHEMICALS_ .;� .. E] 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives 5.Toxic Chemicals FOOD FROM APPROVED SOURCE --.ani Ti 1�EMPERATURE CONTROLS Potemlall Hazard _ ❑ 4. Food and Water from Approved Source �� ( y_ ous 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)! El ❑21. Food and Food Preparation for HSP 10. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices C�OJ�ISUMER ADVISORY,,,,,, 12. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below c x by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-z)590.0 4) order of the Board of Health. Failure to correct violations 25.'Equi and Food Protection (FC-3)(5x0. 0a) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. �C 30. Other DATE OF RE-INSPECTION: � S.SHOImspecfFomKrl4 tlx � l ( � �a�, Inspector's Signature:r �ll A Ate /V�uPrint: PIC'sSignature: Print:��, �� ��l I Page I of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 1 ( 3-302.11(A)(]) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* I Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* I I I I Contamination from Raw Ingredients ,I 2-103.11 Person in charge -duties 3-302.11(A)(2) Raw Anined Foods Separated from Each I Other* EMPLOYEE HEALTH ( I I Contamination from the Environment I 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* 590.003(F) Responsibility Of A Food Employee Or An I 304.1 l Fond Co Utensils*tact with Equipment and Applicant To Report To The Person In I I Contamination from the Consumer Charge* 590.003(6) Reporting by Person in Charge* I ( 3-3(16.14{A}(B) I Returned Food and Resenice of Food* Disposilfon of Adulterated or Contaminated i 3 590.003(D) Exclusions and Restrictions* + Food 590.003(E) Removal of Exclusions and Restrictions 3-701.1 I I Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* l 4 I Food and Water From Regulated Sources ( 9 I Food Contact Surfaces 590.004(A-B) Compliance with Food law* I ( 4-501.111 Manual Warewashing-Hot Water 13-201.12 Food in a Hermetically Seated Container* I' Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* I ( 4-501.112 Mechanical Warewashing-Hot Water I3-202.J3 Shell EM* I Sanitization Temperatures* 13-202 14 Eggs and Milk Products.Pasteurized* I ( 4-50t.114 I Chemical Sanitization-temp.,pH, 13-202.16 lee Made From Potable Drinking Water* I concentration and hardness. 15-101.11 Drinking Water from an Approved System" I 14-601,11(A) I Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* I Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- ShelBish and Fish From an Approved Source I Contact Surfaces and Utensils" 4-702.11 ( Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 14-703.11I Methods of Sanitization-Hot Water and I . 3-201.15 Molluscan Shellfish from NSSP Listed Sources* Chemical* Game and Wild Mushrooms Approved by I 110 I Proper,Adequate Handwashing Regulatory Authority 2-301.11 I Clean Condition-Hands and Arms* 13-202.18 Shellstock identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 12-301.14 I When to Wash* 3-201.17 I Game Animals* I I Ll I Good Hygienic Practices 15 Receiving/Condition I 12-401.11 Eating,Drinking or Using Tobacco* 3-202.11 ( PHFs Received at Proper Temperatures* I 12-401.12 ( Discharges From the Eyes,Nose and 6 I 3-202.15 I Package Integrity" I Mouth* 3-101.11 I Food Safe and Unadulterated* ( 3-301.12 I Preventing Contamination When Tasting* I Tags/Records:Shellstock I 112 I I Prevention of Contamination from Hands 13-202.18 I Shellstock Identification * I 1590.004(E) Preventing Contamination from 3-203.12 I Shellstock Identification Maintained* I Employees* 13 Handwash Facilities Tags/Records:'Fish Products I 1 I 3-402.11 Parasite Dcstruction* I I Conveniently Located and Accessible 1 ( 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590,004(j) ( Location and Placement* 1590.004(n labeling o1 Ingredients' T Conformance with Approved Procedures I 5-205.11 I Accessibility,Operation and Maintenance /HACCP Plans I I Supplied with Soap and Hand Drying Devices 3-502.11 Specialized Processing MetMethods* I 13-502.12 Reduced oxygen packaging,criteria* I 16-301.1 L I Hand washing Cleanser,Availability 18-103.12 Conformance with Approved Procedures* I i 6-30J 12 ( Hand Drying Provision *Denotes,critical item in the federal 1999 Foci Cate or 10s CMR 590.0(10. CITY OF SALEM nn BOARD OF HEALTH Establishment Name: Rg oAAeQ__P P n lo,,.X� Date: �� Page: of 2 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item �nPL SE PRINT CLEARLY ��Mn,"�'�J Verified OJIUn/$"q, Q�6g '. �a(") - (� A ,_.Q� I iii n do) 6b gInMIIMeI� P MLD1t cin /yI IIn�[�(M(_ 1 I U� 3"JU�4f l I��CnV ((in-D k7 ,, t JA A_,, _ n Q iL � — W?YDJ Ac ?c}uiB MnliJl� cz I CVA19 ()A -� Co- C' rbc I!P�ito�__ 1 UI ;51�AQR5 4 �dL (;II A Discussion—With Person in Charge: Cor ive Action Required: ❑ No I dliFes I have read this report, have had the opportunity to ask questions and agree to correct all >zr voluntary Compliance ❑ Employee (Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P 4Re-inspection Scheduled l ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that p� l() d noncompliance may result in daily fines of twenty-five dollar r spension/revocation of n rgo ❑ Emergency Closure your food permit. — \ \t1 ❑ Voluntary Disposal ❑ Other: / d 1 3-591.t4(C) PHFs Received at Temperatures Violations Related to Foodborne Otness tnter�endons and Risk According to law Cooled to t Factors{trema 1-22) (Cant.) 41'2!45°F Within 4 Hags. L 3-501.15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS ' 29 PHF riot and Cold fielding r 14 Food or Color Additives 3-202.12 Additives* 3-501.16(B) Cold PlIrs Maintained at or below 590.004(F) 43'145°F=' 3-302.14 Protection from Unappraved Additives* f 3-501A6(A) Hot PHFs Maintained at or above Poisonous or Toxic Substances 15 1400F. * 1-101.11 Identifying Information-Original , � 3-501,16(A) Roasts Held at or above 1300F. Containers* 7-102.11 Common Name-Working Containers* 2® Time as a Public Heah of l Control Centntral' 1 7-MIA1 Separation-Storage* 3-501.19 Tante as a ie eis 7-202.11 .Restriction-Presence and Use* ( 590.004{H) Variance Requirement 7-202.12 Conditions of Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 'Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals* 21 't-SOI.il(A) Unpasteurized Pre-packaged hires and 7-204.12 Chemicals for Washing Produce,Criteria* a Beverages with Warning Labels* 7-204.14 Drying Agents.Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-'_05.11 Incidental Food Contact,Lubricants* 13-801.1 I(D) Raw or Partially Cooked Animal Food and 17-206.11 Restricted Use Pesticides;Criteria* f Ran Seed Sprouts Not Served.* 7-206.12 Rodent Bait Sumans* 3 7-206.13 Tracking Powders, Pest Control and i ( -801.11(C) Unopened Fond Package Not Re-served. " Monitoring* 1 CONSUMER ADVISORY ` TiMEti EMPERATURE CONTROLS 22 3603.12 Consumer Advisory Pouted fur Consumption of 16 Proper Cooking Temperatures far f Animal Foods That are Raw.Undercooked or Not Otherwise Processed to Eliminate PHFs Pathogens.*�'" V'Mef 3401AIA(1)(2) Eggs- 155F15 Sec. Eg.s4s-Immediate Service 145°Ft5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 340L I I(A)(2) Comminuted Fish.Meats&Game fittgs* Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 moo* j 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,injected Meats- 155'F 15 sec.* catering, mobile food,temporary and 3-401.1 I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited udder the appropriate sections Poultry or Ratites-165017 15 sec, * above if related to foodborne illness } 3.401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and tisk factors. Other 145'F* 590.009 violations relating to good retail 3-101.12 Raw Animal Foods Cooked in a } practices should be debited under#29- Microwave 1657* , Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. E 17 Reheating for Not Holding I VIOLA77ONS R i1 4TED TO GOOD RETAIL PRAC77CES 3403.11(A)&(D) PHFs 165-F 75 sec.* ( (Items 23-30) 4 3403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations,which do net relate to the i 'Time* foodborne illness interventions and risk factors listed above, can be 3403,11(C) Commercaaily Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F" 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef 11 Item I Goad Retail Practices 1 FC 590.000 i Roasts* 1 21 i Management and Personnel I FC-2 .009 1 18 Proper Cooling of PHFs i 1 24. Food and Food Protection I FC-3 .004 1 25. Equioment and Utensils I FC-4 005 i 3-501.14(A) Cooling Cooked PHFs front 140°F to 26. ! 'Nater.Plumbinq and Waste ! FC-5 .006 i li( 70*F Within 2 Hours and From 70'F 127. 1 Physical Facility FC-6 .007 I to 41`Fl450F':Fithin 4 Hours.* i 28. Poisonous or Toxic Materials FC=7 .008 i 3-501.14(B) Cooling PHFs Made From Ambient 1 29. Special Requirements i .008 Temperature Ingredients to 41°F145'F ! 30. i Other Within 4 Hours* s s w.••�_ Denote,critical imrn in the federal 1999 Food Cale or 105 CMR 590.000. r r CITY OF SALEM BOARD OF HEALTH Establishment Name6((;)A( .1 Date: i 01�t Page: 3 of Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY / l I . f I COQ �F�i�t rr��`-�`�A..-�\.P.i.�.Lv�Y�P -•����G' G� l�0 �G.o� d��' Ul o�ill e, a C� ` 1 Cio Y�)('en- U -P.r_o j 01l � A� AQI1. C_� /XI _ - r �C i Q,Q ( cZnn ( A-) ok rte" � AA(I)C -1-rJAZ.-I , /"-.��- 10 O (Q�acJ it P l 'V O tiiVL1�OkV2'd1V'j/ /�Zn '✓\A �l,,bbb\/�0_/10J f 1L1� Y rl /(J(Y P.4 �P v( QUA O2>, Po- Prt -fin �A 1� ,�.a. -301 dA ��t-�10��,,,,f J c1 l —OiKc �— Discussion ith Person in Charge: v Corrective Action Required: ❑ No yes r I have read this report, have had the opportunity to ask questions and agree to correct all J,* Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P Re-iCspection Sc eduled ❑ 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 spension/revocation of onbargo a ❑ Emergency Closure your food permit. /1 0 r , /�,i(/1�✓In ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures 1 Violations Related to Foadborne Illness Interventions and Risk According to Caw Cooled to 1 Factors{items 1-22) (Cont.) 41'Ft45°F Within 4 Hafts. PROTECTION FROM CHEMICALS - I 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives119 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202,I2 Additives-" 590.004(17) 41°145"F* 3-302.14 Protection from Unapproved:Additives" I 3-501.16(A) Hot PHFs Maintained at or above 115 Poisonous or Toxic Substances I 140017 * 7-101,21 Identifying Information-Original 3-501.S6tAi Roasts Held at or above 130'17. Containers* * I 20 Time as a Public Health Control I 17-202.11 Common Name-Working Conmiaers* I '3.501 19 Time as a Public Health Control* I { 7-201,11 Separation-Stooge* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement I 7-202.I2 Conditions of Use* { REQUIREMENTS FOR HIGHLY SUSCEPTIBLE j 7-203-11 Toxic Containers-Prohibitions* I POPULATIONS(HSP) 7-204.11 Sannizers.Criteria-Chemicals* I 21 "t 801.i 1(A} Unpasteurized Pse-packaged luiees and 7-204.12 Chemicals fur Washing Produce,Criteria* I .Bevrnures with Warning labels* 17 204.14 Diving Agents.Criteria' 3-801.11(8} Use of Pasteurized Egos* { 7-205.11 Incidental Food Contact,Lubrecants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria= I Raw Seed Sprouts Not Served- 7-206.12 erved7-206.I2 Rodent Bait Stations* { 7-206.13 Tracking Powders,Pest Control and 13-801.II(C) Unopened Foul Package Na Rn-served. " Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or Not Otherwise Processed to Eliminate PHFs �„*,," 3-401.11A(1)(2) Eggs- 155'F I5 Sec. Pasteurize.* Eggs-Immediate Service 145'Fissee, 3-302.13 15th Pasteurized Eggs Substitute far Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Ems* Animals-155'F 15 sec.* SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pori:and Beef Roast-130°F 121 min* { 590.009(A)-(D) Violations of Section 590.0(}9(A)-(D)in 3-401,11(A)(2) Rates,Injected Meats- 155°F IS catering, mobile food,temporary and 3-401.1 t(A)(3) Poultry,Wild Crame,Staffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat. debited udder the appropriate sections Poultry or Ratites-165'1715 sec, ' t above if related to foodborne illness 3401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145°F n I 590.()09 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. i 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. ' ( i7 Reheating for Hot Holding 1 VIOLATIONS R ELATED TO GOOD RETAIL PRACTICES E 3-103.11(A)&(D) PHFs 165-F 15 sec.* I (Items 23-30) k ( 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can be 3403.t 1(C) Commercially Piecessed RTE Food- jaunt!in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Pardons of Beef { item j C,oadRafailPraetices IFC 590.000 I Roasts* 123. i Management and Personnel I FC-2 .003 i { 18 Proper Cooling of PHFs 124. 1 Food and Fob Protection I FC-3 .004 i 1 25. I Equipment and Utensils 1 FC-4 .005 1 ` 3-501.14(A) Coiling Cooked PRFs from 140`F to 2.6, 1 Water.Plumbinq and Waste FC-5 .006 [ 70`F Within 2 Hours and From 70'F 27. Physical Facil ty FC-6 .007 to 41`F/45'F Within 4 Hours. * 1 28. ' Poisonous or Toxic Materials 1 FC=7 .008 3-501.14(B) Cooling PER Made From Ambient 129. I Special Requirements .009 Temperature Ingredients to 41°F/45'F 1 O mer t Within 4 Hours* s,s"�` 'Denores critical mu,in the L-decal 1999 Food Cale a'105 C-MR 90.000, t CITY OF SALEM QQ BOARD OF HEALTH Establishment Name: nn lr2 A ��ia�—� Date: Page: of Ali Item Code C-Crltleal Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION v + Date No. Reference R—Red Item I Verified PLEASE PRINT CLEARLY I I - �rAPeAq /V2- P ity, L) L Q U 1C� d n-A- R — PA-aM-4- I v I I � I � I I I I I I Discussion With Person in Charge: Corrective Action Required: I (3 No I O Yes II have fead 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 ttwent -fiy_ ve dollars o spension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. N ! � ❑ Voluntary Disposal ❑ Other: I 3-SOI.14(C) PHFs Bee,ived at Temperatures L Violations Related to Foodborne illness Interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cont.) 41'F/45'F Within 4 Haus. PROTECTION FROM CHEMICALS 3-501.15 Cooling.Methods for PHFs � 14 = Food or Color Additives 19 PHF Hot and Cold Holding 3-50136(B) Cold PRFs Maims ned at or below 13-202.12 Additives* 590.004(F) 41°145'F* 15 1 3-302.14 Protection from Unapproved AdditivesY 3-501.16(X) Hot PRFs Maintained at or above Poisonous or Toxic Subslonces 1400F. 7-101.11 identifying Information-Ori ' at f ( 3-501.16(X) Roasts Held at or above I300F. Containers" ' j 7-102.11 Common Name-Working Containers* I 120 Time as a Public Health Control { 7-201.11 Separation-Storage* I 3-501.19 Time as a Public Health Control* I 7-202.11 Restriction-Presence and Use* 590•004(H) Variance Requirement I 17-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(MSP) 17-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(X) Unpasteurized Pre-packaged Iuices and j Beverages with Warning labels* 7-204.14 Drying Agents.Criteria* 3-801A I(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contac.Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 1 7-206.11 Restricted Use Pesticides,Criteria* Rase Seed Sprouts Not Served,; 7-20&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 3-603.21 Consumer Advisory Pasted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods That are Raw,Undercooked or 16 Proper Cooking Temperatures for i Not Otherwise Processed to Eliminate PHFs 1 �,�,,,nr�t 3-401.I1A{1}(2) Eggs- I55`F 15 Sec. � Pathogens,' Eggs-Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Sheil 3-401.11(A)(2) Comminuted Fish.Meats&Game Ems* Animals-155'F 15 sec. 3-461.11(B)(1)(2) Pork and Beef Roast- 130'F121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Rattles,Injected Meats-155`F 15 ! 590.009(A)-(D) Violations of Section 590.009(A)-(D)in see.* I catering,mobile food,tempora y and 3401.1 L(A)(3) Poultry,Wild Game,Stuffed PHFs, � residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-I65'F 15 sec,* # above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3401.1l(A)(1)(b) All Other PHFs- 145'F 15 sec. 117 Reheating for Not Holding I VIOLA77ONS R=LATED TO GOOD RETAIL PRAC77CES 3.403.11(,A)&(D) PHFs 165-F 15 sec.* (Items 23-36) 3-403.11(B) Microwave- 165-F 2 Minute Standing Critical mrd non-critical violations,which do not relate to the Tiace* foodborne illness interventions and risk.factors listed above, can be i ( 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3403.11(E) Remaining Unshced Portions of Beef 1 item I Good Retail Practices I FC 590.OW i Roasts" 123. 1 Management and Personnel i FC-2 .003 f 18 I Proper Cooling of PHFs 1 24. 1 Foal and Foci Protection ! FC-3 .004 I 125. ( Eouinment and Utensils i FC-4 .W5 i ( 3-501.14(A) Cooling Cooked PRFs from 140`F to 1 �6 i WaW.Plumbmq and Waste ! FC-5 .006 { 70°F Within 2 Hours and From 70'F 27, 1 Physical Facility FC-6 .007 to 41`F/45'F Within 4 Hours. ° 1 1 28. Pasonous or Toxic Materials FC=7 .008 I f 3-501.14(B) Cooling PHFs Made From Ambientt 129. j Spezia!Requirements .009 Temperature Ingredients to 41*F/45°F I Other I ., Within 4 Hours" s•u::,,,.,�<.:G 'Dmoms critical ium in the federal 1999 Fwd Cale of los C±Ni 590.000. Massachusetts Departm�,nt 6��Pj btic Health �a em Boarc of Health Division of Food and Drugs '"11 Y X120 Washington,Street,4'" Floor 9 mC C� Su -� C Salem, MA 01970-3523 FOOD ESTABLISHMENT WSPECTION R&ORT - v -<�,Tel. (978) 74`-.11-1800 Fax (978) 745-0343 Name rr ' } <baw, Throe of Operationts), Tyge of Insoection �,A -_ C. Food Service @ Routine Address I =Risk Retail ❑'Re-inspection 11 A Leve Residential Kitchen Previous Inspection Telephone Mobile Date: Owner ` ACCP Y/N ,Temporary ❑ Pre-operation 1�0 ern I Caterer ❑ Suspect Illness Person in Charge(PIC)( Z'�nr V 1 lime I LT Bed&Breakfast E] General Complaint /sr:ni i � ,/hn /.+'1 In:4 ElHACCP P Inspector t, In�1 a�i �, i J i i �� I\061i. / 7 ermit No. ❑Other Each violation checked requires an`expllanation on theInarratjve page(s)land 'i 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 immedfate corrective 590.009(E) /❑ 590.009(F) action as determined by the Board of Health. .__-.� . FOOD PROTECTION MANAGEMENT' _ -•,�, , ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ; i [(� 13. HtON ash Facilities EMPLOYEEHEALTH �IC.�1 / PROTECTFROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC - - ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded O15.Toxic Chemicals "FOOD FROM APPROVED SOURCE - ❑ 4. Food and Water from Approved Source j TIMENEMPERATURE CONTROLS(Potentially Hazardous Foods) . `•; ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures '❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18,Cooling PROTECTION FROM CONTAMINATION ❑ 19, Hot and Cold Holding i;1L�L1 8. Separation/Segregation/Protection ❑20,Time As a Public Health Control LJ 9. Food Contact Surfaces Cleaning and Sanitizing • REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP _iEl110. Proper Adequate Handwashing I . 11. Good Hygienic Practices CONSUMER ADVISORY , ❑22. Posting of Consumer Advisories A Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions �J 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 5 23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations J i 24. Food and Food Protection (FC-3)(5900.004).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 G 1 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: ' I L 5 5XIns IFOa 14 dw U ((/'L7 h. .42 �� ��4u ,:�.0 f �: � _��,! V✓�_ Fri Z�� Inspector's Signature ,Print: PIC's Si ature: Print: f Pae of-Pa es \A6}t4� Ll=f� J I g g r ' Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 18 Cross-contamination 1 590.003(A) Assignment of Responsibility* I 3-302A 1(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* ( Cooked and RTE foods* 2-103.11 Person in charge-duties I ( I Contamination from Raw Ingredients 3-302 1 I(A)(2) Raw Around Funds Separated from Each EMPLOYEE HEALTH I I Other' 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 13-302.11 If 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* I I Contamination from the Consumer 590.003(G) Reporting by Person in Charge" I 13-306.14(A)(B) I Returned Fora and Reservice of Food- ( 3 590.003(D) Exclusions and Restrictions* I I Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions i I Food 1 3-701.1! Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* 141 Food and Water From Regulated Sources ( 19 Food Contact Surfaces 590.004(A-B) Compliance with Food Law'^ ( 4-501.1 1 1 Manual Warewashing-Hot Water 3-201.12 rood inn Hermetically Scaled Container* I S:miti::ation Temperatures* _ 3-201.13 Fluid Milk and Milk Products* I 14-5011 12 Mechanical Warewashing,Hot Water 3-202.13 Shell Eggs* I Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* I 4-501.114 Chemical Sanitization-temp., pH, 13-202.16 I Ire Made From Potable Drinking Water* concentration and hardness, * J 5-t01.1 l Drinking Water from an Approved System- 4-601.1 1(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean' 590.006(B) Water Meets Standards in 310 CMR 22 Wt 14-602'11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* J 3-201.14 Fish and Recreationally Caught Molluscan 14-70111 Frequency of Sanitization of Utensils nd Shellfish'" I Finrd Contact Surfaces of Equipment 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 ( Molluscan Shellfish from NSSP Listed I Chemical* Sources* - I Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing Regulatory Condition-Hands and Arens" Regulatoryy Authority 2-301.11 Cl I ( 3-201 IS Shellstock Identification Present* ! ( 2301.12 Cleaning Procedure* 1590.004(C) Wild Mushrooms' 2-30114 When to Wash* 3-201.17 Game Animals* I I it I Good Hygienic Practices 151 Receiving/Condition I I2-401,11 Eating, Drinking or Using Tobacco* I 13-202.11 PHFs Received at Proper Temperatures` 12-401 12 Discharges From the Eyes, Nose and 13-202 IS Package Integrity" I Mouth* 3-10111 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting` f 6 Tags/Records:Shellstock I 112 Prevention of Contamination from Hands 3-202.18 Shellstock Identification'" ( 590.0(4(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* I Employees* Tags/Records:Fish Products I 13 Handwash Facilities 3-402.11 Parasite Destruction" I Conveniently Located and Accessible 3-402.12 ( Records,Creation and Retention* 15-203.11 Numbers and Capacities* 590,004(.1) Labeling of Ingredients` 5-204.11 Location and Placement* 7 I Conformance with Approved Procedures 15-205.11 I Accessibility. Operation and Maintenance_ /HACCP Plans ( Supplied with Soap and Hand Drying 3-50211 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging, - ( yg I gin„«,criteria' 16-301.11 Handwashing Cleanser,Availability' 8-103.12 ( Conformance with Approved Procedures* I 6-301 12 Hand Drying Provision Denotes critical neni in the federal 1999 Fuat Cale or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:T<P.M-�I'a'tti�aQ�, �_��� u pro.,. �^ Date: MI - ,v- i 0 Page: of Rem Code ( C-Critical Itemv DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item PLEASE PRINT CLEARLY -- 2A�n verified ^ {� �(ft-'y�_ `w' �7;brD an.A I-Q,0?4alk�2 r1 �l ur ','�,y�c�l! �Dc (�(.�a, �� lGi o�/l°z to A r??AA n �l � 4nn 1�1 t�h T ,JCS I/�IAA ,h V( ' I�r111�1 (�, Gl (�ra,tVl��� U1 (� `/� Y V C 1 ` EO ��('�)i,r L�J'// �G�_L .-I I I (@DU_n_,I Past " T) ii , upNS, �n,- e A/%n�,_, P. C� Pt12M. ,?ll/ A.8) an/V ��a, , — �(nOld �nP r��114 fl �r, rrv, -� � rlr��(o1D, ) ��o� nn I XV YAC r��`Y7lt,t aN''l ( 4Z(- (AoO Iv AM On X^ .VnA9 Lafln r� iYT/n'�. IM7lT �tttP lY/� P7 Pn T I >a,?h� CAke71) M,Ory Yw.2 � w rnMoPo (Q, AAe \Ctrc,v Discussion With Person in Charge: Corrective Action Required: I ❑ allo ❑ Yes { I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ 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 dollarsuspension/revocation of El Embargo ❑ Emergency Closure ,,r your food permit. A A A, ❑ Voluntary Disposal ❑ Other: V - I r 3501.t4(C) PHFs Received at Temperatures Violations Related to foodborne Illness Interventions and Risk According to Iaw Cooled to Factors atoms 1-22) (Cont.) 41'F/45°F Withia 4 Hours. PROTECTION FROM CHEMICALS I 13-501.15 Cooling Methods for PHFs 1 I ( 19 PHF Hot and Cold Holding 14 Food or Color Additives I 3-50L16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(1 41°/45°F* 3-302.t4 Protection from Unaporoved Additives* 115 Poisonous or Toxic Substances I 13-501.16(A) Hot Plus Maintained at o above 7-101.11 Identifying Information-Original I 140F. Containers* 13-501.I6(A) RoasRoastsHeld at or above 130°F. 17-102.11 Common Name-Working Containers* 120 I Time as a Public Health Control 7-201.11 Separation-Storage* I 13-501.19 Time as a Public Health Control" 7-202.11 Restriction-Presence and Use* I 1 590•004(H) Variance Requirement 17-202.12 Conditions of Use* 17-203.1] Toxic Conminers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria* I 121 3-801.11(A) Unpasteurized Pre-packaged Juices and 17-204.14 Drying Agents.Criteria Bev-ra s with Warning Labels* 7-205.11 Incidental Food Contact.Lubricants* I 3-801.11(B) Use of Pasteurized EM* I * 13-801 11(D) I Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria Raw Seed Sprouts Not Served. 17-206.12 Rodent Bait Stations* I 3-801-II(C) I Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERNTURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for I Animal Foods That are Raw.Undercooked or PRFs No Otherwise Processed to Eliminate 3-40i.11A(1)(2) Eggs- i55T 15 Sec. Pathogens.'`r`1 Eggs-immediate Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game Em* Animals-155°F 15 sec.* 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 1 3.401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Gate,Stuffed PHFs, i residential kitchen operations should be Shifting Containing Fish,Meat, I debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. * I 17 Reheating for Hot Holding I VIOLATIONS R LA TED TO GOOD RETAIL PRACTICES 3-403A I(A)&(D) PHFs 165°F 15 sec.* I (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standingf Critical and non-critical violations,which do not relate to the Time* J foodborne illness interventions and riskfactors listed above,can be 3-403.11(C) Commercially Processed RTE Food- found in the follaming sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsticed Portions of Beef 1 Hem I Good Retail Practices FC 590.0w j Roasts" I 1 23. 1 Management and Personnel I FC-2 .003 ,) 118 Proper Cooling of PRFs 1 1 24. Food and Food Protection I FC-3 .004 3-501.14(A) CoolingCooked PIs from 140°P to 1 25. Equipment and Utensils FC-4 .005 1 26. Water.Plumbinq and Waste i FC-5 .006 f 70°F Within 2 Hours and From 70'F 1 27. Physical Facility FC-6 .007 t to 41017/450F Within 4 Hairs.* 28. Poisonous o Toxic Materials i FC-7 .008 j 3-501.14(B) Cooling PHFs Made From Ambient 129. Spaniel Requirements j .009 I'E Temperature Ingredients to 41°F/45°F I i 30, 1 Other ! 1 Within 4 Hours* 'Denotes critical iter in the federal 1999 Food Cafe m 105 CMR 590.000. 4. Al v Commonwealth of Massachusetts i City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo"etail Establishment Permit DATE PRINTED: 12/14/2011 ESTABLISHMENT NAME: Fantasy Island Restaurant File Number:BHF-2004-000138 515 Loring Avenue Salem MA 01970 LOCATED AT: 0516 LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2012-0034 Jan 1,2012 Dec 31,2012 $420.00 ESTABLISHMENT Total Fees: $420.00 x PERMIT EXPIRES Oecelnber 31, 2012 Il Board of Health r'1� This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a.prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS Sa '! BOARD OF HEALTH 120 WASHINGTON STREET,4...FLOOR TIa.. (978) 741-1800 KIiv1I3ERLFiY DRISCOLL F_\t (978) 745-0343 MAYOR 1Lamdln(( nelem.com LARRY RANIDIN,RS/10:1 IS,CI IO,CP-FS I-I F,\i xi I A(i l'.N,l, 201_ APPLICATION FOR PERMIT TO OPERATE FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Offh }SY �S 47V V 10qk6 IfJ0 P' TEL# 6) �g' �y'��'/ / 0 � ADDRESS OF ESTABLISHMENT S / I�0 n'/� 6 AtiC—S M.4 FAX# N 7 b' 7 (FD MAILING ADDRESS(if different) EMAIL- Business': Website: D � I tl OWNER'S NAME 3�/1/{� f� b*0 TEL# k/� �Y JCGZ 1 cA--e_- ADDRESS I �Li-fm rA,.�2 Hl9n4L-wt' , ",f- 01 9Y- STREET (ins.�' r -TY10 1, I STATE &7-�6 V OY6 Sn CERTIFIED FOOD MANAGER'S NAME(S1 1 �W�T14 QL14-Jb" -oJ 1� CERTIFICATE#(S) 5/ -J qti- (Required in an establishment where1.potentiallpy�hazardous food is prepared) ISI ?>/ y C� EMERGENCY RESPONSE PERSON ,/660 44* � HOME TEL# to i 2 _97 V A z3`°� DAYS OF OPERATION- j Monday. .! Tuesday j ,Wednesday j Thursday !' . Friday,' Saturday Sunday j HOURS OF OPERATION r 3 0 I( 3 p q° 1 11 3p�M 113 e, -vq ; 1 1 :?i D,+/6: 113fj l�—Nve� Please write in time of day. (Forexamplellam-11pm) j 11'"'-'.10A 11130PM ! 1130 i ((•,i�Ltj•yvti 1 AIA l A"M i/ 30fn/ TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - ---------------= -- RESTAURANT -YES NO less than 2----5 sea-ts =$14-0---- (Outdoor Jrcli Vilify 1 oad Ci111 y210) 25'012 udGI5 =$28V more than 99 seats -$4�U BED/BREAKFAST/--------------------YES NO----------------------------------------------------------------- $100 CHILDCARE SERVICES/NURSING HOME - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state tax s required under the la Signature -- • Date Social Security or Federal Identification NtIlnber $1� '1 Updated 523/11 FOODAP2011.adm CheckH&Date I Cj�[ � Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Fantasy Island Restaurant File Number:BHF-2004-000138 516 Loring Avenue Salem MA 01970 LOCATED AT: 0516 LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0220 Jan 1,2011 Dec 31,2011 $420.00 ESTABLISHMENT Total Fees: $420.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS * BOARD OF HEALTH 120 WIASHINGTON STREET,4`FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL F AZ(978) 745-0343 MAYOR DGREENnAUNlna SALEN4.COM DAVID GREENBAum,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT PA-N'7fY�51Y -LS 1/h7,� V E %A21�yh7 TEL# 175 5� /70 O ADDRESS OF ESTABLISHMENTS/ iir/ /L /Nb 411t�- SM,&,Ll/��AX# q 7? 7 V0 912-1 MAILING ADDRESS(if different) EMAIL- Business': A-0L Website: OWNER'S NAME Da�t)" 14 IA-" TEL# (v (7 ?-3C( e62--? ADDRESS / M�IS . �'IfI 0/ q s`r STREET r4-;,Q6, K#-k)6 'y&P/ _ STATE S// -7 V-Gk ZIP CERTIFIED FOOD MANAGER'S NAME(S) Wb( &1 A 7� G. N-u -,3(o CERTIFICATE#(S) S^/-7 9-k 7� (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON DF;30 ,ea-14 ,410 HOMETEL# V' IfDAYS'OFOPERATION;1, I I; Monday—. ,I . ;Tuesday ;;-.-,Wednesday,F.:, =Thursday : _ HOURS OF OPERATION I( 3�f1✓1) q:joAft, 11 ,'30" OA-M; 41 ,'3 0 -Yy Please wdte in time of day. (Forexamplellam-11pm) II , :111.'3 OPM : /;L A^^ i2--14M / DU 4✓kq j 1, DOdl'M 11,2-4141 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 R---E--S--T--A---U--R---A--N---T----------------------------YES------NO---------------------------------------------le-s-s-th-a-n---2-5---se-a-ts---------------=-$-1-4- -0---- (Outdoor Stationary Food Caii$210) 2 -99 seats -$200 more than 99 seats ----- ----------- --------------------------- -- ---------------------------------------------------------•---------------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES/NURSINGHOME ---------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. I I f 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 faze required under the law. ' Signature Date Social Security or Federal Identification Number Revised ionli I FOODAP2011.adm Check#&Date I `1 b�1 I 1 I �a- $ Q 117) �,_ ....f "a v* ,+..,,.naw--r ...,-'I�.r,•,,. +, r1. . . .,r+,..,.,,;_ ,,.,41._.-.1�. t All.M�: a �..�....�+W-..n^+P'•'*,�'1 ..., Massachusetts Department of Public,Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4th Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT- Tel. (978) 741-1800 Fax(978) 745-0343 Name t� Date Type of Operation(s). Type of Insoection M� A 14_10-0q I I Food Service ®® Routine Address � �j Risk Retail ❑Re-inspection Jr\ �G /a AA/tir ,r\r 0 Level ❑ Residential Kitchen Previous Inspection TelephoneElMobile Date: q -lK '► �:5�� `7no Ownerp, I HACCP YM El Temporary ElPre-operation P IIA v� vvl ❑ Caterer ❑ Suspect Illness Person fn-Charge(PIC) \ I�v`G Time I ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires aiPexplanation on the narrative page(s) and a citation of specific provisions) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking /Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E).12 590.009(F) action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties _ �C] 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 ', {-/f--'-- D E] 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18• Cooling PROTECTION FROM CONTAMINATION - ❑ 19. Hot and Cold Holding 0 k_I� 8. Separation/Segregation/Protection ❑20.Time As a Public Health C41rol C�i[5 ' 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)' ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing �PA1. Good Hygienic Practices CONSUMER ADVISORY n P 22, Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related ❑y 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 by a Board of Health member or its agent constitutes an J� 23. Management and Personnel (Fc-2)(ss0.0 4) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-9)(990.004) cited in this report may result in suspension or revocation of 6'1f/ 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food �k 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 501nsp cfForm-14 dw t J( Inspector's Signature: �n Print: PIC'sSignature: � 7Yw>, Print: 3"Awts L�i�c� Page t of ages . r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT' j 8 Cross-contamination j I 500.003(A) Assignment of Responsibility' 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of hnowtedge Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-3021 liA)(2) Raw Annual Funds Separated from Each EMPLOYEE HEALTH Other - 2 590 003(C) Responsibility of the,person in charge to j Contamination from the Environment _---� require reporting by food employee, and j 3-302.11 i A) Foci Ptote.tion^ applicants', j 3-302.15 Washiu¢Fruits and Vegetable; 590 003(F) Rcsponsibilit)Of'A Fad Employee Or:1n ( s-30.1 It Food Contact with Equipment and Applicant To Report In The Person In I litensilO Char€cX Contamination from the Consumer j 59().003(0) Reporting by Person to C'h arpe* j 3 306A4(A)(B) Returned Foal and Reservice of Foal* . 3 590.003(0) Exclusions and Restrictions' j Dispos.¢ixi of Adulterated or Contaminated 590.003(Ft Removal of Exclusions and Restncti,,ns j j Food 3-JUi.11 Discarding or ReconditioningUnsafe FOOD F IOM APPROVED SOURCE rood* 41 Food and Water From Regulated Sources j ( g j Food Contact Surfaces j 590.004(A-B) Compliance with Fwd Law" 4-501.111 Manual Wdrewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container" S:mitization Teniperamresr, - J Ilof t3 Fluid Milk and Milk Products* j ( '4-501A i2 Mechanical Warewashing-I-lot Water j 3.20-7.13 Shell Eggs* j Sanitization Temperatures" j :-202.14 Eggs and Mill:Products.Pasteurized:" 4-50 1.114 Checmeal Sanitization-temp.,fill. 3-202.16 Ice Made From Potable Drinking Water* j concentration and hardness. " i 5-101.1 i Diinking Water from an Approved System* j 4-601.1 I(.y) &lu`pment Food Contact Surfaces and I 590.006(.4) Bottled Drinking Water* j Utensils Clean" 1590 O(K)(B) Watet Meets Standards in 310 CMR 220'' j 4-602.11 Cleaning Frequency of Equipment Food- Contact Shel(frsn andFish Froman Approved Source 4-702.11 Surfaces and Utensils k 4-702.11 Frecuencv of Sanitization of Utensils aid 3-201.14 Fish and Recreationally Caught MolluscanFoodContact Surfaces of Equipment* Shellfish* ; .1-7()3 11 Methods of Sanitization--Hot Water and 3-201-15 Molluscan Shellfish from NSSP Iisted Chem!eat* J Snurces* Game and Wiid aYlushrooms.at pprovedby j 10 ( Proper,Adequate Handwashing ' j 2-301.11 Clean Condition a RegulatoryAuthority ! 1-Hands and Anus' j 3-202.18 Shcllstock identification Present* j ,2-301 t2i Cleaning Prix:cdarex j 590.004(C) Wild Mushrcums' j 2-.;01.14 1 When to Wash* 3'201.17 Game Animals° 1 j 11 j i Good Hygienic Practices j j 5 Rece,Mng/Condition ) j 2401.11 I Earing.Drinking or Using Tobai.co'' j 3-202.11 PHFs Received at Proper Temperatures* j ( 2-101.12 I Discharges FYum the Eyes, Nose mid j 3 202.15 Package Integrity- j Mouth' 3-101 11 Food Safe and 1 inadnitetated* j 3-30i.12 Preventing Contamination When Tasting* j j 6 Tags/Records;5hellstock i 12 Prevention of Contamination from Hands j 3-202.18 ShellstockIdenti0catinn" 590.0()4(E) Preventing Contamination from 13-203.12 Shellstock Identification Maintained' L'mp " j iovees* j TagstRecords:Fish Products j j 1-3 Handwash Facilities 3-102.11 Parasite Destruction" ( Convenlently Located and Accessible j j 3-402.12 Records.Creation and Retention" j j 5 203.11 Numbers and Capacities* j 590.004(7) Labeling of Ingredients" ( j 5-204.11 j Location and Placement* j 9 Conformance with Approved Procedures ( j 5-205.11 j Accessibility.Operation and Maintenance j /HACCP Plans I Supplied ivdh Soap and Hand prying 3-502.11 Specialized Processing Mefiods* ( Devices _ 3-502.12 Reduced oxygen packaging,criteria' ( j 6-301.11 Ffandwastnng Cleanser, Availability 8-10112 Conformance with Approved Procedures* j 6-301.12 j Hand Drying Provision Denotes critical nem in the fe lend 1999 rood Code of t05 CNIR 590.000 CITY OF SALEM nx ��� �BOARD OF HEALTH , Establishment Name:�rV� ?.HoerLV_o_ v ,n ( Ary - Date: -L�-(7� Page: c,)-, of CL Item Coda C—Critical item �\ I Date DESCRIPTION OF VIOLATION/PLAN OF CORkECTION _ No. Reference R—Red Item '• ' ) I ..-W ! 'EPR 1 �(' Verified b(�U / t AU/�9 PLE�SE PRINT CLEARLY I r�/WL X�DA/tl �/ /A On - 1II 1G) G—(��A4�� RI I X,PA q, _Jxka.n,/,,}t,.;, ,f' Z- 'Pnm(a=ccfa�/1 r' i t-�rG) 1,*_1 f1�QlA��.D(� A_ ) v liolro � ° ✓> /�J( �L'Od', )f�' /LJ r I' ' f II(/, I _)j r/fi n 4 L I �IIYW ,M/V xC�v` %fiUG�D��n JjG -(Pd t- CAA D/IM Ct I,Uru 1,41 LU I s Ia a u `(JFK; f)r, ()k I I 1(00C) n�t/ t�V Pn1r� ( SAP. CC4\S% ( A nAn ,, 10 ( ),0/1 c�\a,'UA lk /� 1 f-J-Pnn n, J(A�>) (-YA D lln� f k�pn`� �X D (,�P? P t V K P_ 1 > (jA opo _ AAP_ Se lk�ti' rAQILA 1 / N1PAA /1 (Jln?� iv\P 1� �� n _ - 1 [ %{ff�'I M r�,� �tZ)!).D , non��� i t �''�J1L � �n P� , ��rnv� Y . \)V-A�t/) tAl o� Gv 7r/ZAn e, ao- 4-VA1 , �.L1ZlX L� S,w lY�.ri.� \,nr vl �Yrn v -�i,.�if cam - Az \00 �1l/ aL \re� I J,-J)_ AA 0,9-0 �>, V) � \ Yan)'-A JPtn .k Af.(,e \, moi', STI C`r ,\7)���n�,rI_ n.V(�i_)lJAu r�/a ,, L_ 1�.I{/^ �r-nn.1 a_A,1Yi 7'/ 0�1 '— �rA 1 �(1 i. a , 1 4� �` V 1Y� `]Q Y ,1 rDiscussion With Person in Charge: Corrective Action Required: I ElNo I�❑f Yes V_ 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 y ' Exclusion violations before the next ins P LJ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that anoncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ,1 ❑ Voluntary Disposal ❑ Other: JJ ✓ v ?-SUI.i4lt.') PHF&Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cowled to Factors(Iters 1-22) (Cont) 141'F/45'F Within 4 Homs. * _ PROTECTION FROM CHEMICALS 3-501.15 ( Coli ing Method,fix PHFS 14 , Food or Color Additives I 19 PHF Hot and Cold Holding 3-2U2.t2 x ?-St11.16fB) I Cold PHFS Maintained at or below Addttn ca" 590(Mlz(1 ) 410145u F- 3-302.14 ( Protection front l;nappru ed Additives t 3-501.Ibt:1) I tot PHFS Maintained at or aMove }> I Poisonous or Toxic Substances ! 7 !()1.11 ldcntifying Inti-:mahon - Original - -- is"ontainers` _ '-5ia.14t.11 Rt,.:ati Hcld at or.iboz e 130'F C,cannlon Tame R 'Cut,uun.:ra' 2-0 7 itR I 1 --�,--- ---- -..—"_ Time as a Public Health Control —i rk�*•t� I'in,c as a Public IIcalth Control ! i-20L17 i $spar'uott-Stn:aC.e" -` � -v :! `t>U.'?tilr}it ! V:rsr:e Reytnretnutt � '1D2.1i ! l:ntricdon -Prrs;:nci,u;d t.,e• 7-202._12 C',aulrti,xr:.-of Use° L-------- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203 f 1 loxia Container: -Prnb;hrbm,` POPULATIONS(HSP) i ','-20.1.1 I J.,mwer,,Criteria -Chc•nti,a'.^ 7-2N.;2 Cjmaaal�A,t "N'•r hm}, CC,iter.c;, =1 e -TO? I1,U Unpaaeun.cd Prc-pacfagcd Jmc<s wtd ! j 7-204,14 Ur,vth:Y✓cote,t'nt,:ria_' ze<«ith Wfuninf,labais' j . -80! 11113; C's:of Pa,wimzcd Ev,v ° '?QS i. ln:id::mel t•Axl Conlnct,i,thr;;:an!s'-'-- <-;`: , --- i L.l IfDf Kati ,or Pnm.ci!•+Ga?ti'd:larma( Pahl and "Ob.l ii{;.;n;.t,:n , sr (e>nirdc: (.'rrtena` Kana ti.cd :ysoatr \-v Screr.i. 7"2390.12 t:cvi•^e. fieri S1;mort>- --- t•.NR .n�.l ci Pa:i;as:r lit l P,n+der, (lilt Cowl.,,f : .,::u —..--._-._--_--- Ilrcntn:r:'. CONSUM.ER ADVISORY T{P!E!fEMPERAl'UP,E CONTROLS ?= :,n: Rt ; ,,,, (',rzt,,i :,if,C ousnt:,l'ti„n of i ! 0 lg Proper Conking Temra Tempel a4us for 0i r$het c; �: I PHFS r -(Oi 'i.\(I I,�i r' i5,5;.x,. _ _ ._..____- Fi�:- -Untaad:etc Se:,:iu ;f:. I'll, =.awshell1IS:ec - .attL.'1tA)1,. (-utz',;rrnh'al',.n. ti._t. .. C'..m, --- - -- - - -;-------- - -' S7CIUa R ,M LAL HEQ ' ENTS -.Li1!113r'ip? Pitt, anti blotkeact I `irti- 3i; r,i:.' _ ------- St':ifu - HiSX'r`I`,t ,Dl d,H.1•(AR_ k.,+nc , i,u•�:ra 4u qsp I�, (r�!. ,+�,,d � - and 5 :t1.lieA1, 4, ! Pilo 1o;.b,iIjGar'::. Slit hi,i ,,Ir(, 1t,:r2. il '. iihcni?p;:_b:;n,:,taaldt:r S, ;'.,ntan,:n• ris!z, gSe,,:. .:r3':p:'rl :r:tri lill:, ,r: !,rlfit tCt 1!om, r i:_ :t.,.-!. a .•t•r,. 118 .. t ' t q;'8rapnq for"1,yt 1_rta!n4-.._ -- VilATiONS R .- - ._ L,' - `^ ,. cL.'1tEi Ct7ix`7fi,'9T+'eTs})L F`f�srC'T:'i"v:; r. : titewk 21-3w f03.1 l tit \11,,,n,a,.; ins' 1 ? Ahntn,St:mdut j C;'i': i -r:J 11"n-, ::..al r ::t...':,. .. :,h du me Z.Ilt 1 fit, ( ,ti+. ;•arz':r. :atx'r':n. y. 'n: nratt.,•i, .o,::r'i>x kk.l .', 6vrdrrnrc. ,<m Lr• r P}3.1 J;0 n:nct.;e!h {leas tJ ft'I'I' E,.,hi 7 ;nd is:. , r.. n, a;: r boat C'a,. ..:.f I":C,i(R I tU r, -40> ;IiEn i ox�.;unin:' 1::,,ii.c.J trern -`_.{;nod Retst:Pract,ces FL - i i 1_t-_^ Managn,ne atadr _ -_60I: da, Pror Cooling of PHFS OIXI1N 1 aiFPoi, ^orK -3 Gn,; -_ . Zb. Eeuipme"nta7 Uie•'s:�s __ __--_.--tf.,_ _ - S 5ilt.3;U ''t�iiute Gxth dPHFS front I}(:`F t+' "- -- - -�: ----- i - -- -' ' T'r-i5 ” R!thi»-i Hnnr. ° "Pw ,.: .. i _ Doti 1 l '=n a '7cr iV111:m 2 Hoff and From;'r l' - ' F"ys,ca•ractky--- _ FC -D GOT : i,: ?i" cc sJ,..�d5��i -�OX�r. t:7:?ir-i,:> ILLI: - > D(?t-- "__. ! 3 SW 461, Coolit, PHE Mvdr Flom :mhtjtt :' S"ru'al r,.x:txrerre;lv.: - - Tcngrranachr8redit:nt',it,-+J`P%•151' 3" imp, . i`.onm u i l.an . . .' n lt*'n..o, Y. ••i,,., i. ,t '.ti. )t)',Ula., J 4 CITY OF SALEM BOARD OF HEALTH Establishment b t AZ 1 A Date: W_t n-fq Page: of Item Code C-Critical Item JvDESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item � PLEASE PRINT CLEARLY f Verified � 0A_' I D) W\' InAA A/ I , ,V (n 4)Ar\ fxQtQ _.Nb _f1(Y)(` Lr 1 / � ` V I^ , • jJnvi / V'� f�Vlitl. Y I P.aQI (J� P_+in C� V JC A .l1 !/L. h�/l.�!/1_ �C/lpw. � '��/Vln�c>r/ •Pn x0.,.- , A� PA 0 A - (q)p 4-6�\p n_ Ile�Vvi.o,� ill '1 t;F (iln o,.. ;u.< Y c vl � I, '�Vt'( rn�z,,t Q Y_ka -�n,. , �j n ���.1 U1 .-. - Ut P\tel \ -IJ_ \a%�—, ' Y f �ijl - t �(�a 1� j 1/A 073 1 n,. �l/�� v-e,' .1_ 1 _ \v�✓In Le 1 1� �CQ/Y\1 ��,7_�On �n_ �( �D/Y X�n� V_e`�P0,e_A �- } y 1- ,)(i ivIDn Fnn t,� \r(�ie A- Civ\ _ YJ C_OoA i_v n Y/\rnXy:s� 1/!- / `-'Y��1 /�� V / i n."l ��./t"p OA;,f 9v1 �1 LLQ'V �.;7� 6��� �1Y�/ l� I �Q � -�•' -�'Vl(�t0 Ctn_o.t.(�.rV ` tA10,on� C �n� �D�O + p ��. rl�(y� n �y..z /\ . • Dien �� rni �J Yn yr n x Pn. I C� 1)A111 rnn`S ri l/n , r� ( .Pit OM n t v n_r ,��� l7PDQ . �rr�� �o,��>�� ()pA/L_Q ';,.A (11\17A/./A n .in i A I I-FlY N/n/..A T !a.t.l • a/J/\/V�nn.�7l _ Discussion With Person in Charge: I Corie'ctive Action Required: I ❑ No I`C�Y Yes ► f / 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. LI^^� 1) ❑ Voluntary Disposal ❑ Other: - v 3-5411 1d(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk Aticording to Law Cooled to Factors(/tents 1.22) (Cont.) 41'F/45`F Within 4 Hours. PROTECTION F130M CHEMICALS i 3-501.15 Cooling Methods for PHFs j j 14 Food or Color Additives j 19 j PHF Hot and Cold Holding 3-501.16(B) I Cold PHFs Maintained at or below j 3-202.12 Additives'" � 590{N)4(F7 41"/45°}:- ?-302.14 Protection from lh}aPDru;ed Additives` I 3-501.16iA7 Hot i'HFs Maintained at or above i 1S j 1 Poisonous or Toxic Substances 7 101.11 r ldenuf im,. Infiautanon - 0n"incl 14(t'F. Y ?->tN.l6{A7 Roasts Hcld at of.,hove 130°F. + t t ontainer> i Time as a Public Health Conti of + i 102 1 ( _ ' Comnznn Vsmr - 441, rF in2 i,,oram�rs` �-'tl -- --- i t.11 � -t-Srrn: aeon- 4tr •1*,t1.!'.};)I4r'H7 fi . t public Health<nnuoi' 7-202.11 Kc,trit4:ou-Yr<'at nu'.uza t ,e' -------- --- - j 7-102.11 j f' Ont of Use" 1 ! REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ! '_03 (i `rr,xir C'nntainel• -4':et1Gln:��.:n,'' I 2@l.i l j lanitiret',.Criienu--Cbnnicnls' j POPULATIONS(HSP) j x 04.12 C'htnti.'ak fol NNa,hiee L!'r,t.;urc,C ritcra' It :-1`}, I N,%) L'npaaeunu:d f're-pock:sed lw4es wid--_� ---"------� I I Rever.t2ea t'-itlr 4inrrinr labels 7.(04.14 Dr,im,Ar etitt.C'nteru_r' ! - 1l _-_ i <-Rtt: I tits} t;,:r,t Pa,trazized f:ca:'" ' 7 305 Lnu;ental C 1-.x+tl on4a;a Lehr:cants' ----1 ( j ' bdl I It!)) i>.n+, or P,uuall'. C,�rk:d Antm<il Rx J and 7-206.11Rc:.in,.n'Q 1'sr Pa:nudc'> f_ttre!ta' .ipnan, hot 7-206.12 1 R+xkc: t3,:,+ 1 _.._ . .-_.._-._ }'ai.sl:' ,1or r 1 1 306 13 Rr fer.v, 1 ,binnro;n}:� I ------'____J _ CONSUMER :' }{,i,: ( t t:,z,unzcr •ki,tsn+v i'r,.zi�,7 1;!r C.nt:am,ti,tn of TIMEITEMPERATURE CONTROLS �..__ , . .:.} t- vnl. t}za: est R:,;., t'uticrax,ycd c: 16 j Proper PiiF-s ConAirig Temperatures for ' �•,.t hz:;rc,iSc Pn,;essr,i:e ill,till i-101 11tf U( Fvv', - 155 F 1 15 511 1 --- - - - - - - - - '----�- --- t+ae: —t_,. •-lnnnrd.ati S_��In e.. ' .u, t'( 1 •'' l,:,r;;;l;;p::.'(1.i..`YCn'c C: i,,.lit , ! __._ nzi*, _ aronc.(_Itd_F1Gf'_.SitREMEiVTS.- IiAli%1 Rd,{,t li.l•• ;,, 'ii ab i`S is i` •, .t:r dill -401.1!Chi'.3t i': +i a;,Wild 5}'!I o:PHF7 _ rG.t:`'nP :! S74Cnen :(h':::i ifii'r th oold 15,: 1 Str,i'.',:P f,7intt'itt of F!sh, M-;— n;'F'rrCF Bail", flit' htfe ! ! 3 . .. ..._�_ __ - _____ - •- .. - ... ..4th e , t r , m *;,i +, s r." 6-0 .. .. `3 toiiI, l ,_ _- - ;3 _.f,A li-E„; 7t_, f? RETA ti. i 4113,l f,A­ ( i'i-tb• it„„<'"7 ,� .0 _ _ tlleza4 i_387 _103,11(b, 11,oow.,w i,?' 1 ^ 11 1 t, i nS it C,' ,'. r, r "u,,. .L.;:r7.. rr ,tr;r{.:r ., .. 1 11{1" d R, r4. ,rla:'±. .."J:rid.,I .In,;l it 1w wise ( � ,.{:L%,.,,r c r;y 1'r' -ih° 1itC`: t•'nanez:Iaih 14... ...E„' R:'i 2..;,t t _R ..... j ?.i li I; R',tn,unmr r l:rt l;nt; R,rIl �,o.;.o! ct, ,_ttsm Undo Rara,t Pr.:;trees FC. AtX1 s-j!; E k,.a,z•' « `Ianawrimt rt ane Pci:or reg _ � FC' ...?4 -_ _ - .-. .. _ _ .. • 24 Fc'xz n7,ti`o:7d P'_pip`Cpr C 1g Proper CoeEing or PHFs __'---- -- -- - - — -- - -- --- -F 2G t ` `iul i4lA7 C'tx,iine C:x,l;xt VHF, hntr I tt-I'to i tg - __ •:+er i.rnbo• _ ' pf _ 'JU yt. . `__. F 1 b '(- Within 3 Rory "d }7,nn'iii”} ; >7 Fd _F _^ ..,Ira i r t1:rz H,•t;', j rd . -. .., Kt !'J ri, --t7E7_ i t7Ul.id!f31 C of ltus,N IF,?i,trl. k om.Unh:eu[ ...... 6C,9 Trmp.reture a_3C- -'- - CITY OF SALEM BOARD OF HEALTH Establishment Name: Y(.7N �I,1 rP �I�k� enti i� 4�PST! P A a�1/6 L1 r Date: —I 11—t )� Page: 4 of 5� Item Code C-Critical Item J DESCRIPTION OF VIOLATION!PLAN OF CORRECTION Date No. Referent R-Red Item 1 � /� ( V M PLEASE /PRINT CLEARLY Verified � " ' V �I JIM A Y��YZ `� ('^' a_1 1 )�.011- r,..Cs� IP A_A/ - /�1.Q-P'AVA /Y�7) I lY-(F��I /F11Y l-moi/l 0-0, A,1 ,k Y�9,INA J I A vu ` e �2 . — �LP�c GQ \c-n (�K_. A)v�I — Hoin l9)aPh, (-^ '1-P, NAQV.Q--1 V)1_- 0k,91MV_jf,2 . P t I t s 1 j Discussion With Person in Charge Corrective Action Required: ❑ No D/ Yes , I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee Restriction inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: V it)1.14(C:) PHFs Received at Temperatures Violations Rotated to Foodborne Illness Interventions and Risk I According to Law Cooled to Factors(items 1-22) (Cont.) I I T145`F Within 4 How's. k PROTECTION FROM CHEMICALS ?-5(11.7 5 Cooling Method for PHFs 14 PHF riot and Gold Holding 14 ( � Food or Calor Additives � � 1-262.12 Additive," 3-561.16(B) Cold PHFs Maintained at or below 3-302.14 Protection Front UnapprovedAdditive,;' i 540004fFi 41`/45`F` t i tS61,16i A) I int PHF<Maintained at or above 15 Poisonous or Toxic Substances 7 (6L17 � Idaanih-mglntiamanan -Orlgsnal I 146'F. ' :2-JtH,Ihi A) klm„tb Held at or abovc 13011 i'ontainers' 20 I Time as a Public Health Control 102.11 I C'nnmou Namr - Wnrk n,t C,nua .ua '- r:.” _ � =--1- --- -- I '701 IP Fim�•as a Public health Control• 3i)t.I1 tirpzcictan-Stural;c` -� _� --�-'---- i "r0:ir)ar}il. --- 11'nriaecc!:eyuuemtnt-�-l- ?-2D2.1!--If 72ent,'ieUon- Pi-,:arice,mJ l 7-202.12 Glnd+aon,of U,a" j i 7-'.tit 11 ' -r<.r.ic C'initainel; -Proluht:i,ttl,,,; REQUIREMENTS FOR HIGHLY SUSCEPTIBLE i 26.1.11 5.mittcetti.CrIlerki -ChruliC.0111 - -- POPULATIONS(HSP) 7-204.12 ChemietlS lIq XNaI hit.Prodnce,(;Toz, a, ! 11 i_tit't !J(A) 1'ttp:,atunrcd Pfe-I,adaltcd Jao.es and i-?6-1.14 Urtin-;;:'hent..Cmcria'- -..-- Rcv!'rages with Warnui:; -- --- --- ------------ �-Skl; 1103) L. •(If Pa:trunzodEL-n` 7 '65,1} _ Imid:mwi F:+><I Conra.a. tuhr "- 1`7-206.1 t ke,Vu n'.d i'tic Pc•:!it.uiee.i-+cera' Pdti,9ll::Ci .,1 Animal FoIj acid kw', tic:d \ Spr"ut, n Rt>;4t rt 13 JIT Sdi IVo-, + Srrti•rd. �tuni(o(in°� - ` -- - ---- - - - CONSUMER ADVISORY TIME(TEMPERATURE CONTROLS I 16r. i -- Proper Cooking Temp^tatutp5 tN i -1h e:I IvrJ. 3'fr,n e:< k»>~. Cn:i�•lar.,4.cc,•: _ I Vin,,'1t31r• ii�c ! t tt tit t - �---`----- PHFs i .. , 7 i .tot H ( •' ! F-. .g. }' }j tar !-_' _- `'e_!±_:ren, nl �_P,.ai,•.:rl,_^,`, liar. hs!:!w, !a;'ii;:w'4Iic77 i nn,,&ac i I rini;;..;i., i?; i' L G�. 0l i _____ _ . ,: r .j- .__ - - _- SPECIAL �`,1`(11Lf{R6it.++ ' + 9ff t.i.QE}r1 . 1' I RIO, ::,:; ,.�',:.i kcl.'..4 F 1. ! (At( I'. ) ; •y^��,-- ,i _d.l•',. d'J•b,: :'t St',.Tdd! "j{i.($t`;!=.1 (it: L. .. �.it�ai 'tit:L i.; 't, i I ` :131:!t.i,� :ih•1'7!, f<n$.. WIIIPOI o,, .IPC 4i C. PnWrr, ld lid t4sm�:. i...°r,.PFF, I n':ad ;it .ti Li..rcn c•}'..<.t%r'a.: •,Itr;td „ , 'aud.• ,'t',,:a:an'rm, PI,n p'ec, i t r.t•i';ir:. li-d;,l f4, pri-p;imc ;t i:o!iy , .- ci lis:, . •. .. .. -77 ------- Il rtent:atin< for Hot P 3i% r, f r .- 1 .11:1.1':vl}t.,ii• Fill !C` t : °. sc,. ' ! ?Itktws 23-Jit) : .1{;2.1 IB; .-__" \4i.nm,,•..:- Ir-.^"(' )_ �11n10:•St.!n,1i'i, (`'o. .:,u.d,:,,n-. -,. ,cif � < . t:, •, , a'rrt-ii,.r,::d':c'r•tE< . .r,: ! ,, r. ..ri,r•rrr: '�(::,•.. ,r. .z,<•tq ,., rn<7:t:N:o:t(.,%<,t.t(nr, � .—i:l3.i It C) ,.ril ti(if :C 4( I- 1 34o3 .1 ; 413 t1(t:t Rtrrunit;C Ln,iurd Fv:no^.,of Fscrt Itear Good Retad Fract:ces FC _5:717 ON, f i+„a,:,• ” `.9aragernc:.t n-;d per.�q^nl ! Pi: ? , I�._.. _. 11R Proper Coaling of PHFs 7: tcuxi r,ad i=a:>n Fa:crCo, it shl IIt Ai I Clx,low ct.a,�'d PH!': E:nin I APF to t u,)ro@n,anti U:e.-e:.`}-- -- _-.._.___ _ .. _ .cr . . ,__ 7v 6141thtn ? tloure::ntl From i'l'I r, _ - --- "-c- ( tint+( f <"S I-CII oa& .,ter:47atrs:t:a - -�C-7- -- ri-5111.1 (Bi y Coo!;wr PHF Nlx,u.- F!,mt,AIDII]Cnt •°_._.. S��a_,.if R,-„iren:e:�'..___ ______ �__.___ L_ :' ._- .-jti -7"t t: ! _.air'� !�tgi�rndnre Int�rc,iic;.;" . 'd.) � �_ °•.- . .� L ITIIW I1 1!.9 tp::, , •r{ iDd l l}` , ai .".11: , tom' i a ` Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2008 ESTABLISHMENT NAME: Fantasy Island Restaurant File Number:BHF-2004-000138 516 Loring Avenue Salem MA 01970 LOCATED AT: 0516 LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0272 Dec 29,2008 Dec 31,2009 $420.00 ESTABLISHMENT Total Fees: $420.00 PERMIT EXPIRES IDecember3l, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS • BOARD OF HEALTH 120 WASHINGTON STREET,47 FLOOR TEL. (978) 741-1800 KINIBERLEY DRISCOLL FAX(978)745-0343 �y KkYOR IDIONNE&S,v rNl.COM JANET DIONNE, ACTING HEALTH AGENT 9,`008 6A1-FM �CTy 2009 IA-PPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Y*fJ 7A SY JSLgTJO 121!5-r"IZArJ l TEL# 9 ?k 7 `('S 17 0 O ADDRESS OF ESTABLISHMENT - L-D A(/J AZ7 5 A'tIvil , MA- FAX# 7- MAI LING - MAILING ADDRESS(if different) EMAIL- Business': L7�l� 7 L{)-M C-) A-V L. CC M Website: A-Ai o 5A-t-cM , co M OWNER'S NAME Dt=_Ad 12-A-0 LA-M TEL# ( 13 K3 y ?b 1<3 ADDRESS 15- iti a5 / 1t1 /A) 12-0 l(1 k`{'" 0/ 91" STREETCITX / STATE S((7 'It-C �+/ ZIP �G�(r (�>�-rt(r Yon.Cr CERTIFIED FOOD MANAGER'S NAME(S) W 14 9-f14-A& fd'UA J G' CERTIFICATE#(S),S-(7 vft va (Required in an establishment where potentially hazardous food is prepared) Ce•2 6 i?,fj3�• 'Y� EMERGENCY RESPONSE PERSON T)Z rLA lI Lff M HOME TEL# 7�1 -"/-9-Y99 IDAYS OF OPERATION: j'- Monday ;Tuesday 'I Wednesdays > Thursday 1 ` Friday I Saturday Sunday _ -1 HOURS OF OPERATION 1130�l130 `1l)o_ /130 ',tl3o -lf3v tl o 1il;3fl/1M (1 : 30fi-Al ppppnl Please write in time of day. ttM prvl I kM PM M PM 3 (For example 1lam-11 pm) I( BM / ' ��A"f`9 IDOA-Al j ( 1: 3�J'� TYPE OF ESTABLISHMENT FEE (check oniv) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -------------------------- - -- - -- ------------------------------------------------------------- -------- ---------- RESTAURANT E NO less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats - ----------- --- ---------------------------------------------------------------------------------------------- BED/B-RE-AKAYES $100 CHILDCARESERVICES ------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT(SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. . In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. 154- �,,a�.1,� t.,.,,� I I I v-f/ D V b if � (o"� l Cl Cl Signature Date Social Security or Federal Identification Number Revised4R4/07FOODAP2008.adm Check#&Date_/o2. 0516 LORING AVENUE Fantasy Island Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: 745-1700 Owner: Deborah Lam PIC: James Lee Inspector: Elizabeth Salandrea Date Inspected:Correct By: 1/27/2009 Risk Level: Permit Number: BHP-2009-0272 Status: SIGNED OFF '#of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: ;All violations noted in the 1/8/09 and 1/22/09 inspection reports have been corrected. 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®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 27,2009 ) 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®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 27,2009 ) Page 2 oft t� 0516 LORING AVENUE Fantasy Island Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-1700 Separatio Segregation/Protection FAIL Critical ❑ RED Owner: omment:GE freezer had meat directly next to vegetables and meat above other ready to eat items.Organize freezer to properly Deborah Lam separate PHFs from RTE items. PIC: Food C/oonnt Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED Deborah Lam sc omment: Provide additional sanitizer bottles on the back side of the prep table across from the cookline. Inspector: J1{ (/Buckets tongs are being stored in did not register as sanitizer.Tong/utensil buckets must have sanitizer of proper concentration in Elizabeth Salandrea them at all times. Date Inspected:Correct By: Violations Related to Good Retail Practices (Blue Items) 1/22/2009 Food and Food Protection FAIL Critical BLUE Risk Level: { IiComment: Upstairs walk-in had several bowls with covers laying directly on the food.Provide properly fitting covers for all 1 containers,or use plastic wrap to cover these bowls. Permit Number: PAt time of reinspection,employee was observed eating in downstairs prep area.Employees must eat in separate designated BHP-2009-0272 employee area to prevent cross contamination. Status: Equipment and Utensils FAIL Non-Critical BLUE PARTIAL COMPLY k/Imment:Wire storage racks downstairs have accumulation of grime.Thoroughly clean the racks.PIC states new racks have been #of Critical Violations: ordered for this area. V)Qu-) rcLpk 3 Time IN: Time OUT: Urgency Description(s): BLUE: Final reinspection to take place in 3 days; all remaining violations must be corrected. Violations Related to Good Retail Practices (Critical All other violations noted in the 1/8/09 inspection report have been corrected. 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®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 23,2009 ) Page 1 oft 1� 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®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 23,2009 ) Page 2 oft Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: Fantasy Island Restaurant File Number:BHF-2004-100138 516 Loring Avenue Salem MA 01970 LOCATED AT: 0516 LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0094 Jan 4,2010 Dec 31,2010 $420.00 ESTABLISHMENT Total Fees: $420.00 PERMIT EXPIRES IDecember3l, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,Improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 � � 9 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4T FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 �'q ^ MAYOR DGREENBAUMI7U.SALEnt.CONI E DEC A"w %V E DAVID GREENBAum, C 7 2009 isp ACTING HEALTH AGENT Ca r Y -JF bALIEM BOARD OF HEALTH 2010 APPLICATION FOR PERMIT TO OPERATE AA� �FOOD ESTABLISHMENT 2+r NAME OF ESTABLISHMENT f NN7A Sy l'7 "� d P-b1W+t4i, TEL# a/ ? k 7 1f-r 17 d O ADDRESS OF ES i ABLIS'HMEN I S-/ 6 Lo rL//v (� A-0r�- FAX# 1-?W 7q-0 1( LI MAILING ADDRESS(if different) EMAIL- Business': Website: OWNER S NAME Jl)1;A D lvR'l t-44TEL# 617 8-3 rF 2--3 ADDRESS IJP (n 117PI Art-r— O NA- ®JIBS STREET !A4 K. 1 /6- _ yVA) 9F' STATE S// 7V9k ZIP CERTIFIED FOOD MANAGER'S NAME(S) f W y 4-(,14-"A (r- k4 Uk� CERTIFICATE#(S) .S/ 7-2,0 7-0 (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON ILrP'M HOME TEL# (�I kI f 631 —P cfgy Id©PYSF®BOpERATI.ON1 ,o Ma days , `i'Nk_Tuesday, ; VJetl iesday i iTf Vrid"a'yL,?Z`I V8` Fpda$aP ! %r-d6y;W-,,iV t unday l HOURS OF OPERATION i1j :_ 0C*M— (1 ;30*A1 III :,3O.A +'1 (13°A+� ( j : 3v� � ! 11 :3vgrV1 i12A10o� Please write in time of day. �, I U 0 D 2J o 0 It'1 �} A30fog (For examde Ilam-11 pm) 1 1i- 113 Pry1 , I PM I 3 1 113 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 -- - ------ ---------- RESTAURANT E NO less than 25 seats $140 (Outdoor Stationary Food Cart$210 25-99 seats =$280 more than 99 seats 420 ---- ----------- ------ ---------------------- ----- --------------------------------------------------------------------------------------------...... BED/BREAKFAST/ YES NO $100 CHILDCARESERVICESINURSING HOME --------------------------------------------------------------------------------------- ---------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES O $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements, or equipment changes are made,all plans for ;such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belier,have filed all state tax returnsand paidall statet es req red under the law. Signature Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date /7j?� 103 $ 0516 LORING AVENUE Fantasy Island Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection - ((a'' - lv 30 HACCP: ❑ Item Status Violation Critical Urgency a Telephone: PROTECTION FROM CONTAMINATION 745-1700 Separation/ egregation/Protection FAIL Critical Q RED iOwner: 'd omment:True fridge had chicken above vegetables.Organize fridge to properly separate potentially hazardous items from ready Deborah Lam to eat items. is PIC: —GE freezer had meat directly next to vegetables and meat above other ready to eat items.Organize freezer to properly separate 1 James Lee PHFs from RTE items. Inspector: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED (Elizabeth Salanc rea ✓Comment: Cutting boards throughout establishment are stained and scored.Resurface or replace cutting boards. Date Inspected:Correct By: _ne� '"" d bean opener downstairs needs thorough cleaning and scouring. 1/8/2009 �y I Risk Level: 'li�licer downstairs needs thorough cleaning and sanitizing. Wanitizer throughout establishment was too weak.Provide sanitizer of proper concentration at all times. Permit Number: l�'Procit kaz.G *Lda- 0 BHP-2009-0272 vide more sanitizer bottles along the cookline. �=v1• 5 P Status: Buckets tongs are stored in did not register as sanitizer.Tong buckets must have sanitizer of proper concentration in them at all VIOLATION times. Prevention f Contamination from Hands FAIL Critical RED #of Critical Violations: 7 omment: Employee downstairs observed using non-disposable gloves and washing them for reuse.All gloves used must be Time IN: Time OUT: i disposable and not re-used.Gloves discarded at time of inspection. 9I Handwash F cilibes FAIL Critical RED Urgency Description(s): omment: Handwash sink downstairs had bowl with food debris in it.Hand sinks may only be used for handwashing,not food BLUE: � prep. Retail Praonsctices Related t0 Good • 44athroom downstairs had broken soap dispenser.Soap dispenser must be stocked&in working order at all times. Retail Practices(Critical violations must be correctedof water in women's room only reached temperature of 106°F.Turn hot water up immediately to minimum of 110°F. immediately or within 10 days)(Non-critical violations mustbe corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 14,2009 ) Page I of Item Status Violation Critical Urgency RED: TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Violations Related to I Hot and Cold Holding FAIL Critical ❑J RED Foodborne Illness Interventions, omment:Small silver 2door fridge measured at ambient temperature of 55°F;chicken in top of fridge measured to be 527,and and Risk Factors (Require beef measured to be 58°F.All potentially hazardous items must be held cold at 41°F or below.All meat from this fridge discarded at immediate corrective action) time of inspection. Fridge may not be used to store potentially hazardous items until repaired to maintain 41°F or lower. Time As a ublic Health Control FAIL Critical WRED mment:There were bowls of rice downstairs at room temperature.PHFs must be held cold at 41°F or below,or hot at 140°F or higher.Rice put into refrigeration at time of inspection. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 14,2009 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and F od Protection FAIL Critical BLUE mment:Ceiling over produce sink downstairs is stained, peeling and in general disrepair. Repair ceiling to intact condition to prevent contamination of food at sink. LA/Owl of pork was on the floor in front of pork ovens downstairs uncovered.Cover all food to prevent contamination. Vt rn starch barrell had scoop handle stored in product,and flour barrel had bowl as scoop.Provide proper scoops for both barrels &store correctly with handle extending out. ,/Ck sauce barrels cut milk jugs being used as ladles.Use only clean,sanitized ladles for duck sauce and do not store in the barrels. ep table across from downstairs walk-in freezer had some eggs on it at room temperature.PIC states this table is not used.Do d�tr 5'\ not leave potentially hazardous items at room temperature.Eggs discarded at time of inspection. e \ I�nstairs vegetable walk-in had some uncovered food.Cover all food in storage to prevent contamination. r�\ ,7,y-� ownstairs meat walk-in had some containers with spills&splatter on them.Thoroughly clean all food containers. ' d1" —Upstairs walk-in had bowl of rice with lid layibng directly on the rice.Provide properly fitting covers for all containers and do not allow them to touch the food. "Both steam tables had uncovered containers.Cover all food in the steam tables. 41-ow containers upstairs next to True fridge need general cleaning. Equipment nd Utensils FAIL Non-Critical BLUE 2m � ment: Right pork oven needs general cleaning inside and out. ,4goods area downstairs has accumulation of flour on Floor and items.Thoroughly clean entire area. —Wire storage racks downstairs have accumulation of grime.Thoroughly clean the racks. ki-t w) rocks 6Y"gjgticad all downstairs behind fryolator, pork ovens&rice cookers needs general cleaning. j Ownstairs walk-in freezer needs thorough cleaning beneath racks. 6Pl0wnstairs meat walk-in has accumulation of grime along inside of door frame.Thoroughly clean this area. "pstairs walk-in needs general cleaning beneath racks. 1,811elving in back cookline area needs general cleaning. Oelck cookline area needs thorough cleaning, including along walls. Vfrue fridge needs general cleaning. VWhite GE freezer needs thorough cleaning. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 14,2009 ) Page 3 of ^., Item Status Violation Critical Urgency 604"loor at fryolators needs general cleaning. /^ II silver 2door fridge needs general cleaning. �En re cookline needs thorough cleaning of food drbris. Tread drawers need general cleaning. Veeepsi fridge missing thermometer. Provide visible,accurate internal thermometer for this fridge. Ydgen's room needs cover for trash barrel. Physical F lity FAIL Non-Critical BLUE ment:There is an accumulation of water on the floor downstairs near food prep sink; PIC states it is leaking in from outdoors. Source of leak must be found and repaired. l+�ood prep sink faucet is leaking.Repair faucet to good working order. WFll000r at front of liquor room is in disrepair.Repair floor to be impervious&easily cleanable and in good condition. m'rh�ereare a few areas upstairs at back cookline where the ceiling is leaking.Determine cause of leaking and repair immediately. There are several floor tiles missing at drain in front of fryolators.Replace tiles. Peights above dishwasher do not have covers.Provide protective covers for these lights. Reinspection in two weeks, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 14,2009 ) Page 4 of IMPORTANT(MESSAGE FOR --L-KeS �N"��71�ri�5 DATE ��` Oji /�� TIME,LI�,h M. M OF PHONE AREA CODE NUMBER EXTENSION 0 FAX 0 MOBII G _ AREA CODE NUMBER TIME TO CALL (TELEPHONED I PLEASE CALL CAME TO SEE YOU II WILL CALL AGAIN _J WANTS TO SEE YOU �{ RUSH ' RETURNED YOUR CALL {� WILL FAX TO YOU ' MESSAGE T4 d l �7`y�inrSn� nl I A SIGNED FOR MA E U009 I r . _ ___ �_ _ _.� _ �` . ��I �^� -J - - -- - - _ _ � - - - - - -- - -- --_ ' - - -- - - - - - - � ____- __ I I Commonwealth of Massachusetts s City of Salem Board of Health IGmbedey Drisooll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/07/2008 ESTABLISHMENT NAME: Fantasy Island Restaurant File Number:BHF-2004-000138 516 Loring Avenue Salem MA 01970 LOCATED AT: 0516 LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions!Notes FOOD SERVICE BHP-2008-0202 Jan 4,2008 Dec 31,2008 $420.00 ESTABLISHMENT Total Fees: $420.00 PERMIT EXPIRES IDecember3l, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonadons,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health: Page 8 of 24 r 1 c QTY OF SALEM, MASSACHUSEM BOARD OF HEALTH P--.-a, 120 WASHINGTON STREET,4" FLOdR 4"� C TEL.(978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 #0 MAYOR ISCOTTI&SALEM.COM eu,��U oFSRCFM JOANNE SCOTT, H HEALTH AGENT STN 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT r S X SStA*IV X 6L> ' g4,tr TEL# q 7 S/' 7 10- —O o D ADDRESS OF ESTABLISHMENT 9-1 (1 LO i` /XJb v �S Maw ' FAX# q 9 k 7tfo q MAILING ADDRESS (if different) EMAIL-Business': Website: OWNER'S NAME .D7'CS o kA t hA4 TEL# ADDRESS-"_ lu .1� ��S7M .6 7&41-Z �� MAnISL�I% L / M.� 0(9 ter STREET CITY STATE S-(/ ZIP CERTIFIED FOOD MANAGER'S NAME(S) —J 4w;" LL--ice CERTIFICATE#(S) 3 0�-7 k3 Z (Required in an establishment where potentially hazardous food is prepared) C-);y- 6(-( , 8"3 k6 ZJ EMERGENCY RESPONSE PERSON DMO" -1,A HOME TEL# 7 / ' 6 3 DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION /130 //3U //3U /(3U /130 (/ ✓ /' / Please write in time of day. /] (/3U o/Z. 3 /2i,3,0 (Forexample Liam-lipm) 113u //3 J TYPE OF ESTABLISHMENT FEE (check onlv) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - --------------------- ---- -... -5,--,- -------------------- ----- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$2101 25-99 seats =$280 more than 99 seats =$420 ----------------------------------........ ........-------------------------------...-------- ---- ----------------....................... BED/BREAKFASTI YES NO $100 CHILDCARE SERVICES ------------------------ ------------------------ ------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM,YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. �Xp — Il / ,3 /07 0it2 W 05V Signature's Date ' Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008.adm Check#&Date lI qlV 1 113 3k] $ CITY 4F SALEM BOARD OF HEALTH Establishment Name: 'FA07A_'NS\'\ ISSR�� Date: " `� � S' Page: of Item ) Cade C—Crtttcal Item y DESCRIPTION OF VIOLATION 1 PLAN OF CORRECTION I Date No. '' Reference R–Red Item PLEASE verified - c r� 1k" c'� PRINT CLEAR(� L } III � �VU 1C� t J1 2'�t'�K.+�c �- ti \ \ '^ t3�.} -)�;+,} I I I I ��7 Pitt>S e cr^�cS 1 vwfi�l i 7'\A i �1S C���-a,:i� Q.N(> Sra.�' I �4 t\ C`i�n� '�L%r JCt('f'� • I i,-`4 a_sv­� I1,t r... M-1 T s�l i st tem iii zr -rJ 71S i a>.ti s t . 4 i I �w� 3'�, w, �.�,. P.•aa-� ttic�- �, ;�,�, `fit s�r�; cni d,�C x-18 - T4s - I i31y, I ttv'j" t � •-� �a �•� �c,i\`�.'O ��' ���.�v;� -rc�tL- ti ry SSS r?vet a,J cai,al�, ^,-t3 �t�L�L.j t I Ii J 4\ t I I �6J --�1 M ♦ , I I Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that U Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. (i-.— ❑ Voluntary Disposal 0 Other: � e-`,4!l.,�l<C} P(€Fs ttea•:t•td^t�lemp;.talarea Violations Related to Foodborne fitness Interventions and Risk According to Cooled u; i Factors(items 1.22) (Cont) Ca+l;ng 1' llk-aS(U* flli s PROTECTION FROM CHEMICALS 1y PHF Hot and Cold Holding j Id i Food or Color Additives i t s01 A VB) COM Ptl l'a 41ananned at orb b'u 3-m 12 i4:'• s-i W/ ^ 3.102.13 1 Pn>.ccLon Prost itnupprmed Addtttve;' ' 4 15 1 � Poisonous or Toxic Substances ! j � �i" '.? FF1T��'. h9aan,ain>.d i rr abota- 1 1 ' 101.11 kh;mifpuig tnti,mmion - Otl,nnal i 1 Ru:tsi: Held.anr lbow, I30"F 1 Container,' -0 Time as a Putshc Hearth Control j 7.102.13 Co anti n—S - N'„rkin;.C=nttat,trr'* E '"tic,+v' a i'ubiic health Control' 7-20£.11 Sr(rarart+,n-Siorxge'� � GRI)r?t}3! 1'dr r.;4 n n• Rest;icnon- Yn•sc:ncr and t,><` .. -- 7,(12.11 C1mdlipm:.of!J;,d” 7-103 11 T,xtc Ojntatnu;.--Proliibui<tl+ : RCOUA-PO S I{ FOR HIGHLY SUSCEPTIBLE ' 7-204.'t SenniMe ,Criteria—Ctcnticals" } POPULATt+JN`' lieiP} 7.10W i2 Ch,m ca3a for W,:hinp,t'rodocc.C.ttt"To),: ' 3t ::.q:`? t£i.!? ::nl,;gate:srt.<a!Pr. ?+a,l:a�.cJ;,4icec:,nd 7 {)d.14 Urrint;rt,lents.Crlwfia` —.___.,,. 13e�ein•:.ea+tithti•'a[nraglah<Is$ 1',c of Pantomle'l i:nil�, '1.2(15"1 Incidental F-o,+I Contait, 1 ubrit'xnts°i 31:ti?) kzw or Partially t:„ok,d :wiuml hiiA and 7_v0t>.t a R,sui+.ie,i iisc Pe.riode:.0iterta^ j P.t•;•�it;d. t. 7-20k.IZ, Rodent F:aif Siattons' 1IfQ (nEopoled FoEki T^+t l,ais IN,,), Re-skn 1. j "'G:+ 12 Troikhly Rradec,. Fest C'untr*t and ._ ..._. -_ I 4lunitoring' CONSUMER dcLlYi:aORY 22 i+,0:.t i t Y?u,ta.ter:Lf t iscra•Poeted l, C'cninomption of TIMEITEMPERATURE CONTROLS :<nin;:t 1: dr't'Et,u:rt 6: u. L?ndcr.,xtked tHFs a" 3b i Proper Cooking Temperatures for ".`ot Oth: 0516 LORING AVENUE Fantasy Island Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: D Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 745-1700 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:The wood ramp outside the back basement walk in needs to be cleaned and painted. Deborah Lam PIC: + James Lee Inspector: i GENERAL COMMENTS: David Greenbaum All other violations cited in the 8/16/07 inspection report have been corrected. Date Inspected:Correct By: 8/30/2007 Risk Level: Permit Number: BHP-2007-0177 Status: SIGNED OFF #of Critical Violations: 0 Time IN. Time OUT Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 30,2007 ) Page I oft " Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) G 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. Aug 30,2007 ) Page 2 oft 0516 LORING AVENUE Fantasy Island Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-1700 Food Contact urfaces Cleaning and Sanitizing FAIL Critical RED i Owner: ommgAf.Dirty knives found stored in the knife rack. Properly clean and sanitize all knives prior to storage in the knife rack. Deborah Lam PIC: I' Provide additional spray bottles of sanitizing solution in the cook line. .lames Lee T e cutting boards are stained and scored. Resurface or replace all cutting boards. Inspector: Goo ygienic Practices FAIL Critical ❑d RED David Greenbaum C more Employees food and drinks observed in the food prep areas. Employees must eat and drink in a designated employee Date Inspected:'Correct By: rea or in the dining room to prevent cross contamination. 8/16/2007 Risk Level: Permit Number: BHP-2007-0177 Status: VIOLATION #of Critical Violations: 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 29,2007 ) Page I of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require mment:Only one pair of tongs being used for all items in the silver reachin. Provide separate utensils for all items in this unit to preven oss contamination. immediate corrective action) T re is uncovered food in the small silver reach in. All food in storage must be covered. Equipment an ensils FAIL Non-Critical BLUE m t:The service line has an accumulation of food debris,spills and splatter. Thoroughly clean this area. e m ' cookline needs a thorough cleaning. T e small silver reach in in the cookline has an accumulation of food spills and splatter and grime. Thoroughly clean this unit. TGE freezer has an accumulation of food debris and grime. Thoroughly clean this unit including the door gaskets. Th ru reach in has an accumulation of food spills and splatter. Thoroughly clean this unit. T sa unit needs a visible,accurate,internal thermometer. �ba p table near the True unit needs a thorough cleaning. U;, cook line area needs a thorough cleaning. shelves at the back cook line area need a thorough cleaning. The ooring throughout the kitchen has an accumulation of food debris,spills and splatter. Thoroughly clean the flooring i ludi g under and around all equipment. bo,,,eee s and lids in the walk in need a thorough cleaning. ease barrel needs to be raised off the ground and the area around the grease barrel needs to be cleaned. T e b ement stairs have an accumulation of food spills. Thoroughly clean the basement stairs. e bas ment prep table needs a thorough cleaning, including all shelves. T ba ent cooking area needs a thorough cleaning. TJa dry�ngredients area has an accumulation of food spills. Thoroughly clean this area. (rV/ d/ redient barrels need a thorough cleaning. T e m�etal-shelves in the basement have an accumulation of grime. Thoroughly clean the shelves. �elng basement flooring needs a thoroug cleaning. of the Bally walk in freezer needs a general cleaning. 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. Aug 29,2007 ) Page 2 of 3 Item / Status Violation Critical Urgency L'�The back basement walk in shelving needs a thorough cleaning. JyDThe ramp outside the back basement walk in needs to be cleaned and painted. `Ihe-amall Pepsi unit in the wait station needs a thorough cleaning. h"7 a same unit needs a visible,accurate thermometer. GENERAL COMMENTS: Reinspection in two week, all violations to be corrected. -'t CL-� AA- 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. Aug 29,2007 ) Page 3 of When Seconds Count, Inc. Location:Fancy Island restauar t ^ m Americam liesat CPR & Course: Ncartsaver AIC CPR Fast Aid ® Date: Sunday,March 25,2007 Training Instructor. Erik Ingersoll Data Fatty' Complete: Y/N Please fill in all ihfom�ation I www.wheateomdsoour�t.net Cards Done: Y !N or tivil)be �� Invoiced: Y/N _ ••PLEASE PRM LEGIBLY Course Roster N _ Name/Email Address Address J City/Zip Plane S13ls ( AED I KC Hook m A-edvk C�ai i-r� a f OD OAA 3 - 24W Al� S+ 173 SCiT�l.9�t srl STA N1(�sS L L$� AR4A/AMV MB*C 6 z32 Ljioju sr ,Jh yAUKi 1"VrJ4 /j,imL,ubToW rNg 0/103 f 7f/(I9-;?(3z� I 14 Ya.49t. s-T A o MIAli? MLb ZV rtA o-21 41 611911414 � I 1J3cc:dd,1%e AWd ,Sro� >��- -04eg1 !� �bA�� S�cc��t�t s��c,�scnttnA a l I Ii m m N 1 N FAlvT/9 Sy TSLfiN�J E ,¢ DAoNN6 Massachusetts Department of Public Health Salem Board of Health 120 Wshington Street, Division of Food and Drugs Sa emaMA 01970-35234 th 190-35234th Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name / Date Type of Ooeration(g Type of Insoection v) SL/ �s/�h a[. Q/Food Service ❑ Routine Address Risk 'LJ Retail D Re-inspection LevelElElResidential Kitchen 'Previous Inspection Telephone _ Mobile Date: - -7-ej�-- Owner �/ ' / v HACCP YIN [:] Temporary El Pre-operation I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) �9j t n c ®� Time ❑ Bed&Breakfast ❑General Complaint wr17� d" In: ElHACCP Inspector ` )'-yjT-W A a I Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. ` FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ' ., _. . _ . , .. . _ ...,. ,._d .�... ..., .. .� . .... , .._ _., 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-if 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 "' "' ❑ 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 ❑ 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 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)(590.003) order of the Board of Health. Failure to correct violations x'24. Food and Food Protection (FC-3)(590.005) cited in this report may result in suspension or revocation of '25. Equipment and Utensils (Fc-5)(990.009) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 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 5001 Vs (Fo, 10&c Inspector's Si� a ire•I Print• ` PIC's Signatures` J ^/ ^ r Nl Print: ��'71 n f Z,A'14- A17-1-1 I Page-o of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 18I Cross-contamination I 590.003(A) Assignment of Responsibility* I 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* ( I Cooked and RTE Foods* 2-)03.11 Person in charge-duties I I ( Contamination from Raw ingredients 3-302.11(A)(2) I Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other' J 2 590.003(C) Responsibility of the person in charge to I I Contamination from the Environment require reporting by foot(employees and 13-302.11(A) I Food protection' applicants* 13-302.15 Washing Fruits and Vegetables 590,003(F) Responsibility Of A Ford Employee Or An ( 3-304.11 ( Food Contact with Equipment and Applicant To Report Jo The Person In Utensils* Charge* Contamination from the Consumer 590.003(6) Reporting by Person in Charge* I 13-306.14(A)(B) I Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* I Disposition of Adulterated or Contaminated 5O0.003(E) Removal of Exclusions and Restrictions I Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 ! Food and Water From Regulated Sources 19 Food Contact Surfaces 590.004(A-B) Compliance with Food Law h I 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* I Sanitization Temperatures* 3-201,13 Fluid Milk and Milk Products* I 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 13-202.14 Eggs and Milk Products,Pasteurized* I ( 4-501.114 I Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water, I concentration and hardness. " 4-60L1 I(A) Equipment Food Contact Surfaces and 5-101,11 Drinking Water from an Approved System' I Utensils Clean- 590.006(A) Bottled Drinking Water* I ( 4-602.11 Cleaning Frequency of Equipment Food- 590-006(B) Water Meets Standards in 310 CMR 22.0* I Contact Surfaces and Utensils* Shellfish and Fish Froman Approved Source 4-702,11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreadonally Caught Molluscan Food Contact Surfaces of Equipment Shellfish* 14-703.11I Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I Chemical` Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by ( Regulatory Authority I 12-301.11 Clean Condition-Hands and Arms* 3-202.18 Sltellstoxk Identification Present* I ( 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* I 12-301.14 When to Wash* ---- 3-201.17 Game Animals* I I I1 I Good Hygienic Practices g Receiving/Condition I 12401.11 Eating,Drinking or Using Tobacco* 3-202.11 I PI-IFs Received at Proper Temperatures* ( 12-401.12 Discharges From the Eyes, Nose and 1 Mouth* ll J 3-202.11 I Package Integrity" * I 3-30 L 12 Preventing Contamination When Tasting* I 3-101.11 � Piwd Safe and Unadulterated ( _- 16 Tags/Records:Shellstock 112 Prevention of Contamination from Hands 3-202.18 Shellstakldentification* 590.004(E) Preventing Contamination from � s* ee 3-203,12 I Shellstock Identification Maintained* Employ 113 I Employees* Facilities Togs/Records:Fish Products I 3402,11 Parasite Destruction* ( I Conveniently Located and Accessible 3-40212 Records,Creation and Retention* 5-203.11 Numbers and Capacities* - 5 - 590.0040) ( Labeling of Ingredients' I 10411 Location and Placement* I 5-205.11 I Accessibility.Operation and 7 I Conformance with Approved Procedures I Y� ( /HACCP Plans ( I Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* I Devices 3-502.12 I Reduced oxygen packaging,criteria* I 16-301.11 Handwashing Cleanser,Availability 8-103.12 I Conformance with Approved Procedures* 16-301.12 Hand Drying Provision 'Denotes critical nem in the federal 1999 Faxl Cale or 105 CMI2 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: � Sl� /�`J� Date:_ 3 2/- Page: of �— Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY , /ih � r��J Al� - �7/ a hd /ati,�c I /5t/ -,Mi/d ` I � 1 / /f 1 I tT/I L/ ����f iii r�af7 ins n � olti /2�Y/ rUv7`i/2� / c 17 Dis ussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ 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-f�larslo, r suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. v�— rte/ ,� ❑ Voluntary Disposal ❑ Other: 3-50i ho;C'! PHF elecetaed at Temperatures - Violations Related to foodborne Illness Interventions and Risk Accurdiro i o E..nv Cooled+n Factors(items 1.22) (Cont.) i I T45'F Within 4 Hours. j PROTECTION FROM CHEMICALS 3-'d'il 15 i^ooiirw lferhois for PH'r5 j 13 I Food or Color Additives I 14 PHF Hat and Cold Holding 3-50;.10(6) Cold Pf TF,37mutainea a[or below 3-202.1^_ .Additives- : Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Namel Date Tyoe of Ooeration(si Type of Inspection �)l f7�a r T^SiOl?7Z( -)- 7 '6)77 121 Food Service ❑ Routine Address / n )` /(„, ,r._ Risk E] Retail 0 Re-inspection J� tr Level ❑ Residential Kitchen Previous Inspection Telephones �_ /y(,_ ElMobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation �_ Yy� I ❑ Caterer ❑Suspect Illness Person in Charge(PIC) [ J Time El Bed&Breakfast [I General Complaint IIA t'1t 0 1 J f 1) 0_ ❑ HACCP Inspector I, r" it A I Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Noncompliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminenthealth hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT,'. m' ;, ❑ 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',,-,' , .. . .. TIME/TEMPERATURE CONTROLS Potemtall ) ' El 4. Food and Water from Approved Source R ! y Hazardoris 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 ❑ 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)(590.003) order of the Board of Health. Failure to correct violations i 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 V 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 501nspnfFom 14 Eoc Ins ector's+Si tune: Print: t + J PIC'sSignatutej'�n �� P J Print: � P)l� LUN r A.in.1 I Page/ of2Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT j S Cross-contamination j 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 j Contamination from Raw ingredients j 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other" 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by foal employees and 3-302.11(A) Fond Protection- applicants" 3-302.15 Washing Fruits and Vegetables --_--j 590.003(F) Responsibility Of A Foci Employee Or An 3-3011.11 Fcod Contact with Equipment and Applicant To Report To The Person in Utensils* J Charge' Contamination from the Consumer 590.003(G) Reporting by Person in Chatrce* j j 3-306.14(A}(B) Returned Food and Resererce of Food* 3 590.003(D) Exclusions and Restrictions* _ I Disposition of Adulterated orCertaininated 590.003(E) Removal of Exclusions and Restnctions ( Food l 01.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food' 4 Food and Water From Regulated Sources I j 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 501.111 Manual Warewashing-Hot Water j 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201 13 Fluid Milk and Milk Products* j g0 i.112 Mechanical Warewashing-Hot Water ( Sanitization Temperatures*3-202.]3 Shell Eggs* � -- j 3-202.14 F„gs and Milk Products.Pasteurized* ( 4-501.114 Chemical Sanitization-temp., pH, j 3-202.16 ( lCc i`4nde From Potable Drinking Water- i concentration and hardness. * J 5-101.11 Drinking Water from an Approved System' 4-601 11(A) Equipment Food Contact Surfaces and Utensils Clean' 590.006(,0) Battled Drinking Water* J ;6()2 590,OO6(B) Water Meets Standards in 310 CMR 22.0" Contact 1 '11 Cleaning and Utensils" Frequency of Equipment Fnvd- j Shellfish and Fish From an Approved Source I ( � 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Shellfish'" Fond Contact Surfaces of Equipment 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 j Proper,Adequate Handwashing Game and Wild Mushrooms Approved by ---- Requ/atory Authority ( 2-301.11 Clean Condition-Hands and Arms.* j j 3-202.13 j Shellstock Identification Present., -- - -� 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* j 2-301.14 When to Wash* f 3-201.17 Game Animals* j 11 Good Hygienic Practices g Receiving/Condition j ( 2-401.11 Eating,Drinking or Using Tobacco* j 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202 t5 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock j j 12 Prevention of Contamination from Hands j 3-202.18 Sbellstock Identification* ' 590.00.1(F) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" j Entphiyecs* Tags/Records:Fish Products j ( 23 Handwash Facilities j Conveniently Located and Accessible j 3402.11 Parasite Destruction* j 3-402.12 Records.Creation and Retention* 5-2203.11 Numbers and Capacities* 590.004(1} Labeling o'Ingredients' ( 5-204.11 Location and Placement* - j 7 Conformance with Approved Procedures j 5-2(>5 I I Accessibility_Operation and Mai nlrnance j - /HACCP Plans ( Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* ( j 6-301.11 Handwashina Cleanser, Availability j 9-103.12 Conformance with Approved Procedures' ( j 6-301.12 Hand Drying,Provision j "Denotes cridail item if,the Weral 1999 Foal Cale or I(5 CMR 590,000. CITY OF SALEM / BOARD OF HEALTH Establishment Name: Date: -� -7 Page: �"'� of Item Code C-Critical Item o DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified «-^ti PLEASE PRINT CLEARLY I ,�P-r���nf-h�ri%y�f-�`lrr�,-� ?� � ��//t��Urr�a i,��Pr� �'lor-�c✓ _,/7r/A Td by I 0"ah JJG 7i /oif'. �.�/•U�IQ� ��lS /�.Sf�/t� f7ilt� 1 f?'���Yr Ta. �1/ti ;-� lam/ �✓1 St`7���,� �����J r��.5-�s .>L j jwne� f�fhrKr G1)1i_P16 _ '7 aVVId - v,427werz 1, 194 Z t1l 4r, ,�ccir� ont r7/��ne. i Sf�f�' lfio �e,Sa{e `fC L04 . _harp �r e- Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all LI 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. � ���. 11 Voluntary Disposal 0 Other: -`.al.1 i�C'} PI:F�:Rrcetced at Peoperaturr: Violations Heisted to Foodborne Wriess interventions and R.'sit Aocordimg h:Iaaw Caded it) J Factors(Items 1-22) (Cont.) -1 I'F745"F W ntbin v Hume n • i 3-50. 15 Cheung Afethod;fol PHFs PROTECTION FROM CHEM,t,ALS . . PHF Hctt end Co[q Holding 14 FooU or Color 4ddntives j I lg 9 3-202.12 Additives' z 501.1618) ^,oldYflFsis4audamect:,tra helc,v 59000-1(F! 11'1.15°F'• 3-302.1=4 Protection from Unarpruced Additive;* ( j E$ Poisonous or Toxic Sub:;tancrs x-5 01.100) !lot PFIF>Maintained at r,r above f 140')'. * 7-101.11 Identifying Information ( n ! �-SU!.l;z(A) Roaet�i-Icld.,i ur;:F.m:e I30`r Conwiler..' 7-102.11 Common Name -N'orkimg Container:." i 2o Time as a Public Health Control 7-301.11 Scis.iratiun--Stur,tee^' i-lfrl.li Tim(•e:a Public Health Control` iL..'r I o)OA04fH) \(:mance Rey::!rement 7-_7 0_. > t i Reaiictinn -Yrtscnce and t., 7-202.12 Conditions of Use" 7-203.11 ' Tox,c C',mtaiuer.,.- ! ohibitiursS REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-..U�t.l I ( Sanitizet's.Criteria-C'ttemicnls^' , POPULATEONS(HSP) 7-204.C? ( Chemicals for N'oshui_e Produce,Cri0.•ria' 21 ( 3So1,11('A) Urlp.:steurizcd Pre-pa'.kaged Juices and 7-1.0.4.14 Dry;n;*A>;ents.Criteria" j Bevenoz s with`Namine ! ohels"' UB) Ll-'e of Pa.tenrized E;trs" j 7-205.11 incidental Pu(x1 Comact. Lubrtrmts" i 3-80,,11(D) Rat,'r Pattiall_,Caked AmniA Fwxl and 7-206,11 Restricted Use Pe+Her eid .Criteria" Rase Sced Sptuuts Not Served. ,r 7 06.12 Rodent Brit Stctiuns" j i-SOL11?C) Unopened P(xxf Package N,,t Re-served ,-''06.13 'Pracking Put,-dee.,Ycst Corarul and j Mumtoring CONSUMER ADVISORY TIMEITEMPER ATURE CONTROLS 22 503.11 Consumer Adsisor, Pus-ed for Cun.eumptiun of .%mnrd Funds-ft;at are Raw,Undc;cooked or J5 Proper Cooking Temperatures for PHFs Hol.O:;:erwior Proccxsed to Eliminate 1 3-401.11A l) ^_1 E,>,,_ F t,5ec, Pathcrens.; Eggs-Immediate Sen,tce 145`I�?5sec' =e,•:.,,--.-z" . ( ( `by Sec. ;_502,1 3 Pasteuoied. Eggs Substitute for Rats Shalt 3-401.11(A)(2) Comminuted Fi':h,Meat,8-Game Animals- 155'F 15 sec. r ?-401.11(8)(1)(2) Pork and Beef Ranst - 1 F '2I min4 SPECIAL REQUIREMENTS EQUIREMENTS 33-4011.11(A)(?) R.,ttrs. Injected Metas-- 155'FIS 590.000(AH11)) tiiolaliot;s o;Sectio n 590.009(A)-(D)in see. catering. mobile fen d, temporary and 3-401.11(A)(3) Poultry,wild Game,Stuffed PHFs, restdcntial kitchen operations should be Clefting Containing Fi,,h,Meat, debited under the appionriate sections Poultry nr Ratites-165'F715 scc. *` above If related to todborne illness 3-401 I hC)(3) N'h•,le-muscle,Intact Beef Steak,, inter4•clitions and risk factors. Other 145°F* 590.0C9 violation<relating to good rut.)iI 3 =401 12 Rcw Ammal Foods CoAed in a I practices sbould be debited under#29 - A1tcrawavc los-Y �" Special ker.uirements. 3-4011 l(A)(1)(b) All Other PHFs - 145'F 15 sec 17 Reheating for Hot Holding VIOLATIONS A.:LATCD l"O GOOD B'ETAdL PRACTWES 3-403.11(AWD) PHFs 165'1' 15 see. " (ltetr.523-311) i-403,11(13) Microwave- 165'F 2 Mumte Standing Critical uIld n.a-crilwal violations. vhich donal relnte to tile, Time" e l,,Jburn e t hwss interventions and irk ice(toe+ Lard aborti, can be, 3-40'.I I(C) Commercially Ptocessed RTI.Food - ,foand re tilt follmi ung sertiewse of the Fond Cute and 105 CMR 140"F"! 590.000. 3-403.1 1(P) Remaining Pnsliced Portions of 13;ef Item Good Retail Practices FC 530.000 Rnzsts 23 bl6naaetroent and Pe,acnne! FC -2 J 003 1 Proper Cooling of PHFs 24. Ford aid Food s'rocact:on FC- 3 001 j 2 ?- I 14(A) C'onhne Cooked PHFsfrom 140`F to 5 5glupme;ti arid utensils FC-4 005 5(I 1, 23 'A'e',ei Piumoncla,.d Waste `C-5 .008 _) 70"F Within 2 Hour,and From 70''F � 27. Phvslcal Facilty /_;-5 .007 J to 41":=145"F ib'ithm 4 Aouc. " 128. Fasorom or Tows Mffienials FC-1 .008 4-501,14(8) ("holing PI-IFs Made,From Ambient 29 Sve el RectOrmen?s ! 009 Temperature ingredients ta41`F(45"F _30 Offer Wnhin'lflours ` ''0". : Jd,• Denotes'.meal item m dm I:•ders! 999 Fnud Code or I'J5 CMR 590000. Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,0 Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name 7 Date Type of Ooeration(s), Type of Insoection l 0-11 p'Food Service ,©Routine Addreas I l p . Risk LJ Retail ❑ Re-inspection r I 1 n I ,"I rV'1 L41 1,0_ Level}�? El Residential Kitchen Previous Inspection Telephone /' I ❑ Mobile Date: Owner HACCP YM ❑ Temporary ElPre-operation 'F)P`�/ �� �1 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast El General HACCP Complaint A 1� \ In: El Inspector ' ( in Inn I Out: Permit No. ❑Other Each violatiori checkeif requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. _ FOOD PROTECTION MANAGEMENT ,,., ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑V 13. Handwash Facilities �L) EMPLOYEE HEALTH ' ._ ' ' i PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC W W ❑ 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 TIMEIrEMPERATURE CONTROLS(Potentially Haiardous Foods)" " ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling PROTECTION FROM CONTAMINATION _.. ❑ 19• Hot and Cold Holding i' 6. Separation/Segregation/Protection 20.Time As a Public Health Control . REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 9. Food Contact Surfaces Cleaning and Sanitizing (HSP) r ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C 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-3)(5590.90.0 0044)) cited in this report may result in suspension or revocation of y 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. ti 30. Other DATE OF RE-INSPECTION: S 590,nspedFom 14 c r Inspector's Siatarepl ! Print: PIC's Signature: '�A,,x.,e.,, _ - Print:' _171 A 11Pagel of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) r PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(A) Assignment of Responsibility's 3-302.1 I(A)(1) Raw Annual Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* - 1 2-103.11 Person in charge--duties � - Contamination from Raw Ingredients 3-302.11(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other' 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by focal employees and 3-302.11(A) Food Protection- applicants* 3-302.15 )Vashing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-3(M.1 I Food Contact with Equipment and Applicant To Report To The Person In Utensds* Charge' i Contamination from the Consumer 590 003(6) Reporting by Person in Charge* ( 13-306.14(A)(R) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* I Disposition of Adulterated or Contaminated 590.003(EI Removal of Exclusions and Restrictions Food f 701.1 I Discarding or Reconduiomng 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* 11-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Condoner* Sanitization Temperatures* - - 3-201.13 ( Fluid Milk and Milk Products* 4-501.112 Mcehanical Warewashina Hot Water 3-202.13 I Shell Eggs* Sanitization Temperatures* * 14-501.114 I Chemical 3a itirttion-temp-,pH, 3-202.14 Eggs and Milk Products.Pasteurized 3-202.16 Ice Made From Potable Drinking Water'" concentration and hardness. 5-101.11 Drinking Water from an Approved System' 14-b01.1 I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* ( Utensils Clean' J .590.006(B) Water Meets Standards in 310 CMR 22.0* I 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 14-702.t 1 Frequency of Sanitization of Utensils and Shellfish" Food Contact Surfaces of Equipment* 4-703.11 ( Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 I Proper,Adequate Handwashing Game and Wild Mushrooms.Approved by ( ; Regulatory Authority 2-301.1 i CleanCondition-Hands and Arens* 3-202.18 Shetlsto ck Identification Present" 2-301.12 Cleanine Prcxedurc* 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* ' 12-401.12 I Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 ( Food Safe and Unadulterated* 3-20t.!2 Preventing Contamination When Tasting* 6 Togs/Records:Shelistock I ( 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(L) Preventing Contamination from 3-203.12 Shellstock Identification Mamtaine& I Employees* - Tags/Records:Fish Products ( 13 Handwash Facilities 3402.11 Parasite Destruction' Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.00401 Labeling of Ingredients* ( 5-204.11 Location and Placement* 7 I Conformance with Approved Procedures ( 5-205.11 Accessibility.Operation and Maintenance /HACCP Plans I Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* I Devices - - 3-502.12 Reduced oxygen packaging.criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision Denotes critical item in llie tedeud 4999 Ford Cede of 105 CMR 590.000. e CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: I z 1 U Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I ► �>>Jt�v> � 1��,�ch( ti1 ri�� pCrab�li.�Y��ti� oacf lA� � rov)A( > 4-4 . _i V1-u_-(i) 11t)w) 11 I> OW nvlerl 11_�Iro_ ��h fe(A Itr) ('a.>C�mov 1(o . . 1k3i linc� Stt)rIn IlQ I ►. I � 1��Or{i -tiiv (/��vvl,tnv ��SUr71�r�i � 1 J/3 c 0 -,r_r`ll� r115��1n�vvs nk 11nn� Sll� k� flok Ij,) rAty)A WOVEN ot'd�1,tq - _ y / YrUVI/EO_ Abv�e U 2O'n ✓,? � Oano12Prua hn `fionx4hiq CJo_anori W OLD . ,x I f` vlq 7h re LuC�s . 1 )n t�j)u-P r-M in i x-pf) ajw-(J, .Smu I 1,) IiJU_UbJ'l . A-fl -4)7DA 1vI Sfi�04_e A t 1 k Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance O 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 r your food permit. ) ❑ Voluntary Disposal ❑ Other: v , 407) PHFs Received at'leniperarurvs Wofstions Related to Foodborne fitness into,xverfions and Risk According to i,aw Cooled U Factors(Items 1.22) (Cont.} 4I'F4i'F V,'irh;n•1 Hours. PROTECTION FROM CHEMiCAI..S 3-Sul.Ii Coolin;,Methods for PHFs 13 Food of Calm Additives I i4 PHF Hot and Cold Holding 1 '= 5nA.1 b(1,') Cold PHFs Maunamed at or below ?-2{12.12 Addidvas' 590004(1, 41'/45° F 3-30)-.1.1 Protcc!wn ivau Un_uric�,ted Addihves^ v; Poisanoas or Toxic Substances 3-501.Kr(A) Hut PHF. Maintained at or above 7-101,11 i I 140''F.� = ta i 3-50'.16(A) Roasts Held at or above 130`17. " Cunc;dm_r;' Time as a Public Health Contra! 7-102,11 Cormn:a:Name - Workinl,Conta;rmrs" ' 3:;07.19 Time a::.t Public Health Cum roi* 201.11 Sepatation-Sforane" - f 7-2U2.i i Rcstnction-Presen,.o ane! Use,, � ( 5"`).OU4(H) variance Requirement i 7-202.72 Con(bron;of Uta' 7-203.11 )oxic Container:: --PiehibitivnO I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 1 7-204.11 Sanitizers.C7titena-Chetnic:ds` POPULATIONS (HSP) t, 121 3-ao 1.i i(.A) � Unpasteurized Fre-packaged Juices and 1' 7-104 12 Cbewiru:for aOma i r:xinre,Cr;iccia"' 7-204.1.1 Dr t ( 1 Bcverages with Warning I ab,.ls^ yng.�eens Crdena' 3-80!.I7(H) Use of Pasteurized Ewes^ 7-205.11 'acidcmal Food Contac;,Lnbocar,a' 7-206.11 Rettriued Us- Pesticides.Critvrtn 13-8b1.11 tI}i i Raw or Partially('coked 9nimal Food ,trd I kae Seed Sprouts Not Set Ned. 7-206.12 RouLnP Bait Statirns' 7-206.13 Tr::,;kmg Powder<,Past C.:cir!I srd '-801.11(Ct Unopened Food Package Not Re-servrd. x h4nr.itJ�Ing* j CONSUMER ADVISORY TIMEITEMPERA?URE CONTROLS 22 3-603.11 ConCUtnt't Achisory Posted for('onsuntptiun of Animal Foods-llrat are Raw, Undercooked o, l6 I Praper Ceukiny Temperaturas Sue I PHFs Not Otherwise Procersed to Eliminate �, _3-40;.1 L%(Iit2) El,w- 15;1 15 Se, Pathozcns.* Eggs- itwnediate So v;.c 145,rl Sser, 3-302.13 Pasteurized Egg;:Substitute tet'Raw Shelf 3-401.1I(A)(2) Comminuted Fish,R§rus&Came Egg., i Anim:d�- 155'17 ;�nee. 3-401.11(!3)(1)("_) Porn and Bcef Roset- 130"7 121 min" SPECIAL REQUIREMENTS 3-401.11(A1;'2) Rantes, Injeued IR'cats- 155'F 15 5e)')001)(A)- D) Violations of Section 590.009(A)-(D)in SVC. I caterinfi• mobile food, tem m ary and 3-401.11(A)(3) Poulttr,Wild Game,Stuffed PI-1Fs, residential kitchen operations should be Stuffing C'omaining Fish, Meat, debited under the appropriate secdons Pouitry or Ratites-155=17 15 sec above if related to foodhorne illness ! 2-101.11;C)(3) R'hole-muscle, Fntict Beef Speaks interventions and risk factors. Othcr 145'F ! 590.009 violations relating to good retail 3-101.1? Raw An;mal Foods Cookv! :n a nracttees should be debited under#29-- Nltero,*-ave 165'F * ( Spcci.il Requirements. 3-40 1.1 i(A)(1)(F:) Ali C^disci ?19,"s- 1-: 3F 15 sic. 17 Reheating for Hot Holcing VIOLATIONS RLLATED TO GOOD RETAIL PRACTICES 3-403.I1(ft)gill! Pus ':55'P 13 ncc, 1: (Iterrtc 23-30) 3-4613.11(B) Microwave- 155'F 2 N intoe Siandina Critical and nun-critical vinkawns, ahirh do not relare to the 7::11e'` toodhornr illites.s ones vennen,c unit risk jirrtors listed above, run he 3-403.11(C) Commerciail), Puaessed PTE Food I inand in the follnn-ing sections ujthe Food Code and 105 01R i 40'F'-' 590.000 3-403.11,,E) Remainiuv Lnsiieed Portions of Reel item Good Retail Practices FC 590.000 Knady" 23. Management and Personnel FG- 2 .003 (g Proper Cooling of PHFs 24 Food and Fond Protection----------- FG-3 004 25 Equipment and Utensils FC-4 .005 3-501.14(:) Cooling.Cooked PHFs from 140'-F to 1 25 tNatel,PNmbinq and Waste FG-5 .00£ 70°F Within 2 Flours and From 70'F ?7. Physical Faciidy FG-6 007 to 4i'-F/-}5'F W oh;n 4 Hums. " I 28. Poisonous or"roxwc Materials FC 7 .008 j 3-501.1.0) Coolin,PHF,vf•tdeFrom Ambient 29. SpecialReuulremelts 009 T,maer ture!ngredientst•.,41"F145 30. Other ! - --- YFnhin 4 l louc;t °+•nor i:e..:o.z::,,. T Denote<cn,-al;teat:n tho, !z:i i9v4 Fond:'A or 105 C%II:500000. CITY OF SALEM BOARD OF HEALTH Establishment Name: LA Date: Page: l of Item Code C-Critical Item 1 DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Referent R-Red Item Verified � PLEASE PRINT CLEARLY a % G t�liP✓I '(PocAi (.1/i rou Chic°((cn cl abDU-e - rpcj ( I -h) -a I -(-h-�S • Stn t�P. �f l ria I a) fit a r'� i ; �I 0 i,u �it�t�' -�) e c(if- -�71/l�I C 1 inn--I ll ( n rrf 70 n,n, IIn ,vl�- krs , Al I o G o c Li o l;l-k r1o+ i v) I I ry-) / r 17f)!�PII ( i J U11114f Q1 �DY7f l 1 (�D1TlP i V� 002)z (.()/)r2 �l /o 4yf l b.12 �100 0Aro ( ( '(pa H 17 Q . e ' I I z 1 1 F Discussion With Person in Charge: Corrective Action Required: I ❑ 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. •�///II ❑ Voluntary Disposal ❑ Other: rt ^ V 4 3-SO;,;-a C') ; 'rHFai2eceiwed:t'I2:mperuures Violations Relefed to Foodborne fitness interventions and Risk � Accutdir.•=kr Lok-C,n>led to Factors(items 1.22) (Conk) i -4!'P7=t5'F GYifllin-t Hows. " PROTECTION FROM CHEMICALS 3-SUi. I C:;,;111 wlcd_ods;,sr PH 14 ! Food or Calor Additives 19 PHr Hut and Cold Holding 3-501.1,"(Bi Cold PIlFs Maintained at or below 3-202.12 Additives" ! `vt10t 4(F) 410/45' F" 3-302 14 Protesliun fruat Unapproied Additives, ( 3-"01,161A` Hut PHFs Maintained a t or above g5 Poisonous or Toxic Substances ( i 141) I: 7-101.11 Identifying Information-Orl,_inal ( 3-501,iu;f A Roasts Held at or aba,,e 13 Containers" ) O'F. . 7 402,11 Common Name -tths6mg G.rtainers' 20 "ime as a Public Health Control 7.201.11 Seo.uation-Suuavc„ ? ^)1.19 i ime as it Public Heol ,ControP '7-202J 1 Restrictiuu - Pr,a•nce;md Use* j 51C.ti041 H) Vail nee Requirement 7-202.112 Conditions of tis,:'' ?-203.11 Toxic Containers-Ptohibitionsi REQUIREMENTS (HSP) FOR HIGHLY SUSCEPTIBLE POPULATIONS(W.1 7 Sai»dzers,CrCriteria - Chemicals^ i 21 3-80 i.11(A) L�: n cnrized Pre-packaged Juices and 7-2(14 12 Chemicals for Washme Produce.Criteria'. I fc" 7-204.14 Drying Agents,Criteria' � ! Bever:rs with\coming f_abels* 3-80I I i!B t Ilse of Pasteurized E9� 7-205.11 Incidental Food Conflict. Lobrieants ;801,t 1 i D) Rcu pr Parfialiy Croke,!Ann:,d txui and 7-206.11 Ne:aricted Use't'csticid-s.Cri lens 1<.rn Seed Sprouts No! SerNcd. :` 7-206.12 Rodent B:til Stations" ( 3-RUL1I(C) Uriapened Food P;ckags, Not Re-served. 7-206.13 Tracking Ponders. Pest Control ,tnd ! Monitorings CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Ct-nsumer.Advisory Putted for Consumption of i 16 I Proper CookEng Temperatures for Animal Funds'Phar see Raw. undercooked ur PHFs ! Not Others*-ise F'rucecsrd to Eliminate 3401.1 l.vt1 l(2) Eggs- 155'F 15 Sec. :':-d E:'ga-hlwlediale Service 1-45"FlS.;nc� 3.3(12.13 rasiennzed Cgzs Suhanntt to.,Raw Shell 3-401 1I(A)(2) Comminuted 1+;tt. Meats(g:Game L`"c Animals- 155-F 15 sec. " SPECIAL REQUIREMENTS 3-.11)1.11(14)(1)(2) P„rk and Beet Roast 130F 1221 min' ?-411.1 I(A)(2) Ratites,Injected Meats- 15517 IS 590.U09(A)-(D) Violations o1'Section 590.009(A)-(D)in see. I catering, mobile ftid, temporary and 3-401.1 l(A)(3) Poultry,Wild Game,Stuffed PHPs, j r"idential kitchen operations should be Stuffing Containing Fish,Meat, debited un;hr the appropri:ne actions Poutt,y or Ratites-165`F 15 sec. ° I s'7ovc if re caned to foodborne itlness i-4{)1 11iC`1(3) Whole-nlcseie. intact Bec•t Stei:k5 intervcv!ions and Usk factors. Other 145°F* I it40.009 ',inlations relating to gond retail 3 401.12 Raw Animal roods Cooked in it ( practices should be debited under#29- Microwave 165`FSpecia; Rec,uirem_ras. 3 401.11(A)(1)(b) All Other PHFs - 445"F 15 we p Reheating for Hot Holding VIOLATIONS RcLATED TO GOOD RETAIII.PRACTICES 3-403.1;(A)K(ll) PHFs 165'F 15 scc. j (Items 23-30) 3-403.11(P) Microwave- 165-F 2 Minnie Standin_ Ciitir/d al!d icon-;ritrrat vinLitunes, +•.high do nnt!elaw/it the Time"' A'odborn,,a?n:•s.c Intel:-ewion F and rick fu(wrs listed of ore, can be 3-403.1 i(C) Commeroally Ptocessed RTE Food- I ,"wand in cite finliow:ab.,ertinn;<n(the Food Cade mid,'O i CAll? t40'F5' .590.6100, 3-403.11(E) Remaining I-mlreed Portions of Beef I 1 item Good Retail Practices FC 550.(HIO__1 Roasts'. ! 23. Management and Personnel FC -2 .003 tg Proper Cooling of PHFs 24 Food ane food Proleetion FG -3 .004 25 Eguipmenl and Utensils FC-4 .005 3-501 14(A) Cooling Cooked PHFs from 140'F to ( 126 Winer.PluutUnq and Waste y4-5 .006 70"F Wlihm 2 Flours and From 70'F 1 127 Physical Facrity j FC-6 .007 to 41`17/45°F Within 4 Hours.* ( -'8. Pc!eanous cr 7oxz.Materials .C-7 .008 3 SOI 14;B) Cooling PHFs;Mack Fr�mt Amhtent 29, Special FleauuermriTs ^Q9 I TeiuPetauue Ingredients it)41`F/-'S`F ( 30. Other Within 4l tuure!; ; ` •"" ",."":'", Dcnow,i enn(al item m the kulcral 191N F...�d-'ode ur 105 Cbit2 590 000. CITY OF SALEM BOARD OF HEALTH �I J Establishment Name: 0-i7A<7a .A J-?�lQ n� Date: J / Cf" (J � Page: / of t - Item Code c-Critical item I DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY �I Tv,nrnUCtht ( tDro ! nit i f ifiS! CISZ l��cfL4� of ICS N n r ' Wv ^( ))rlA--TrT)1 nP Y14"lA3 V)U1 � C� U� aw O G i YU V'P 1040 U P, k�� ,�z�� S t �`�S n l�PvvPcl t.in Pttil p101:� PF � \)D SOVAAY_('V1a -rU LVAS Pr i��_ h� ( i tb. 1.n a rr o� In o I +k 'i nt r d ' �P Hfo_l- o NXI ,/� h Irl �1, 'V�e" 0� twv-e cl axe 5tta rAl) e . I y_kC/ A4 1 CA o .! !�qr2 c�� It�5 C\b� IIS n tit G I OXI C�f� � vtc �. `� �� OuL- I Irl J v '�-t rut Zf:c� . &S !n/lla'� POA -'vY SUU(JQ —tv he r oAYU r Saruh,�o� anC� 1 + In Lfil c� Cl�ly iz1 11a r2 " 1 I a + mak x vA h� 'E �< om ,va -p Ci_.1. g-. - �l)012 6 CI4r GL( nG 1 I nnrl _I )ItisQeyv! olis " lr lv6aL 1-D lie I Wt US a>7r J Sonol nD�. V-PbAIV -06M -- Discussion With Person in Charge: I Corrective Action Required: ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ` �/�� ^� ❑ Voluntary Disposal ❑ Other: i T , V i_,C) PHFs Recer:ed at-I empermrrea Violations Related to Foodborne fitness Interventions anal Risk A,cording to L:w Croled to Factors(Items 14'2,1 (Cont.) PROTECTION FROM CHEMICALS 3- Qt,tS "00ting Methock for PHFti 11'J PHF Hot and Cold Holding 14 ( Food or Color Additives 3 501.16(0) Cold Pf IF,Ma:ntaoied at or bzlcm 3-202.12 Addrtivzs* ( s911.0,04(F) ;-302.14 Protection front Unapproved Additives* j 15 Poisonous or Toxic Substances 13-50 i J 6(A) Hot PHFs Maintained at or above 7-101.11 Identifyiae ir,!brl mLrol-Original140-F z-S' 11(,tA) RCastnHeld atorabove 130°F Containers" 7-:02.11 Common Nante - Working Containers* j 29 Time as a Public Health Control 7-201.11 Jeparation-Sttxa¢,•-` ' 3-5IU.l9 Time as a Public:Health Cunooi- 7-202 11 Restriction-Presence and Use" i90.00d(M `Fi:uiancc Reyuiremcrt 7-202.12 Conditions ort t'so, � 7-103 11 Coxic Containers-Pro!;:h:tions,; RFOUiREMENTS FOR HIGHLY SUSCEPTIBLE t 7-_C4.1 I Saoitizers.Criteria--Ci;emica,l:r'" POP!ILAT!ONS(HSP) 7-204.12 , ! 121 ( '.-gti1.11(11) Unp,:steuiii.mt Pre-packa;;ed Juices and i Chemicals for W'ashnn�f roduee,Criteria" 7-204.14 Dr)inp Agents.Cntarii0 Beveiaizss vnth vVa+mina i.abch F �oj,l':I P.) i Iso of Pasicu 7-205.11 Incidental Food Cunraat, Lubricants:' ( 1 ' rized Ezes* 9-SGL 11(0) Raw or Paa:ad!y Cooked Animal Focal diel 7-200 1 l Restricted Use Pesticides.Criteria* 1 7-200.12 Rodent Bait Stations" I 1 R:nc 5ccd Sprouts Not Served. " _i-SO i A I(C) Unopeu_d Fuad Package Not Re-served " 7-206.11 Tracking Powders,Pest Control and i - -- Mnnitnrin�° CONSUMER ADVISORY TIME)TEMPERATURE CONTROLS 22 s-603.11 Consamcr Advisory Posted for Consumption of .Animal Foods 1 hat arc new. Gndereoo.ed or 'ifi i Proper Cooking Temperatures for 1Qot Ot!;ern-!,e Pn:ccssc,',t.,Etitmnatc 1 PHFs 3-401"1iA(l)(2) Fggs- lis°F IS Sec. Pathogen;; a_ Fy,es (nunediatc Service 145'FlSsec� €� " '3-302.!3 Pa,teanaed Fgg> St�'suture inr Raw Shell . 3-401.11(A)(2) Comminuted Fish,D9eats Fi Gaunt }-gFs" Animads-Beef R st- ! SPECIAL REQUIREMENTS � 3-401.11(Bi,,l){2? Pork andBenf2oast- !3U''F12i min' ( 401.1I(Al(2) Ratites, bicaC.- 155°F 15 Sok)t009(A) (D) Violations of Section 5.90.009(A)-(D) in?- see. caceriug,. mobile food, .emperary end 3-401.11(A)()) Poultry,Wild Game, Stu'ff'ed PHFs, residential kitchen opet:urons should be i Stuif;oe Containing Fish. Meat, dehitcd under lite appropriate sections Poultn.of Ratites 165'F 15 .sec. "` above if relwed to foodborne illness 3-101.1110(3) Whole-n tlSde,Intact Beef Steaks 1 intetvenhons and risk factors. Other 1 35°F' 590.009 violations itsating to good retail 3-401.12 Raw Animal Fonds Cooked in a ipi,1cLiceS shonlu be debited under i129 - Microwave 165"F* Special Requirement.. 3401.1l(A1(1)(h) All Other PHFs- 145'F (Ssee, '- 17 Reheating ter Hot Holding j VIOLATIONS RiLATED TO GOOD RETAIL PRACTICES -303.I1t:7)R(D) PHFs 165`F15sec�. '" (Itetns23-30) 3-403.11(B) Microwave- 165°172 Minute Standing, vinbrlloin, :vhirh,(n ria' relate to the Timm ,foodborne dlness intervetaors and r'SkJiic!ors lisied above. can be 3-403.I I(C:, Commercially Prmcsse i RTE Food- ,faiind io the,toHmi ir,g xertivn;;9"r the Fun++Code and 105 C:NR 140'F 5})0"0 tit" ,_0111(F.) Remaining UnAiccd Portions of Hee( I I deal Gcod.ilet-9fl Practices FC 590.000 ---� j 23. Manac,eme:t and Per^,onne: FC-2 .003 Roasts` i 13 Proper Cooling o4 PHFs 24. Food and Food Proter.t:on FC-3 004 Cooling Cooked PHFs from 140-F to ( 25. Fa tpr Pl t dad Uand'i's FC--4 .005 j 26. Water,PIu,-,binq and haste FC-5 .006 j 70-17 Within 2 hours and From 70c'F ?7. Fhvsical Fac:Ry PC- 6 .007 j to 41 T/45"F Within 4 Hours. * ! 28. Poisonous or Toxic PEalarirds FC-I .008 j 3-501.14(15) Cooling PI 117.D1ade Fnnn Ambient ( 29. Smec,ai Requilemstts Temper avure utgrediems to 41 Tr45'1F ! 30. 0*,er : Within Hours' denote%critical,tem in the r,deial 11-99 Food Cotte or 10S CMR 590 100. CITY OF SALEM -� ( BOARD OF HEALTH Establishment Name�v1�S u .t �' Q4�ll� Date: ' (�� ' 6 Page: _) of (�P Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I�JGt K i r) "h N-eQ G Ca V_A U`9 a VS t-0 I `7�i)^�c I r� -t-�� I�,r s-�,u_f �^,�nS� ��Yt-izt ►-n.c.h ct-h � �t- RUC Y1e11}Q 7VUQev "If)6 c,() tWV� _ t I 12 s�33� Ata_ m (7 �ef2 I ° �&n �'rt rQ �o� ill siv,i. J I � 5w��,_cS � , ���, to ;in n r 0 ,"a-hV- "_J2r1S aevi Aa.l rl oa rte r�C . ,✓� U WA -k Stui-1tM SA-D+r2d _,r ov,9 - bb6 tD V2e 1 Discussion With Person in Charge: Corrective Action Required: I ❑ 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 P ED Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that 1 noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure s your food permit. ( L L✓/�J.oiv�+ `7�-t-C ❑ Voluntary Disposal ❑ Other: i v Violations Related to Foadborr!r•ri&]els Interventions and Rise .1-56 i.14((') PHFS Received at"Cemperuures.According to taw Cooled to ' Factors(items 7.22) (Cont.) 4I F/44'}-Within 4 Rom•;. " i 3-5111.15 Cooliup Methods It,PHFs PROTECTION FROM CHEMICALS 11 Food or Color Additives 19 PHF Hot and Cold Holding 3 1.0'.12 Addiln,--;* 3-So1.16(13L) Cold PILI Maintained at or below 590004(F) 41145"F.` 3-302 14 Ptoteoion iron Uan tproved Additives" 15 Poisonous or xoxia Substances 3-501.1fi(A) Hot PHFS Alaintamed at or abus 140-F. * I7-101.11 ldenni' tIr_ !rionmi'loo-Origins`! ( 3-5O!.16(A) Roasts Held at or above !3WE ContW r,erti" 7-102.1 1 C o wrw,,r;." u; I ! 20 Time as a Public Health Control Taint -- tx!.m_Conavnera'" 720Lii Separation-Storage" 3-501 19 Time as a Public Health Control^" I - .,,,...I 7-202.)1 Restriction-Pe sca-e and Us, 590.0041 H) Valiance Requirement 12 Cundmon;of lj<e: j 10.' 11odic Container,-Yn;hibirrns REQUIREMENTS FOR HIGHLY SUSCEPTIBLE I7-20,1.11 Sa:utize,�.Crit_re:-Chendc:ds' POPULATIONS(HSP) ,. ., ' 121 3-8U1.11(A) Unpasleurt'ced Pre-packagwc. ed ies and j i-104.1'2 Chemical:=for V aih;.ie e rodoce.Criteria"' Bevcraces wrth 1Vm nmq labels". j 7-204.14 fJjynaAeene. Ctner;a.r 1 l 205.11 incidental Food Contact.Luhnrma' 1 3-801.11(B) Use of Pasteurrzed Eves" 7-206.11 Re>t.icied i:se Psticides.Criteria" 3-30),I I CD} Karo ored Sprouts Cooked ServeAnimd. *7=otxl and � i Raw Seed iprouts Nol Served.'x i, 7-?06.12 Rodcw Him Stat�ats' 3-901 II(C) j 11nopened Food Package Not Re-served. ' 7-200.1 3 T;acklo-Powders.Past Control aril CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603 t I Consumer Advisor} Posted for Consamption of 16 I Proper Cooking Tempera?u•es for Animal Furls'That are Raw, Undenooked or PRFsNut(hherunse Processed to Ylimm,ae 1erxm� r.:-oo 3-401.11,4(1)(2) F 155`F15 Sec. I Pathtr,!cns.* `€ ,- r J 3-302.13 Pasteurized Eggs Substitute for Raw Shell E.c,s-lmmedirt, S,roue 145715sce E 3=4f)1.11(A)('. Cotnrnmmed Fish,Meats&(;ante I gel Ani - 155'F'R i5 sec. SPECIAL REQUIREMENTS ( 3-401.11(t3)(l)(2) PutSannndl3eefR-,,ar�.: - ' E-' 30' 12! mire'` I 4-401.11(,4)(1) Routes,Injcried Ng,ats "F 15 590.009(A)-(D) Violations of Section 590.009(A)4))in . - 15,G - I pec. * Icatering, mobile food, temporary and 3-401.11(At(i) Poulin,tiv iicl Came, Stuffed PHFS, restdet'.tial kitchen operations should ba Sluftlnf C'omainine Fish;Meat, debited under the appropriate sections ?,u!tr} or Ratites-165-l' 15 we. above if related to Coodborne illness 3-401.11(C)(3, Whol.-nwscL, Intact beef&Caks interventions and risk factors. Other 145°I' * 590.009 violations reLuing to good retail 340!.12 Rae:Animal Fu ds Cooked in a practices should be debited under#29- I%L ioc.ave 165 F* Special Rc•quiremerts. i 3-401.11(A((i)(b) . 110thctPliF., 1.45'FLiiee. * 17 I Reheating for Hot Holding VIOLATIONS R:LATEO TO GOOD RETAIL PRACTICES 3-403.114 A)&;D) I PHFS 165`F 15 sec. T (I tents 23-30) 3-403.11(B) Mictow',ve- 165' F2 klinute Standen, Grids!and non-nitical violations, whit h do not relate to the i 1 Timerfoodborne illnevs interventinnc tinct fi.skllMtory listed above, can he 3-403.11(C) ! Conener;ially Pr.resred RTE F°od- ,found in the fbllmrine sections of the Food Code and 105 C1111? oRf F" 5'*00(). 3-403.;i(F) Reiaininc, Un,licea Portions of Beef Item Good Retail Practices FC 59OW 1 Ruasis' 23. Management and Personnel FC -2 .003 118 Proper Cooling of PHFS ( 24. Food and Food Piotaction FC-3 004 25. Equipment and Utensils FC-4 .005 -SUI I4(1) Ca�linc Ctx>kcd PHP,fn,m 140`1 to 1 26. Water P�umb'nq and Waste FC-5 006 701;W,thin.1 flouts and From 70'F 27, Physical Facility FC-6 .007 j I to-1 I'Ftd5-F Within 4 Hollis. ' 28 Polsorous or Toxic Materials FC- 7 .008 1 3-501.14(H) Coolw,PHFS Made From Ambient 29 Special Requirements 009 1 Temperancehlgreaients to 41`Fi-IS"F 30 uthet j I)Vrhin a Homs I .,.,o.:. ,L.,..:s,, *Dem td>crus-al Item m q,c @decal 1900 f„rid(],,jc or !!IS CNIR 59'1(LOO _ CITY OF SALEM 1� ! (BOARD OF HEALTH Establishment Name: Yl I '� .��,1 _����( fit d, Date: 2% D Page: I�g of Date R DESCRIPTION OF VIOLATION/PLAN OF CORRECTION } Item Code —Critical Item' No. Reference R—Red Item Verified - PLEASE PRINT CLEARLY 145firms .Suh �� , -moi o os �P - 25 4 all _ 1 I Y Po/71r/ /-/)I I? �o , il) 7/7444 . ' I I (:9U/7OP 01 CP CC //-- . 5'h� /i��//Cl Q0 �<cs'c /Xv z rr6>71Yo l�4 .hr�l `J )iw) C�rP�.h ,-i��i I . sl I � 1 } I � 1 3 I { Dison With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion 't P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that L noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure i your food permit. Q ❑ Voluntary Disposal ❑ Other: If - - V is Ca Pt{F;Recet%ed at Tennper:uures Violations Related to Foodborne Illness interventions and Risk. Acc.,rdmp to Law Cooled to Factors(Items 1.22) (Cont) 41°Fl=IS"F Within d I-Aw:s. PROTECTION FROM CHEMICALS i 3-SUi 15 Cooling Methods for PHFs 19 PHF Not and Cold Holding la l=oad or Color 4ddttives I ,S01.16(B) Cold Pf!Fs Maintained ar or bzhsw I 3-202.12 Ad•dRive ' ( 59U j';U4(F) 3-302-A4 Pn:tection from UnapproGed Additives" 1 s-SHot Pl-lFsMainimned:torabuve 15 Poisonous or Toxic Substances OI Ifi(A) IdO,l, F 7-101A I Identi6ine lntoimauon-Ortgin:al 3-5U1 16(.41 130'1l.Containers' Biosis Held at or above 13U° . ! 7-102. 11 Common Kline-WildJug Containers" j ( 2U Time as a Public Health Control I � 720111 Sip.:rc,ion-Sto,ace"' i , 1-501.19 Time as a Public Health Contro:* i?0. 11 Restriction-Prese rn c^d 590.004(H) Variance Requitement 7-202.12 Conditions of t/se REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2:1.3.11 Tm.ic Containers-P: tLtwiio ls* POPULATIONS(HSP) 17-2Ud.t1 Smti;i:.a;.Criter.a-Chemicals° 7-104.12 Chemicals for Wa:hunt P;';,urcer' , ri L:rii' 21 13-S0i.[!(A) ( Unpasteurized Pre-packaged Juices and Becetrages with Warning Iabcls* i 7-204.14 Dryir,,Ae.ate.Cntet mn' I ;-80i.1 UH) Use of Pasteuuzed Eggs 7205.11 incidental Food Contac:.Lubrtcans- 3-801 11(1)1 I Raw of Partially Cooked Animal Fooll and j 7-206.11 Restrietrd Cse Pesticides.C,iteti:r- i i I Raw Seed Sprouts Nut Set ved. 7-206.12 RoJeut Bait Statir-.ns^ 7-206.13 Traeknng Fo•mders.?est Cvnir:d ,;nd 13_gi11.11 tC1 I Unopened Food Package Not Re-served. " Rtnnii0ing' 1 CONSUMER ADVISORY TIMEITEMPER'►TURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Aninu l Foods''hat arc Raw,Undercooked or 16 i Proper Cooking Temper aiure;for Not Otherwise Processed to Eliminate I PHFG 3-401 I LAI 1)(S) Lggs- 155`-17 Sec. I Pathogens." Fees-hnmneehate S:r✓irc 145`1715scrr j 3-302.13 Pasrennzed Eggs Substitute for Raw Shell 3-401.1l(A)(2) Cottni.nuted Msh, &teat; &Ciente t 1>ees.r An:rualn- 155`P 15 sec. 3-401.11(B 1 l 2) Pork and Beef Rr-asr- t rJ`F 121 min* SPECIAL REQUIREMENTS 3-40i.i1(A)(2) Ratites, InjectedNfeab,-- 155'F 15 590.004(A)-(D) Viulations of Section 590.009i,A)-(D) in sec. , catering, mobile food,temporary and 3-101.11(A)03 Po:.,rry, Wild Game Stuffed PRFs, residential kitchen operations should be Stuffing Containin; FIs Nicer. debited under the appropriate sections I'oultr} or Ratite_-165°P 15 cec. r above if related to foodborne illness 3 40L 110(3) ;i'::ale-musae,intact beet Steaks interventions and risk factors. Other 145`1' * 590.009 vieialions relating to good retail 3-101.12 Raw An'vnal Foods Cooked in a prautces should be debited under !!29- Microwave 105;F* Special Requirements, 3-1011 I(A)(1)(h; All Other PRFs- i-`''F iS see. "- 117 Retteaaing for Hot Holding I VIOLATIONS Ri LATED TO GOOD RETAIL PRACTICES 3-403.1 I(A &(I)! PFIFsi65`1715see. ' I therms 23-30) 3-403 11(B) Mi, owave- 155"F 2 olid Scmdiue ! Crier,al and non-crilicat cralolrnn.» Which do nor relate to file foodborne illness intervennuns and risk factors 1L,t,,d above, can fie f 3-403.11(C) Crmtnerciaily Processed RTE Food- ,fin:nd in the f)Ro)rufg serlions of the Food Code and 105(JIl? Ido"Fr .590.(9)0 --•103.11(E) Remaining Unr;jmd Portions of Beef floor Good Retail Practices FC 590.000 j 23. _ Management and Personnel PC-2 ' .003 ! 18 Proper Coning of PHFs 24. Fwd and Foal Protection FC-3 004 j 1 25 Equipment and Uternsils ll 4 .005 -SOI.i4(:1) CuoimvCookedPFlFe 'roan 140`Fto W ---- - -- 126 Water,Piumbin4 and Waste FC-5--- .006 701F Within,2 flours and From 70`F I 7. Physical Facility FC-6 .007 to 41`F/4.5"F Within v" Hours. ` j ( 28. Poisonous or Toxic Materials FC--7 .008 3-501A4(p) Cooling PIIFs Mad:From Ambierrc ( 29. Species Requiremeots 009 I ernperarurz hngredienta rn 41017r45'F 30. Other Within't Hourc^ ! - -Dell critical hero it.ih_[-4,sai 1(r)v Fo,t ti ods or III]<TII?590 000 Massachusetts Department of Public Health - 120 W Board S Health �• 120 Washington Street,4t"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date� Type of Ooeration(s) Type of Inspection LO-10 U�f 0'Food Service ❑ Routine Address Risk LJ Retail p'Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone J ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑ Pre-op ration ❑ Caterer ❑ Suspect Illness Person in Charge (PIC) Time El &Breakfast ❑ General Complaint 8r �1t In: J) �o ❑ HACCP Inspector ` C� 5-W-)t A& Q OutV01APA-Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ` ` ; " ' ❑ 12:Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities . EMPLOYEE HEALTH ' " ., . .. .. .-. � � 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' M TIME/TEMPERATURE CONTROLS(Potentially Hazardous Fooda E] 4. Food and Water from Approved Source ) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION." "' ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing .REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)' ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices - CONSUMER ADVISORY. ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its'agent constitutes an f23. Management and Personnel (FC-2)(990 ops) order of the Board of Health. Failure to correct violations i 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of V ✓ 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 _4 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S S901nVp Wom 140 , i Inspector's Signature: Print: PIC's Signature: V��Z vict-0, Print: cr 6 w)t55 )_,5L5 Page_ofd_Yages V r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 18 Cross-contamination I I 590.003(A) Assignment of Responsibility* 2-302.1 IWO) Raw Annual Foods Separated from 590.003(B) I Demonstration of Knowledge` Cooked and RTE Foods* - 2-103.11 Person in charge--duties I Contamination from Raw Ingredients 3-30111(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH I Other` 2 590.003(C) Responsibility of the person to charge to I I Contamination from the Environment require reporting by food employees and 13-302.11(A) I Food Protection* applicants* ( 3-302.15 - Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 I 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* I 3-306.14(A)(B) ( Returned Food and Reservice of Fiord* 3 590.003(D) Exclusions and Restrictions* I Disposition of Adulterated or Contaminated 590.003(F,) Removal of Exclusions and Restrictions I I 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* J 4-501 Ht Manual Warewashmg-Hot Water 3-201.12 Food in a Heretically Sealed Contamer* Sanitization'reniveratmes* - 13-201.13 Fluid Milk and Milk Products* I ( 4-501.112 Mechanical Wzrewashing Hot Water 3-202.13 Shell Ergs* I Sanitization Temperatures* 3-20".14 Eggs and Milk Products,Pasteurized' ( 4-501.114 I Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water"` I concentration and hardness. * __ 5-t01.I I Drinking Water from an Approved System- 14-60 Ll I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* I Utensils Clean° 596.006(B) Water Meets Standards in 310 CMR 22.0" ( 4-602.11 Cleaning Frequency of Equipment Food- , I Sheitfuh and Fish From an Approved Source I Contact Surfaces and Utensils'k 4-702.1 1 Fr-equency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish' ( 4-703.11 I Methods of Sanitization-Hot Water and 3-201.15 ( Molluscan Shellfish from NSSP Listed ChetmcaP° --- Sources* 10 I I Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory 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 I Game Animals* I 11 t I Good Hygienic Practices g ReceivingfCondition 2-401.11 Eating,Drinking or Using Tobacco" I 3-202.11 I PHFs Received at Proper Temperatures* 12-''401.12 Discharges From the Eyes, Nose and Mouth* 3-U)L I 1 Food Safe and Unadulterated 13-202.1 S I Package y* I 3-30L 12 Preventing Contamination When fasting* � I and I, 6 I I TagsfRecords:Shelistock 112 Prevention of Contamination from Hands 3-20^_.18 I Shellstock Identification * 590.004(E) Preventing Contamination from 13'203.12 ShellstockIdentification Maintainedr Employees* TagsfRecords:Fish Products I 1 13 I Handwash Facilities 1 1 3402.11 Parasite Destruction* 1 1 Conveniently Located and Accessible 1 1 3-402.12 Records,Creation and Retention* 1 5-203.11 Numbers and Capacities* Labeling of Ingredients* 15-204.11 Location and Placement* I5)OA04(J) I 9 9 1 7 Conformance with Approved Procedures I 5-205.11 Accessibilitv,Operation and Maintenance 1 1HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* I Devices 1 3-502.12 Reduced oxygen packaging,criteria* I ( 6-301.11 Handwashing Cleanser,Availability 1 8-103 12 Conformance with Approved Procedures' I 16-301.12 Hand Drying Provision "Denoies critical item in the federal 1999 Pond Code oi 105 CYIR 590.000, CITY OF SALEM BOARD OF HEALTH Establishment Name: I GtY S 17.�� J—�ICI.ILC 7� Date: IQ 1 U~ Page: /— of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 11nr1 tmLi- WhQnv vAty , or,;i,_�, (Ire StbreA Is � lalrlletr� i'.Yr 6ry--\ 4' URs 4-. � F' M --`17) Mcjtn+-nth Ccn6_ I Y-P-Q-0 -Piv - �o nr pvf,�)reS; -{a !!v_n -e'UP M .t LV k o urL.: �✓U�A- � l itv�batr��l y I F pY' .1- I ou�. I � X nrA IA Inpq n; 1a►Pa �_ _j re Poet _t iF U lm I P10n �� �.utA C)rn1 4 �r omcs2 -Fnv t v- pmt � h t �ntE . i _� dna I-i�r> v G7jltrhr)A _ CPra�iOCqA /I�Y>i12 �UU �X_ M . in t� 1,- Ij 1:. �cP(J Q, n r�A_ Ac5-fir'a r-WtA t t wi l Inc ,�-I- n �-1nv 'Drrn . rAr�1 1f1 clra t Ltd' �l vl J 'fU 1 on o a- paip [),P \( a left A ('_� t K 4 l)a s (,V_t1j )M J crh(ry,, 0-F I YMo)C� n4 Y1'rk o . Ir4 -)-vin (' L( v-P --�o he, -rh uy? h 1,cj otQUv � 61-3Ozfl47) 7 Y nthd VPiVWV bUllel. tip - J r1)4-PA nboire c~ gwns+ogs bac(c orpo hand SIt? ,^ I i�'i ,vin�P� .has ln,�Q-r n trh fi',P�l. -N�a n�� ��ks• � � i���>' � I � Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes t I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ t ` violations before the next inspection, to observe all conditions as described, and to Exclusion t •� - P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that toncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit., ❑ Voluntary Disposal ❑ Other: u r, r -_i(!! i•!;C'J � rr"RFs P.ec,=tie;at Ter.;cratmes Violations Related to Foodborne harass interventions and Risk According to[:t\v('nolud to Factors;ltems 1-22) (Cont.) j -F;`= 5`G" itlrin A Hours. * PROTECTION FROM CHEMICALS 3.501.15 Ccalin;=A"et, ods fur PH"s j 14 Food or Color Additives � � 19 PHF€lot and Cold i fold,r,g I - 1,IN 3. Cold PFIFs Maintauicd at or below 3-202.12 Additit-e.' 590 004(r- 41'145" F^ 30.^..14 Protection frem tinapPr.ned Addinvesx Hol PIIFs Maintainer)at ur above ! 15 Poisonous or Toxic Substances 140'f' k ',-101.11 ldenat,ine lnformatiou--0n,ma! 3- I.16(A) Roasts Held at or above 130'F. " Contautet:,' I , 7-102,11 Common Name-VX orki,ty Contaicers'r ( ! 21i I Time as z Public Health Control 7-'_01.11 Scpora;ion-Storage' 3-501.19 I Tine ai a Fubiic health Comrd* 7-202 11 Restriction-Presence and Use 590 UU4(H) Varirnce R_quirement i-202.17 Conditions of t'sc REQUIREMENTS FOR HIGHLY SUSCEPTIBLE j 7-Y03J 1 'ionic COntainerr.--Prohibitions% 7-204.11 Samtizets, Cntena-Chemicals' POPULA'f"IONS(HSP) o ,,, I 2d ! 3-801.1 :(AJ Unpasteurized Prd-paeka,rzd(uiccs and 7-_04..2 Cheuncals for Wa..}mig u.lucc,{'rue:ria^� 7-204,14 Drying:lyents.Corer;:?' I Set ci e;zes mrh\1 anion_ lahels' 3-RU:.7 i(Bl t!se„f Pasteurized Eel„sT ',-205.11 Restricta: Fail egticideact,Lnbucan Ls" I ;.801A I1 D) -':aw or Pa!tially Ceekerl Anhnai Fuad and 7-206.1 I Restricted t B Use Pesticides.Criteria" kaw SCaal Sprouts Nut Served x 7-206,12 Ruderal Ban d r s,Pe ?-801.1 UCy Unopened Food Package N�.t Re-screed 7='Ofi.13 'I'r:,ching,Puwders,Pest Control and ivtnnimring i CONSUMER ADVISORY TIMUTEMPER 4TURE CONTROLS 22 3-603.11 Consumer Adv,.ory Postcd for C'c.,:snmpticu of Aria u' Fo-ils-that are Raw, Undercooked or lfi Proper Cooking Temperatures for I PRFs Not 0:her 'sc Processed to Eliminate 3-40L1IA(1)(2) Eggs- 155F15Sec. F.;zgs-hunrediate Service 145'F15i,w 3-302.i 3 Pa,t'urzed Eggs substihne for Raw She'll 3-401.11(A)(2) Comminuted Fish, it$catn&Came I Eggs* iAnimals- 155"F 15 sea 't 13-40i.11(R)(1)(2) Pork and Beef Roast- 13V F 121 min" � SPECiAI REQUIREMENTS 1-40L11(A)Q2 Ratites. InjectrdMews-155''Ft5 590009(,1)-(D) Violationsof�.ection590.009(A)-(D)in Cec. , cateiing. mnhile food, temporary and 3-401.11(ArQ) Poultry,Wild Game,Stuffed FRFs, resideut;al kitch?n operations Should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratite:-165°F 15 sec. * a:)ve if ielowd to :ondborne ifnese 3401.1 I(0? -) Whole muscle, Intact Beci Steaks rtnerve,itiens and risk fa.-tors. Other 145°F " • 59(1005 t-iolatians relati::g to a0od retail 3-ii)1.12 Raw Animal Foods Cooked ma ( practice, should be dehil;d under 1{29-- Kciowave 165`Fx Special Requirements. 3.461.1 I(A)(1 t(b) All Other PIIFs- 145'17 15 sec. 17 Reheating for Hot Holding ( VIOLATIONS BELATED TO GOOD RETAIL PRACTICES 1-.103.11(A)&(D) PHFs 165'F 15 sec. * (ltems?3-3i1) ?-403.1 I(k) Mi..rowave 165'i'2 Minute Standim! C+ia,ut and non-rrilrcui cioiemams, x'hr,h no not relate to dw Time* foodbornc 86,rsv mte,venoms mad;iA,;,r.tors listed obove, can he z-4103.1 I(C) Commercially,Processed KT'F Food- found br rhe folk,„ang flections,.(the Foad Codc,,,nt 105 CMR 140°F* ! 592000. _ 3403.1 I(E) Remaining Uashced Portions of Ecef Item Coed Retail Practices FC 590.000 i Runstye: 'i. Klanacoment and Peisonnei FC --2 .POS tg Proper Cooling of PHFs 24. Food and Foci Pioteciion FC-- .004 3-501140k! Ccx�lin,>Cooked 1'HFs fiom 140'P to ' `d' Ecuipment and U!ensiis FC-4 _.0.35_ o 26. Water,FlumUncl and'Oaste (, FC-a ( .006 70`F Within 21!ours and From 7017 ( ??. Phvs,ca:Fac:6ty FC _6 007 J to 41°F/45'F W itltin 4 Hours. " ! 28. Fciecnous or Toxic l^aterials FC-7 .008 ! 3-501 1443) Cooling PHFs Made Front Ambient I 29, Special R sij.remsots ( 009 Temperature In nedients to 41`F145'13 30. Other Within, Hours` Den'a';orn.ai item In 1110 Gderal 1999 F,nnl Code or 1,15 CNiR 59(1:)(10. CITY OF SALEM 1 BOARD OF HEALTH F Establishment Name: U! I Sj ��1Q Date: ) b - 1 D o (O Page: of " Rem Code C-Critical Item ! DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 1 No. Reference R—Red Item /'� Verified 4 0 n�! PLEASE PRINT CLEARLY ' I '2nrmoInn noro'jltlr,n. WIA �olimj (1116 r1"L� � 1nG 06 0, 1 - �0 4, Ire On n ,4'-. t t I I c I _IMAA -s11 �� \� V4 �f�l xPV stn feS_t 25DY11L/ f"n,c.Pl n leo c c�o�ur� SIS 112', 1 1 i u1/_1 t 60\<;�60 em pI m i-r o ro�krubm ho d h do A , I (_L F ';Q -4- ( °,? Y'7a r,� Y'rpclvecu '�t I S /YGi r hr-1 ; U n �Pa Cd_ t I T Qyv o p1 �- I �t�v� �,� 1�e �P t (XV16 l.Q c1. /)1'()k o tz I -�n I to{=)wyu `?20H \!v ih i n ;� t,cffl-t LS r>-C _k ntio_ 4v�4. r1k C V1 (a em ( Q rh h (G`-Q/i -�D 122 ')o<`�d,� G IP o g(n(pzZ 0_� S'fihrnH in amof cGSh nt I 1 h 1c Q SCmP? o n oI sttve to 1 csz WI-4) h/jndC o AK o K /t rn-_"-Fc7111 o n If-, �)P 10 (A I I cQ _r-v_wp I ' i oi}'t k \/IftIe►a (qjs C,t.`ed, IV) - U 9-fl Vo Kmig-el have, )'ol? <>wWe lecl Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ 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-ins inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension f comply with all mandates of the Mass/Federal Food Code. I understand that ,f Noncompliance may result in daily fines of twen -five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure t' your food permit. (�f 0 Voluntary Disposal ❑ Other: PH F�R-:,eked at Ftniperatur'. Violations Related to Foodborne ff!qess interventions and M.A Acoadin,it)1.tw Cooled to Factors(items 1-22) (Cont.) 41'F/45'�p Within�:Hours. T coohu�'mc7h"'& fo;PHF" PROTECTION FROM CHEMICALS j 14 Food or Color Additives jq PFF Hot and Cold Holding 3-501.16;8) Colu?J`Frs Nlljintaincc:at of below 3-202.12 AddftiNesk 59g)004(:) =0'145" F 3-`102.14 Protection !.,oat(Inappakned Additive;" 1(-(A)) firt Pllre Mairnamed;:; ,irabove 1.5 Poisonous or Toxic Substances 140'F. 7-101.11 identifying Inticrolation-0!initial ; 3-50'. (,"A) Roasts Hold at or above13W1. t Containers- I 7-iO2,11 Connnou Noinc--NV,-'rkina Ctaita;ners'� 1 20 Time as a Public health Control -;-2it I I I .SeparationSbVagc" 3_501 I,;; 'Time as a Public Hcalth C,,)v;rot"* 7-202.11 Restriction-Presence atid Uso* j546.004h!+ Varilaice Requirement 7-202,12 Conditiong 4 Usol REQUIREMENTS FOR HGHLY SUSCEPTIBLE 7-203.11 Toxic Container;-Prohibitiom! POPULA'f iONS(HSP) 7-204.11 Stilitizea!"Cr;ter-"�-chtinj�als.. 7-2(4.12 Chemicals for Washing Ili cghice, Criloria' 2! 801.11W Unpa"'telin'ud Pre-pack."gei Juices and Y-ing AgeDtF.Crjoa i�; Bevciaee.,with Warniiw Lab 7-204AJ Dr 1, 7-205.11 incidental Food Coulao. LoN'icantst -80 L I I(B) fl�c of Paste:;i-zed P,^w: 7-206,11 Restricted Usc Pesticides.Critcri:l I II U': Raw or Painajiv Coot,ed Animal Food and Raw Seed Smouts Not Scr�-ed. ;1 7-206.12 Rodent Ban Siaflons^ 3-401.1110) Unoprne:i 7o,,d Package Not Re-sdrved 1 -106,13 Tracking Powders,Pest Contiol and Monitorial- CONSUMER ADVISORY TIMEITEMPERWURE CONTROLS 22 3-603.11 C'unstu-nor Ad,isory P,,Lsled for CotozimiptiOn of 16 Proper Cooking Temperatures for Animal Fowisu,.,t no Raw, Undetcooked oi PHFs Not 0alicnviso Frocessej to Flinunate Pathogens-'-`"°:91`;;; 340 1.11 A(l 11,2) Fgp- 155°F 15 Sec. Eggs-linmedi fac Ser 145'Fl 5se- -,-;(;2.13 FaSt'M_�led Eggs hLn-StitiltC .or Raw Shell 3-401.11(A)(2) Comminuted Fisli, Moats&Game Eggs;:. Animals- In-F 15 s 3 401.11(B)(1)(2) Fork and Beef Boast- 130'F 121 min* j SPECIAL REQUIREMENTS 3-401.1 l(A)(2) Ratites, Injected Mems- 155+ 15 590 Violations of'Scclion 590.009(A)-(D)in sec. catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Soifled PITFs, resident:jl kitchen ovetations Should be StuffinL Containing Fish,Meat, debited under the ':Pfunpriatc sections llriu!tiryor Ratirt-g-lf.5'1', 15 scc. nbuvc it rcizA,;d to foodborrie ilhiess 3-401A 1(C)(3) Wholc-muscle,Intaci Beef Steaks interventions and rill; factors. Other 145°F* 590.009 violations relating to good retailI 3-401.12 Rog Aninial Foods Cooked in a prac:ives should be debited .coder#29 - Miciowave 165'F* pedal Re qui; 3-401,1 I(A)(I)(b) All Other Pfif's- 145F 15 gee, 17 Reheating for Hot Holding VIOLATIONS MFLA TED TO GOOD RETAIL PRACTICES 3-403.111 A)&(V) 'I'-IFt. 165`17 15 sec. :_ (Items 23-30) (B" Microwave- 165° F 2 Nfinute Standing I (:,nwal and nrui-criltcal violatioin. r.hkch tin r,tq reline to the T]me" foodburne illpmv ihrenemioio ,nd o iA fi-ictors li.wrd above, can he 3-403 i I I(Ci Commercially Prkkessed RTE F(gid- found in 4w f6flwong vecolmis of the Food 140�F* 5(tck 0010. Cod-und 105 C111? 3->03.11(E) Item coca Betant Practices I FC -�O3�1 I(E) Reoiainin,,,Unsliced Portions or Beer 1 590.000 Roasts' 123. Maiactom,mt and Personnel 1 PC 2 .003 18 Proper Cooling of PHFs 24 Food and Pvocl Protortion, FC-S r.Gzl 25. Equi.-Iniora and Utens,ls PC 4 1 005 3-501.14(A) Cooling Cooked PHFs from 140`17 to 26. Watec, PlumbiiQ andNaste FC 1-5- 006 -------I 70'1`Within 2 Hours and l7n)m 70'F 2i Physjr.ai Fadh1v to 41'F/45"F Within 4 Hours. 28. Poisonous or Toxic Mate,-Ials FC- .008 3501.!4(3) Coolina,PHFs Made FroinAmbient Sooecial ctoouiretnent& ooq Temperature Ingreditnis to 41'F/45'F ?O. Other Withip 41-lours` D,n,ies-Titical iiem in ih,,fMial N99 Fool I C,xie or:05 0,18 590 000 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, Division of Food and Drugs Salem, MA 01970-35234 19 0-35234'h Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name ^r DateT�pe of Operation(s), Tyne of Insnection f 21q� Scj -f<k4 ` ill ��"/1�� I �J Food Service ] Routine Address Risk ❑ Retail '❑ Re-inspection 51(o Loa (no Level ❑ Residential Kitchen Previous Inspection p ❑ Mobile Date: Telephone /1?> J + � Owner "I\'f XI"_ HACCP Y/N El Temporary El Pre-operation I 9 bov:ih ( rl n1 I ❑ Caterer ❑Suspect Illness Person in Charge(PIC) ,fK Q' Time ❑ Bed&Breakfast El General Complaint In: El HACCP Inspector ) . , ,r /Yn h 6' I Out: Permit No. El Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT, , 2. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties . , Isrl 13. Handwash Facilities)/I 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-:­,'_. . . ­1 - . TIME/TEMPERATUREC0NTROLS(Potemietiy Hazardous Foods r_1 4. Food and Water from Approved Source ) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION '- ® 19. Hot and Cold Holding Rf 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control �l W9. Food Contact Surfaces Cleaning and Sanitizing N REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ll ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions F16c 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 In 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)(990.009) order of the Board of Health. Failure to correct violations J 24. Food and Food Protection) (FC-3)(590.004) cited in this report may result in suspension or revocation of J f 25. Equipment and Utensils rjI) (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s ssoinsaacrwmrt-ra as n _ inspect p'r'R$ store: Print: I I A�1_P 11 I Al V L�l.'Li l A(OTA A l IA ilA PIC's Signaf"u're:.- r����, T �� Print: �j`�� G I Page_of/Pages Violations Related to Foodborne Illness • Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT I S Gross-contamination 1 590.003(A) Assignment of Responsibility" I 3-302.11(A)(11 Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* I Cooked and RTE Fc oc 2-103.11 Person in charge--duties I Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person to charge to I Contamination from the Environment require reporting by food employed and 3-302.1](A) Food Protection- applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility OI'A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge' I Contamination from the Consumer 590.(H)3(G) Reporting by Person in Charge* I 3-306.14(A)(B) ( Returned Food and Rescrvice of Food* 3 590.003(D) Exclusions andRcstricttons* I Disposition of Adulterated or Contaminated .590.003(E) Removal of Exclusions and Restrictions I I I Food 3-701'1.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* _ 4 Food and Water From Regulated Sources I 19 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-HotWater 201.12 Food in a Hermetically Scaled Container* ( Sanitization Temperatures' - 3-201.13 Fluid Milk and Milk Products' ( 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Egg,* ( Sanitization Temperatures* i 3-202.14 Eggs and Milk Products,Pasteurized* I 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- 14-601.1 1(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean- 1590.006(B) Water Meets Standards in 310 CMR 22.0* ( 4-602'11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved SoContact Surfaces and Utensils*urce I 4-702 11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscae i Food Contact Surfaces of Equipment* Shellfish`" ( 4-70311 I Methods of Sanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSP listed I Chemical* Sources* 10 I Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 12-301.1 1 Clean Condition-Hands and.Arms* Regulatory Authority _ 3-20218 Shcllst<xk Identification Present'" 12-301-12 Cleaning Procedure* 590.004(0) _ Wild Mushrooms* � ( 2-301.14 When to Wash' 3-201.17 Game Animals* I it Good Hygienic Practices ,5 Receiving/Condition I ( 2-401.11 Eating,Drinking or Using Tobacco* 3-202.1 1 PHFs Received at Proper Temperatures* ( 2-401.12 Discharges From the Eyes.Nose and 3-202.15 Package hnegrity* ( Mouth* 3-101.11 Food Safe and Unadulterated"' 13-30 i.12 Preventing Contamination When Tasting* Prevention of Contamination from Hands 16 I TagslRecords:Shellstock I � 12 ( I 3-202.18 Shellstock Identification* ' 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Enplovees' Tags/Records:Fish Products I 113 Handwash Facilities 3402.11 Parasite Destruction* I Conveniently Located and Accessible 3-402.12 Records,Creation and Retention" I 15-203.11 I Numbers and Capacities* 15-20411 I Location and Placement* 1590.004(J) Labeling of Ingredients' I I 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 i 3-502.12 Reduced oxygen packaging,criteria* 11 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures* ( 16-301.12 Hand Diving Provision 'Denotes critical item in the federal 1999 Fond Code or 105 CMR 59U.000. CITY OF SALEM BOARD OF HEALTH / c ' Establishment Name: Y /AY ` cl �� n 1�� Date: q/7-4 06 Page: � of A0 Item Code C-Critical nem DESCRIPTION OF VIOLATION/PL/AN OF CORRECTION Date .� No. Reference R—Red Item pLense PRINT CLEARLY Verified n� An .-hyrj In,,::'�r-h<yn ('oMor0c� -k 1161ui J iIlPra _ c2� frim hralrlia��h - Iri►c l� x:IPd h(gnd .,w ( in Imo. I(oj)4 ovv)h,�h ,r4pd, nrcl cta-�llr i nk.ro, Y�Cki� n _Q-d- 11 .f.0 —H rm n - - �� C- Pxpo,(J �)Pcl rnn -�1c>ve - d)n -4lrl inn I I hp C-I irFYi Gn �-f o/»2 K-0 10/n-1 to 9 111 010)) " - (y)o I ✓�S G ( 4ehSl I5 -6-,)r -haA I?q inU Ct�v(-j I n I I)a-ke . I )-pre'I I C' -I-r) �1olrl Ih c(1d11f( r/Y� +1 ��E �r E/fl(fYl tvMf-ham ka _hnn-nr) USS . j I %A 4- Su V n-Yno2 �I1 � iv�� ��Lpfi k 0�}vrt�idvr�P� m �I� t-lnf 4nwt arad nal�rVfl NJjdiliem (\f)l)k- 1 d ti o - ' M I i7i/)r,1 a Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes F I hgive read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ F Exclusion i 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. — ,// ElVoluntary Disposal ❑ Other: 3-50; I !:;t't PHFs Received at'I'cmper.:ruriv Violations Related to Foodborne Illness Interventions and Risk According to La%% c7coled!o Factors(items 1.22) (Cont.) :4 N-:thin 4ITOL rs. PROTECTION FROM CHEMICALS I 3 SJI 1 C;loline Ye,hnds;:,r PHFs i� ! Food or Color Additives 19 PHF Hbt and old holding i SE;I.16(B, l Cold Pi IFs Maintained at or helow 3-:02.12 Additives:: :i90U0='(Pitl"7-}5' F;. 3-302.14 Protection from (Jnapproted Additives* 3-.i0 .( k ) 1lot PHFs Mai«tzinc l at or above - ! i5 Poisonous or Toxic Substances I I •40,cr * 7-101.11 IdenUtyitic hilbrm-ni-a-0i!gmat ?._5r,1,16(A) Roa=tsHeld :1,-T. Cntitaincra" j r :hove 1_;0'[ . 7-102.11 Common Nair -N'(rkin¢,Containers' I ( 20 Tana as n d'ublit Hesrfh Contra! 7-201.11 Separation -Ciorak,°^: ' 13-5011.L) Time at.a P,&_•9:.He,Aidn CenVoi ^O2J I ' I :i9t):)OatHt J Variau:e Rzau!rcwcnt I Restriction-Presence and Use' 7-20? 12 Cundrtion,of l ise' ! 7?t71.1 t Toxic Contuinrr•- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7204.11 Saaitizeis,Criteria-Cheaicaloa' I POPULATIONS(HSP) . .; I 21 3 5t}1A 1(A) Un:is'cu;tzcd Pre-packaged Juice;and 7-_04.12 f'.herni.als for Y1•'a..hme t,.u,ace.C:ntena, i Bevriacz::tv;th v:at'iti n�,i-abets^ 7-204.'4 Dr}htg:Agents.Ci,,eru:" 3-80i.!i(ti) 'tise of Pasteurized Eger" 1 7-205.[i incidental Foud Cuniad.I_Criteria* ( 3;;0 i,I I:D) Raw or PaYially Cocked Auanai -FcvId and 7-206,11 Restricted S Pesticides,Criteria* i6w Seed;trouts \,it Sewed. 7-206.1? � Ro;ient Baa Strnums' 06.1 s 1 rocking Potcders,Pest Control and 3-501 I I(C) Unoeened pore-i Packagz N,,t Reserved. a. CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 12 3-60.; 1 C-r-swner Adtisory Posted for Comuoilr.:on of i Aram.11 Fix-alc'I•har or.Raw,t:edercooked or 16 Proper Cooking temperatures for PHFs Sot 0dncew!ce Pes�ttssed to Eliminate ens.., Pd� 3-4t}7. 7 A(U(2) Eggs- 155-F 15 Sec. j hlg. I Eggs- Immediate Service 145°F15secr = 302.1 i Fastecri7ed 1-11,a Su')Aituie for Raw Shell 3-401.I1(A)(2) Comminuted Fish, A-iea[,&GFgFt;1 nme Animals 155"F Is sec. " SpgCiA;.REQUIREMENTS ( 3-401.11'Bi 1)(21 veri, and Beef Roaet - 13WF 1?1 nan* 3-401.11(AY 2) Rmacs,Inje,ted Meats-- 155�17 15 '`)t)Of1`I.'A)-(r); Violations of Section 590.009{A)-(D)in sec. » catering, trobile terud, temporat.v avid 3-401.1 itA)(3) Poulin;;W i!d Game,Stuffed PHFs, I residential kitchen operations s!eould be Stutting Containing Fish,Meat, dchited un.ler, the appropriate sections j Poon nr Ratite,A65°F 15 sec. " I aiiove it related to kacidbornc iLness 3-401A 1(C)(,1) Whole-muscle, Intact Bccf StCAR I interventions and risk lactors Other 145`17* 590.09 viol tion.reialinc to good retail ;_-101.12 Raw Ammal Foods Cooed in a ( prockcs should be debited under u29- It?ici.,wave 165'l- t Special Reyuircntent5. 1-101A I(Afl)(b; All Other PHFs- 145`F 15 cec H' Reheating for Bot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403A 1(A)@(Fo PHFs 165`F 15 sec. " (Ifents 23-311) I -403.11(R) b1icrowave- 165` F 2 homage Standing Cr itirn,'r:^d rren- IIl u!t•iu!s;r...... .i'llich,",rad :elan-qr the j Time' !rrrdhome di,WSS nnCOTG'ribonv uncl risk femurs listed above, car, be j 1-403,1 7(C) Cominercially Priacessed R PE KKA- fwtnd in the;o!lve ing.sertiuns q(the rood'ode and 105 Cdl)t 140'F` 5eiU.U00 3-403.11(F,i Remaunng Ur speed Voi tit.ns of Beef I item Good Persil Practices FC 590.000 Roasts' 11 2;. Management ane Persorod F;-2 003 _ 1$ 2e, Foot:and=nod Pmtectian PC-3 .004 Proper Cooling of PHFs -- _ At Cooli(l.t Ccolwd PHFs from l d0`F to I Eguipme.ni and Utensils FC-4 ! .CCS 2F,._ -- Wale. P:umblco and`Haste FC-- 5 'i ,006 ! 70cF Within.1 Hours and From 70`1' I j 27 Physical n-cii:ty FG-6 ! 00; to 41`F/45`F Within 4 Homs. ` ! j 2e Poisonous o: Taxi; Mata::als FC-7 .00' f 3.501.W(B) C.poling PHFs Made From Ambient 129. Spa;ia:F:e,uirements 009 J Temperdlnie Ingredients to 41 F/45°T' 30. Other Within 4 Hours` . •,•:r,.i..,e,..a•< -- Deaudrs c�mcA item In IN,federal 11,390 food Code or 105 CMR 590 000, CITY OF SALEM _ BOARD OF HEALTH (� Establishment Nari n �'�_ nA Date: -1'Z��U 22 Page: \,2) of �b Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. R terence R—Red Item Verified _ PLEASE PRINT CLEARLY ] �1 �o G Ih1Ps{�I ��m �jr �(iPs r)v .eoand - h x Ee�`fuina-I6e -lam . die p6--hr�-ie�' � KNIRS w t_tk -{-»art 00J) s 6 690n Wd a4 nU . I vOl vP s 1D k I rv_ D-onno( 3nl nhPct �trPov, ( )es i%a DYParP ` _ In(i DU ' MIA) ►vvo+5. (Ji , ririn. �rfn(A kd� cc 1 0 51'F L# S . .'� Ch tri e ►� �8. �" l - TV i-Vwi _ naf- bpih4I 1 Ct_F pm Y 4�nt_p Urre /Jr I "mss' -Tlwa�; S-bvrd CP DUeh 116d CrCC0Mu/a-t � Df' Marl( I 411W) /4n Io%c cyan �N�/r� NXIii . /nc�l S�/�rfi rtJtd- ��� CAzutLn� ? Discussion With Person in Charge: Corrective Action Required: ( ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion s 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 F your food permit. D4'---L"(' D-rte/4 �� -r ` ❑ Voluntary Disposal ❑ Other: r ' 3-SOi.:4i(:i �'.If=s Recent rt at"temperatur,;e Violations Related to Foodborne tlt+teee interventions and Risk A.cording to lava Cooled to Factors(items 1.22) (Cont.) ( -t i'!745'F\\'nhin-i Hours. PROTECT!ON FROM CHEMICALS ( ' >;ri I: C.:olinr 1?e;:.e.ds fur PHhs j IS Fuad or Color Additives 19 PHF Hot and Cold Holding 3-20 12 FooAihd or C ( 3-%1.16(8) Cold P1IFs Maintained at or betow .590.(704+F) 41'141' F" 3-302.14 Protec+ion from t:naf>pro,-ed Additive}' i-,10',.16(7,) i-lot Pt-IFs- MaintaineC at or above 15 � Poisonous or Toxic Substances 7-101.11 Identifying hifonna inn-OriginalI ,40 * - Contiener-l' 3-501 VIA) Ruas:,Held atorabove !3I' 0°. r 7-102.11 Common Name-WurFm;:Containers" 20 Time as a Public Health Control 1-201.11 Separation-Sanap•c 3-St)I Ie time as a Public Health Control" 7-202.11 Restriction-Ptesence and Use: 590.004(4) Variance Requirement 7-202.12 Toxic Conditions,( of t ;c" 7-2REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULAT:ONS(HSPI 7 '04.11 Sannireu;,Criteria-Chemicals, ) Unpasiour!:ed Pre hac4 aged htiees and 7.%04.12 Cheuncals for Washwc t'raC1tlBe,Crocria„ ( "t =-&01 17 Ll' ! 7-204.1 1 veying:1*•gots.(vigils` I •• Be'eutges with Warnini,I:ibels" s(!J J i 1 B) I Ise of Pastem ized legs' 7-205.11 btcidemal F:.;ed Contact. Lnbvcmtt* 3-SQi.I i(U) Raw or Paii:ally Cooked Animal Fciod and 7206,11 ke iicted Use Pesticides,Criteria* Rain Se:.d,-^roans Not Ser,ed. " 7-206.12 Rodent Ban Station!:* j 3-80 L I li C) Unopened Pvad Pae}:.:,ze Not kcer'.ed. +` 7-206 13 Tracking Powders.Pest Control and Monitoring` i CONSUMER ADWSORY TIMEITEMPERATURE CONTROLS 22 3 602. 11 Consumer Ads-isory Prated for Concuutption of Oris That ate Rav,:,Undercooked o rcr' 16 Proper Cooking Temperatures for animal Fo ( PHFs Not Citlierm ise Processed w Blirmnate I ( 3-401.i t AI 1)(2) Eggs- 155`F 15 Sec. ! Patfio, 4, ,. ( 3-302.1". Pasteurized Eggs&:hstitute fi,r Raw Shell Ek Vis-Immediate Srrcirc 1».4"FiSsec 3-401.11(A)(2) Comminuted Fish, Itleats&Game Animals- 155'F I5 sec. '% 401.11(+3)(1)(2) Pork and Beef Roast- 13WF 121 min* SPECIAL REQUIREMENTS 59(3.000(A)-(L7) Violal,ois of Section 5;0.009 A (ll)in 13-dCrl.l IIA)(2) Ratites, Injectedltitr<ds-- 755'F IS r ( )- i sec * catering. mobil. food, temporary mid 3-40:.71(3)(3) Poultry, Wild Game,-\tufted PHFs reodcntial kitchen operahuns,ltntild be Sluffing Containing Fish, Meat, I debited undet the appropriate scoions Pouhry or Ratites-1 65'F 15 sec. ' I above if related to foodborne dlncss 3-'101.11(C)(3) Wholemus•rle,Intact Beef Steaks interventions and nsh tactors. Other 145`F " 1 590.009 violas.ons rehning to good retail 3-401.12 Raw Anitnal Footh Corked in a ( nrachces should lie debited under#29 - Mkm, roace765°' + Specialkeyuiretncuts. .3-to Ll 1(.11(1 ab) All Other PHFs - 145°F 15 sec. 17 Reheating for Hot Holding VIOLA TIO<VS'R2LATED To GOOD RETAIL PRACTICES 3-403.11(A,I&(D) ( PI IF, I(i5"F 15 sec.' (Item>23-3tE) 3-103.11(B) I Microwave- 165'F 2 11 untie Standim, Crilwa7 rtud non-rriticn(,iutuhun;:, ahil,h do not relate to die Time* J foodborne dbin:ss wrervennom ud risk ja(iort 1<'.s[ed above, (an be ;-403.11(C) Cammcni:dly Processed RTE Fun)- ,G,vrru(ill tiie jWIoI l;g sections III o e mood Code and 10.1 CPvIR 140'F" 590.000. 3--103.1 t(H} Renaming Uusheed Pnr'rors of Bev( ; Item Good Retail Practices FIC 590.000 Rtr.:ste" ! 23. Menagement and Perscrnei Fr`-2 .003 i F 24 Food and food Pro!ectlon FC - 3 004 Proper Cooling of 1 3-50 L I-I(A) Cooling C ooLed PHFs from 140''u, 26. Eq.-;pm-:I!tP:. and Utensils FC-4 ! .006 - - 25 Water P:urnb�na and Waste FC-5 � 006 70'17 Within 2 flours and From 70"P 27 Pr;ysical Facility FC-C .007 j to 4I`F'/-75`F Within 4 Huw'a. * i 28 i Poisonous or Torr taleteria:s . C -7 ,00E 3-501,14(13) C,ading Pf!Fs Made From Ambient 29. SpSch^I Reauwements 003 - --_� Temperature Ingredients it)41 F/45 30,` 30. ! Otner Within 4 l fuurs* < DLnotac Omcal mem m 11V((doll Nog Fun-\(•ode or 105 CMR 59(1(100. CITY OF SALEM VI�7�Sl BOARD OF HEALTH q'�4 f a f AlEstablishment Name: Y I Date: (p Page: of ✓r! ttem Code c-critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date ! No. Refllence R-Red Item PLEASE PRINT CLEAR/' 10 ,>f Verified 4 1 /� �_ _ tin {hL �t I Ve E N-0- Q A)/))o t 104 � �'.In I y %� k-y)[1pM IP�/j1 }),.1}pc' �gv f-en rim u�-�1aP(A �WJ;IAS - ��n4�11�7'�l�al1�)/yh�o�r�tP I YOss ( (JYI I1ll l �t' t lA (J /l � ��C��-°y� - aft (eu[lA(I-1o�a� -��dS• � ti � ,A-Iv rnnolI -h a i r)r4 a rL t Ai-y_)lrp- 6fctcd 0yep nrPn �A- --k�W -VW' OJ/7 n 4- (�t ,cJ -h) I) AD N . __F� n (I gem &�n( u r. �, l r` �-�� - cr`47) l'� Ir� ov, n��h as -hau 0 in< tPor4wiii_. 1 r Svo I VI r , - rD _ft-lf C- rev- /a r) rl rAnnw<' -{-b Y,p_ MiI tri �h I a - 1 h) '1*1pf�� 1 DY��/r?V1 (a cylpS r1A 1�lm n-P Sruw o n _p7 l) n to r\W w CtA_eO 41\ Sm f (j%! o:� - - S (: 1n.I�r I11� l�_ D+ff D (? h 1� on(1 nt)+ Cl o - - r �n�'� Vin la la .fltif ;I/� _ _p, ��tn� v f ((� h ,� I ��.c�=iiut �qh� V- 4 _1��1nPa h) diveIIn MIvC�'lI_ t Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ les I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ voaons before the next inspection, to observe all conditions as described, and to Exclusion iltib i f 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 twentyy-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �'Lv ❑ Voluntary Disposal ❑ Other: — - - _-SUI 1'1;,:'; Pt{Ps Recerotd at l'emp:ratuttrs Violations Related to Foodborne Illness Interventions and Rise AccnrLn_,to Law Ceoled to Factors(items 7-22) (Cont! 41`Ft45'' 1','idti❑d H:?n,'s. PROTECTION FROM CHEMICALS 3-5(}; i5 Coj:lir Me;:oes for PHFs 14 Food or Color Additives !9 PHF Not and Cold holding ( 3-501.I6i B; Cote' Pffs?Maintained at or below, 3-202.12 Addinv-es'" t 590(104t F) !1'/45'F" 3-302.14 Protection from Unapproved Additives, I ` 3_S,j) 4(v) ( lint PHFs totaintamed ar or abv�'e 1S Poisonous or TONIC Substances i Her P . 7-10i.Il fdentihmglnformanou-O;ioinal 3-501.i 6(.4) j Roasts Held at or above i AFF. Con..:mer," 7-102.11 Comtrmn Name--Vi orS,n;,Containers^ 1 20 time or.a Public Health Control 1 3-50f.i 9 ( Time at.a Public Health O.,^trulX I 7-'01.11 Scpara6vn.-Stomee' j r•u,, - - l -. .00d(H) V;:nane,e Reyuireueaa 7-202.1 I Restriction-Presence and Usz'^ , j 7-2o2.I Conditions of il%- 7-_>03 11 Tmxi Container,-PrnhibitionO' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizes..Criter.::-C'hcmicalc' POPULATIONS(NSP) 7-^_0+.12 C'hemieals for Washing Produce,Criteria" ! 21 3-801.1](A) ! Unp.t,teurized Pre-pacuxnged Mice c and 7-204 14 Di ging.'Agents.Criteria= , ( I R-%erages with Warning F.abelsa- .i-80LI I(H: Use of Pas,cuiized E^as�^ i-20e. I t htculccte UseFooContact. Luh rerui* i Y(,,l.I t(D) Raw or Partiaiit Cooked Anowd Food and 7 30c. I) Reslricu•d Cgz PesUztilzs. Cntern+' - i 7-206.12 Rodent Bait Stations` ( Raw Seed S„r.ru!s Not Served. 7-206.13 Tracking Powders.PesL Control and ' 3-8!%1.1 i(C) Unopened mood Pack,:?e Not Re-served. " :'Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603A 1 Ceuwmer AdvucT} Posted for Consumption of -Animal Foods That are kat,. Undercooked or i to Proper Cooking Temperatures for PHFs I Not Otherwise Pr.;cessed v Eliminate 3-401.11A(1)(2) F-ggs- 15:',r 15 Sec. Pathog=ns.a` Blres-lnunaGate Service f45'Flis-c' .i-3172.':' Paveuriz tSgg�Substitute for Raw Shell 3-401.1 t(A)(2) Comminuted Fish, :Meats&Game Eggs% _ Animals- Ii5`F t sea 3-4(.+1.11(3)(1)(2) Pork and Hecf Roast- 13(NF 121 mine SPECIAL REQUIREMENTS 3-401.1 I(A)(2) Ratites, I^_iceted Wats-155"F 15 ' 590.009(A)-;'D) Violations of Seaton 590.009(A)-(D) in sec. * (;'iering. moLdc-food, temporary and 340i,I VA)0) P,wliry, Wild Gane,Stoned PHFs rmicktttial kitchen op--rations<hc'add he SVting Containing Fish,Nteal, debited under the appropriate sections potdul•ur RStitcs-165°l-, 15 scc. x' above ti relater` to foodocirne illtwss Ii2401.I II17)i:! Whole-muscle,httad Beet S!eakS interventions and risk factor., Other I45`P* Sat)009 violations relating Lo good retail 3401.12 Kati•Animal Foods Cooked in a pfact:ccs should be dehited under 1/29- Nhctcarave 165`F Special Requirements. 3-401.1 1(,A)(I Itb) All Other PHFs - 145'F 15 ser. 77 Reheating to Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(3)&(D) PHFs !W17 15 sec. `" (Items 23-30) 13-403.11(B) Microwave- 165"P2 Minute Standing l Cwt,e/and non-rrt,mll iota?;;rs, wh,,h do nal ;elate?:z!tte Time* J luodhanae i(iness mrrrrrivlions and risk f:r;t:•ra hsf,•d above, car be 3-403.11(C) Commercially Processed RTE Pond- lismd in rhetoll„u iu,q s;:rtian oy`'he F-n,;,l Code and 105 CMR 140"FF: 500.0(10. '140111(E+ Remaining Du,hred Prttions;, rltem Good Reta4 Practices FC 590.00'0 f Hecf Roasts* 23. Nanagcment and Pr zainnel r..-? .003 18 Proper Cooling of PHFs 24 Food and Food Protection FC 3 004 ?5 cgaipmaii arG 5 3-501 14(A) CoolinbCookedPHFs frnmld0`Fto 2 s . 6 "Natci.PlumGincl and Waste - ---j FC-5 .006 70"F Wilkin 2 Hours and From i4PF 127 Phdsical FacditV FC- 007 to-11"F/45"F W thin 4 Hours. " j 28 Posonuuc or Tors 4halerialo FC - 7 .0G8 3-501.14(B) Cuolm,PilFs Made Froth Ambient 29 SDecol RequaemeMs 009 Temperature hrgredients to 41°F/45`0 I 30, other j Within 4 I iours" I •..:.,r,.:�,;,.r.„ D:no:rs cT+noil item uv hr frdural 199v Purl('ado or 105 Ctvtk Sn0 pu0. t CITY OF SALEM e BOARD OF HEALTH Establishment Name: �f " ' �S I Date: V' I2� IQ U/ Page:s of d E nem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified a PLEASE PRINT CLEARLY I � �C" t�'ar, o r�nP� �IGL� Qr/i�mu /��7Ur1 �' n�`iPr/ ��r�l Flo hvis7r�Urcl��h ll✓ { \ji ft's %od rri. i izz be ( h aPd 9laC M h'9<WW9`1� a via . T / — ✓n? �' �!n()2 /✓l h'rC� of-pp 0 t?oa 2-P mlSslha �D�,� 1� , / f���P � !lj�rs ahQeh/Pd e-erD21171 re0/i�r eq-121,l rk27r/ orf_ I- Iu Xcl5 r>_ - S�hlf72 ht v�cc/a�Ce oa GU� S7?l/Y� /�� 1 -h hPX74/11 rPa-(41-0� \f2 Wil 1067Y?'WUib'' /h /y 's /6lr Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ fes a have read this report, have had the opportunity to ask questions and agree to correct all L) 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. R ����� Jf� 0 Voluntary Disposal ❑ Other: -59; :4;t') PHI-!.Rec•.;-.ed:,:Temperatures Violations Re!ated to Foodborne Iffnecs Interventions and Ris6 Ac�onling to 1-as. Cooled to Factors(items 1.22) (Cont,) 41"'F/?5''`h'ithin4 Hill ' PROTECTION ;:ROM CHEMICALS 1.15 Codi,,Mctneik. for PETFS 34 Food or Color Additives I') - PHF Hot and Cold Holding ,-5u L 1608; Ccld PAT 6.laintainw at or below 3-202.12 Additivc> 540004tr1 =12'(45" F" 3-302.i; Protection from i° tlloaAddid.es Poisonous or Toxic Substances 3"50!.16(1) Tilt PHPfa titaintatned at er ahok, 7-101.11 Identifying Inform ,m-Onuiral Idi,F 1 3-50 L! Roasts Held at or abuse 13WEI Containers' 7-102.11 Common Name -"Working Container." � ?•t) Time as a Public Health Ccnfrol 7-20!.I 1 Separation--Storavc', 3-5201 111 Time a,a Public Health Cont:ol" 7-202A I ResG::.non--1=resanre aud Use', 590004(H) Variance Regniremen: 7-202.11 C,)-,ic ons of er,, - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2_`)3 11 Swiic Cys.Criteria pnd--Ch,nai;ms„ i POPULATIONS(HSP) 7-20J.11 Sattitizers.Criteria --f'hemic�Is^ 1 7-204.12 Chemicals for Wshinv Produce,Criteria" 121 3-801.11(A) I hipastem;zetl Pre-packueed Juices and Beverages Willi Warning l.abcic^ 7 204.14 Drying:4gents.Criteria" I L t ll H) Use of Fasletuizcd Li--s" 7 205.11 Incidental Food Cuntr,et, Lubricants' ( 3-01. t(ih Raw ut P:ntiilk Ctwked Animaldu Pilot d 7-206.1 i ( Restricted Use Pegicides,Criteria" ' Raw See,( $stouts Not Sen ed. " 7-206.12 I Rode"rack it Raft Stations- 7-206.13 ere, oi. t,nnpened izwd Pncka e Not Re-served. i 7-206.13 'I'rirhing Powder:,Pest Control and Morutu:Ing* CONSUMER ADVISORY TIMEn'EMPERATURE CONTROLS 22 3-603 11 Cons,nner Advisory Posted for Consnm}:non of iii Proper Cooking Temperatures for Annual Foods"1'::.0 ore Ra.v. Undercooked fir PHFs I Not Cfthenr�,e Fn,cess;d to Eliminate 40 l,u.ac ur> Fg=1- I ss' !5 se.. }s'ges" Inunceliate Service 1:5°'15secl 3-302.13 Pasteunied Fgg> S:,bstionc t,r Raw Shell 3-401.11(A)(2I Comminuted Fish,Mears rG t;auc ( Egost Animals- I55'F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(6)(1112) Pork and Beef R•,ast- l30'p 12i mire" 590.009(A)-(D) Violatio:rs of Section .591)009(A)-(D) in 3-401.11(A)(2) Fante:s,Injected Meats- 155'F 15 sec entering, mobile food, tcrnnotary and 3-401.11(A)(3) Poullry, Wild Game, Stuffed PHFs, resicd;ntial kitchen operations should he Stuffing Containing Fish, bieac debited under the appropriate sections Poultry'of Raines"165 T' 15 sec. " above if related to faodhorne illness 13-401.1 i(00) R9:ole-muscle, Intact Beef Steaks interventions and risk factors. Other '' , laS1 590.009 violat,ons relncing to good retail 3-401.i? Rats- Aninral 'oods Cooked in a practicer,should be dehred under/t29-- Miciossaw 16.5r F* I Spe,ial Requirements. 3401.i1(A)(1)(b) All Other PHFz- l45`f- 15see. '- 17 Reheating for Hot Holding ( VIOLATIONS RvLATE:D TO GOOD RETAIL PRACTICES i 3-403.11(A)D) PHFs 165`F 15 sec. ; (Items 23-30) 3403.11,B) Microwavc- 165'F 2 3fnute Stand'uta G"iti,ai ami non-rrrlrral c;ulaliuto, wInch do iwi,e!ure to the Piste* ,fuodborne illness inter vemion,s and risk fav tors listed eUure. can be 3-403.1 I(C) Commercially Pi o:eased RTE Fold- IvJill d in the Jiarr„r.-lag sec-reons "f th,4 Food C udr rind 105 CIVR 1.10"F" 590.001?. 3-403.11(') Re:,aininj,Un,fcedPortions ofBeef I I Iters Good RetzitPrao+ices FC 500.000 23. Management and'ersonnd FC-2 .003 Proper Cooling of PHFs 124. Food and Fa7d Protection FC-3 .004 2 5- _Fquipfn^mt ann Ui,;usiic FC-a _ _ 005 Ctu7 3-501 14(A) lilt(_Cocked PH's forn !40"Fin zB. --- Vtrarer, L,n Plumq end Waste FC-5 .006---- a.- I 70'F Within 2 Flours and Frorn 70'F ( 27, .,n Ideal=av,14te` Fi;--3 007 I to 41°'rd5"F\*,ithm 4 Flours. "" ! 125. Poisonous or"fox FAaterias FC- -008 ( 3-501.1.41 B) Cooling, PHFs Made Froni A-mbient ( 125 Speciel Requ:minerts 009 Temperature htnredienrs to 41 r17/45'1`i 30 Othoi Wtt!tin 4 Hoots i, , 'Uurotea cnn�nl lien m the ledaral 000 Fon.,Code or 105 Cbtid 590 000 CITY OF SALEM BOARD OF HEALTH Jy { n �'Cl r)(f 912- 16 ID Page: of J/ Establishment Name: c( _ Date: Item Code C—Critical Item 1 DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY in horKP4- -Ec>cicQ t heed Acs- rn(Jcchd-1 -(�nTA 0� _hi q z- . -ih 6 r7)urph �y r U n r) v S apt r �uc /64- on �-,Inrat_o �_�cQ_ G}IMj-po_ rn/\ hared_ 1h P_� I�1r^p ��tr�l�l �sf7-�Yll7.r�� l AS � ,,n/ nr LI ivh IA )hov� �rjr)A_ Ifh ( h ( l) rprt ({ 11 17) PrjT4� ,.� I n nR12 I� vl o__.P ��' 1 r'Q �c� �_I f r n o � <i I 0-t�Y, 1 x �}� �M n ( � t��l t rl In —Cln nYll t ,��1( r / r 1 o a n & lnno v �n o t� Vun-h n6 l � j �� prtl ev1 A 5 1('Q c�_r on,() G.-+ ) « YY�ra r I�_( I-, 4 r �+ ry o n( i- b1ti z) U_n / (�M6 _ 1 11 -1- Co L�e 25' I �l�>7r��icct.ls_ 5-C�mc-1 Ai�n -fzr� C�nriuc�s ,_ e�0) �Iov a r-ea • Y(� l e)rCA �_k o VUJ r a �fin�ecl �� nn Q n l�fn 0 s -E 6nc� OYL6 o c c Discussion With Person in Charge: Corrective Action Required: I ❑ No '1 ❑ Yes i 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 `%4 ❑ Re-inspection Scheduled ❑' Emergency Suspension c. comply with all mandates of the Mass/Federal Food-eode. I understand that i noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: , E F --S�f IW PHFr.Receiwd at'I'emperaturan Violations Rotated to Foodborne Illness interventions and Risk <utnrd!a: is ta•.v Cavled to Factors(items 1-22) (Cont.) =1 t`F14:i`F=cvdizin d Hours. PROTECTION FROM CHEMICALS I 3-30!.i Coohne Methous fix PUFs 14 Food or Color Additives ! 14 PHF Hot and Cold Holding 3-50, 16!13) Cold PHP,mJ oitinted at or below .�-2O? 12 Addintcs" 590.1Ji) 3-302.14 Protection from Unapproz-ed Addiuves" 9(t1 =ti`r-15°1:` 3.501 1:',(A) (int PHF>Manes::red at or above 15 I Poisonous or Toxic Substances 7-101.11 Idenntjanglnlurin,mun--Oruginal I I ';-5i111hIA' Roasts,Hclrlel. ,r:hove 130'17. " Contaiuer�" 7-1021 1 Comnn,n Name-Working Container.'' ( `l! ; Time as a Public Hea'ih Conti of 7-201.11 Separation-Sh,riee° 3-501 It) Taw a.,a Public Health Control` 7-202.11 Restriction-Prescnce wid Uses i 590.004(H) I \'ffiiancC Rua agement � 7-20`1.12 Cond'tions of et.. - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-20> 11 Saxiti Containers a- -Cherni ik- POPULATIONS(HSP) 7-204.11 � Sar»tizen.Criteria--('hemicuis� � 720-,.1'2 ( Chcjiucals for Washing Produce,Criteria" 21 ( 3-80i.11(,A) ! Unpu;steunied Pte-packaged bores and 1 7-204.1.4 Dning Agents.Criteria`- ( E ei;ic:,-pith Warning labels- 3-S0111(13} 11ofFust2uti<edr',C:, _ i-205.11 Incidental Foal Contact.!ubrte;mts* ' 13-S01 fill) Rav;rn Pinfa;ly Cooked Animal F-ocxl and 7 206.11 liestricu,@ Use Pesticides Criteria* Rate Seed Sprouts Not Scued. " 7-201,.12 Rodcut Hail Stations" i-501.1?(C) Unopened Fwd Package Not Re served. 7-206.13 'Pnaaking Pc,%vdcr,,,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 12 3-003.;I Crnsun�er Advisor} Posted for Consumption of Anunal Food. 11;at arc Rate. tmdercookcd at i 16 Proper Cooking Temperatures for N, ;l Othenx,ise Proce�;ed to Elinenate PHFs '4,2001 4401 H A(L(2) Egrs- 155-F 15 Sec. F'athegcns. Ec_s-hnnzet.iate Service 145`17I5se�- 3 3u)-1.13 Pastear:red F;cgs Substftute for Rasa 5hell 3-401.11(A)(2) Comminuted Fish, Mears&Gane Anituala- 155'F I-, sec. � 3--'01.11(H)(I)(21 Pot and Boo Roast - 1 0'F 12 ruin SPECIP.1.REQUIREMENTS 3-401.11(A)12) Ruins,InjcctedMeaN-- 15S•F 15 -590-009iAH0, Violations of Section 590.009(A)-(D) to sic.r catering. mobile food,temporaii,and 3-401.1 i(F,)(3) Poultry,Wild Game, Srurtol PHFs, resuicraial kichea operations should be Stuffing Containing Fish.Meat, debuted under ore appropriate sections Poultry or Ratitee-]WF 15 Sec ,. above if related t-.a foodhorne illness 3-401.11i0(3) Vv'hole-muscle, Intact Seel Steaks intervention,and risk factors. Other 1450E 590.009 violations relating to good retail 3=401.12 Rats'Animal Fwds CtmkM'in a pract;cc::should be dei-,tted under ht24-- Mictowave 165`F* Special Requirements. 3-401.1 I(A)(1)(h) All Other PHFs 145°F 15 sce. !7 Reheating for Hot Holding WOLATiONS RELAI-ED TO GOOD RETAIL PRACr/CES ,4M.11(.A)&(D) PHFs 165°F 15 sec. _ (It:rns 23.30) 3-403.11 IS; Microwave- 165° F 2 69umte Stimding Crirca!an<1 non-crib:rl violydwvs, rvi:ieG do mit re!urc m the Time" ,loodborne ilhten inavwentons and,isd-,f%n avis tis;r•d above, can he 3-403.1 It C) Commercially Processed RTE Food- found in thr j i,!!nt.ing,sections of the.rood Qu&°n„d 10;Cllff.' 140°F* 500.011". _ 3-103.1 I(E) Remaining Unsliced Puttotns of Seef I Item Good Retari Practices FC 590.000 Roasts" 23. Managemart and Personnel FC-2 .003 I Ig Pauper Cooling o5 PHFs 24 Food and Food Protection FC--3 .004 P 3-501 14( 25 Equipment and Utensils FC--3 .005 rU C1xil�ne Conl:ecl HPs from 140 P 11) -- - - -----_--- 26 'JJal;l Plum^ing grid Waste FC-5 1 .00E 70-F Within 2 Hours and From 70'F 12i Pnvsical Favi itv r C-6 .007 to 41'F745"17 Within•l Hours. " 23. Poisonous or Toxic klaterials FC--7 .008 3-501 14;S I Cooling PFIPs Matte From Arnh+ent 1 79. Sneciai R000-meots 009 Tcmperanue hzcradients to 4 i"r;14;,p 30. Other - Within 4 Hnurs' "" "`"•.",- ')en,xes.Woad lie;^u;Ih:Galeral 1994 F„nJ rude vr Inti l'Ry2 590 riOD. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: GIZ� I U�0 _ Page: of Xy Item CgRef dC-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. nce R—Red Item PLEASE PRINT CLEARLY Verified had -�eni pl� YAt) m , O- 1 3o U� `hn/cQ_ o°F or belok) n-S -fv;�nrin4forT . - - € l ucelhr ) �-r'ee-ae2 (71 A --H)M S_iDt-eC� On - -A C)o( _ 1 Ar�)/-A tD Vz ST- DreC Cit n-s (n 1 K)(7k o A t< / Ip_A mrnD -t-v bia lVi n curl nb- a p Dpav tD f2e SPt.I o (_ 1 fwd imphAJOA, LOO-S-11LI 0 oanctio4 ',men c Vi . / ora- ulatieliO I 41) � ���r>rll_��a, dun I k- k n had <;�4910446 t- /-m -Pt t)n2, - 0-11 al) � � Arno pf (YiucQ_ h unci- rn v K I i I(iJs -4) "21)6to Pvn-Ialrtvpr 1 Ui Q �V4Yi / /)It2t S t Ibi : 0 Idea( Dwn a0 4-11 A �hr 0 1-0 0 0 k"Ot l' 5M(-10 i -ty�; PQ >nnl-� (4 Uco' ),Vv / ,� ) .h -�,v7a i �v�Aco o� h��c'_ r)r►_{��� ( - mpev Px �e llr�rr4hrrn i'o�Yi� . Discussion With Person in Charge: 4 Corrective Action Required: I ❑ No I El Yes I have read this report, have had the opportunity to questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction-ask / 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 t your food permit. ❑ Voluntary Disposal ❑ Other: FFII's ReLeiv d ;t rru:ncratnrcr Violations Reload le Foodborne Illness Interventions and Risk: i According to laW C,n.ed to Factors(!hems 7.22) (Cont.) i 4,-M45-`F W,d ie 4 Hours. " PROTECTION FROM CHEMICALS 3-5u 1.15 CooliuL,7NIethodi for PHFs � 14 PHF Hot and Co:6 Halving (1_. 3 2 12 Addiuves'�" I4 ' ' Food or Color Additives 3-50;.16(i;) Cola Pf Ws 5'l.nn!•nned at ok he!ow � _ I 3-302.14 Protection •f !,r . 590,001.,F) 4i"'/75'F- ran! nat,p,of ed Arldinvzs' <-yol Ir. A t 15 Po!so,^,ons or Toxic Substances INA) H:, c'FF:M�i!,tauted at or;;bm:� 7-101.11 mmal dentimm,hrtotatton_Original 149"}'. Coummers' i 3-5(11.i ti(:1} Roasts Field at ur nbovc 130"F .r 7-10211 Common Name-Work m^Containers" 1 20 Time as a Public Health Control 7-291.1 1 ScP=!ration.-Sturave" 3-50!.!9 TancasaP,.!blic 'led NiControl ' Su0 O(i4;H) 7-['?2 7 I Restriction-Presence and Lee' j ( - ( V.riance Reyuiren:rut 7-202.12 Conditions of Ilse.' 7-201.1 1 Toxic Condoners POPULATIONS(HSP) -FrohibidouO REQUIREMENTSONFOR HIGHLY SUSCEPTIBLE 7-204.111 SanitiMS, Criterui - Chemir-als" HSPj 1 3-s0 1. ILo:pa :e,:rz.d Yr:-porkaeed?enres and7-_Oi I_ Chemirds , Vand;�Produce, CriteGa' 7-204.1.1 enwib �f . Be, : L els 7-205.11 _ Incidental Food Contact Lnbnrants� .11/R) � Us--of Pasteurized Eges* - ! 7-2(}6.11 Restricted ii CITY OF SALEM �� BOARD OF HEALTH / Establishment Named [ 1(/ (j �L�t7 {l Date:�l�'1(S,(2 Page: 15 of / l Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY rt I �� YOU h1> nib i� MPIC h()�nd5nK 174 -hap irk' IhcX(1_NIM . i — �'l�Vl(le � 1Dk �All�1PV 4f_1 v1.(AeA It 1P't-e Nkt/-11 f_)1rrI3 Nv/,Ino )YI-t-b N0S121yr -Ed �i hnh� IU(1� S►t'l�C �1'h /'01� ��/)>� Q�C1 ;��I)fl�v Ci�'h i 1 R),;Nf�A 0 1�)Yt)� 0S ,) � r 1 -14 -Somme- Doo. Jheq roAf �n, no& �P�IIYI// /'wl (41 ,1C,01na (�/1_I bI k4 v�j f-�- + riam ►Vl E- 9 7 C. Pour))b�/P.P� I'P��'Y2 y" Y) l-A cam n v I • r> t) �k�1 UPS 4 C3 G CoM T1140 QCIYI�(Ll �P'1 (�I.C�l�G ? I1n+ ( V1 I IG I(( Y� <I ywp . LJ 1 Discussion With Person in Charge: Corrective Action Required: ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that r noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of LI Embargo El Emergency Closure your food permit. 1� 0 Voluntary Disposal ❑ Other: , Recened ac'Temp,iatari Violations Related to Foodborne Inness Interventions and F%sk .tcz;.r3inti to La,x,Cooled to Factors(items t-22) (Cont.) ' 41'17745<F Within l,hour;. PROTEC710P! FROM CHEMICALS I a-50:.:5 1 Coot In',Methods for PfiF, I 11.1 Food or Color Additives 1 114 PHF Hot and Cold Holding 3-501.1G/6) Cold P1IF O Mamtaincci at or belov, 3-202.12 Additix-e>'" 540.)%UkP) 41`745°F" 3-302.!4 Protection fm*a Unaunrosed Addrtves• ( s ilii i(NAt; tEut PH Fs Maintained Iter above 15 Poisonous or Toxic Substances I j 140'17 7-101.11 Identifying Information-Original 3-,101..16(., Container's* I .1) RUrAS Held at or above '.30°F. k 7-102 11 Common More-Nko km^Coaramers" ; 121) I j "lime as a Public Health Control 7-201.11 Separadon-$tui wO, 13-501 17 Tinto a,a Public Health Control I 1 r , , SciU.0U4(Hi i%an-ice Requireute:n 7-Z0...1 , Restrich on-P:cs.nce and Llse�� 7-202.12 Conditions of Usc' II 7-^_03.11 ToxicContainers-Prohibitions;, REOU,REMENTSFOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicois'. I POPULATIONS(HSP) ' 3-801 I l i A} i Unps,bcurized Pre-packaged mice:and 7-20 3.12 Chemicals for Washing Produce,Criteria* n ( , 1-204.14 Drying.Agents.Criteria" I I a. 1 Ezwta}:es IiVarning Labels`. 7-205.11 Incidental Food Corn.ct.Lubricants' -1-60 1.i 1(8) U,e of Fastzm'ized bogs-I 17-206,11 Restricted Use Pest irides.Criteria* ( 3-60 L I i(D) Rawor Partially Cvoked Annul Fw,d and i 7-206.12 R(x{ent Batt Stations" l Raw Seed Sprows,Not Served. 7-206.13 Trackmg Powders,Pest Control and 13-801•11(C} Unopened Food F'aekage!,;of Resen�ed * i A4onras ngH CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 -5+)3.11 Consumer 'dsisory Posted for Consumption of .Animal Food;That are Raw, i.ftrdercooked or 15 Proper Conking Temperatures for PHFs Not Giher,v+se Processed to Eliminate � 3-301.I I A(1)(2) Pgys- 15;°F 15 Sec. Pathogens.' i E'19 immediate Sen-u:c• 145°P':Seco* ( 3-302.1 Pmsteurized Eggs Substitute for Raw Shell 3=10 L 11(A)(2) Comminuttd Fish,Meats<&Game Bgys Animals- 155'F 15 se-, * SPECIAL REQUIREMENTS13-401.11(Bh 1)(2; Pork and Beef'Ruast 130T 121 minx I -40L1 I(A)(2) Rarres,Injected Meats- 155-F IS 590.00()(A) (D) Violation, or Section 590.009(A)-iD)in sec. catering- mobile Riod,ternporary and 3-401.11(A01, Poultry,Wnd Ganz,Stuffed PHFs, resicential kitchen operations shotdd he Stuffing 0,ntainiug Fish,Meat, debited under the appropriate sections Poultry or Ratites-161<'F 17 sec. " above if related to foodhorne i Iters 3-40L111C(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 401.12 Raw Animal Foods Conked in a pt actit'es shrnald Le debited order `29-. Microwave 165'F* Special Rquitrinetits. 3-401,1 I(A)(I)do All Other PHFs- W'F 15 sec 117 Reheating for Hot Holding VIOLATIONS R LATER TO GOOD RETAIL PRACTICES ?-403.11(A)St(D) PHFs 165°F IS sec. " _ (dfC[E?523-30) 3-403,1 1(B) Microwave- 165`F 2 ALaulc Standing Criticnt noel eon-r•rhirul vx,Gukins. worth do not relate t,:tGe Time" mrrrtentr nnv unci;isk/m tors"Med bi,re, can be ' 3-403.1:(C) Commcrctollt Processed RTE Food- I !o+:nd r<; %;e fattuu'in,� sectiorn,qi tire/lion!Code ana 105 C,WR 3-403.1 i(L) Remaining Unshced Portions of Bcef I iters Good Ratio if Practices FC 1590.Ofi6 'I Roasisz: I 23. Manaclement and Personnel FC-° .003 - 1 24. Focd ana Food Prolection FC- 3 004- 13 Proper Cooling of PRFs I 25. Equprneni and Utensils FC--4 .005 3-501 14!A) Cooling Conked PF[Fs from 140°F lo 1 26. `)Vater, u:wtbinq ana Wrste FC-5 .008 70"F Within 2 f lours and From 70'F 1 27 Phvsical F.^,CII'ty -C-6 01- j � Lo 4I'F745"F Within"1 Hours. t 25. Poisonous of Trx,c Maieriais FC - 7 .ons - -- 3-501.14(B) Cooling PHPs Made From Ambient 129, Special Rarnl;reme�ts 0.09 Temperature Ingredients to4l`F(45°F i 30 Other l Within 4 Hours r , De,mty� awcai item m mr Imeral 1490 Fund Code or 105('bi l?590 000. .t CITY OF SALEM E BOARD OF HEALTH Establishment Name: 1 /�1 � /LLII& Date: �12VO Page: / of Item Code C-Critical Item / DESCRIPTION OF VIOLATION/PLAN OF CORRECTION ' Date No. Reference R—Red Item Verified $ PLEASE PRINT CLEARLY y �jh� rhAl 1_ y-a�- 1AW 01)1.i;j(jL oromfe,_�7, had 2 hulas 0 "� �/ E ► son-� clvb2 lwv)';� iii Dren (Ka . hAtPlImo- 01604— 1 K _t7) �hnito' � "r I F r I el 'I Y�M�,In0�UV,%& - 11_C I � I Z:�O 'pr5 % r-ko ("K0 A , Vinty In��tPD Onoos rvu1s� I I I co�( or i tM-1�wvn� i�i lh P(N I N k (oilh� t I . /�5 �rla.L� 'I�P�� -E-�iC�� ►1�QrUQS� i�ZS i�PS.f k�71m�s h11.e_�� Discussion With Person in Charge: Corrective Action Required: I LI No Ll Yes f ❑ Voluntary Compliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to Correct all Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency suspension T 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. h ❑ Voluntary Disposal ❑ Other: i -- f-t-fFs Ret.eived It Tc lopetatur"; Violations Palated to Foodborne fitness Interventions and Risk According to L. v:Co,,Ied to Factors(items 1-22) i(Cont.) 41'F/45`F Within 4 Hours. PROTECTION FROM CHEMICALS 3 501 1S Contin-,R?eflita a ii,r PHI-s 14 Food or Color Additives 19 PHF Hot and Cold Holding 501.161 K: Cold P;IFs Maintautcd at or below 3-202 1' Additives` 9C.004(F) :1 '1-}5° F' 3-702 I d Protection Crum Iluappmved Additives- ( 3-5t;1.16(4) lint PHFS Plaintamed at or above 15 Poisonous or Toxic Substances 14E,,F , - 7-(01,11 Identif'omcJnformation-Qrigina! j 3-501.16(A) KoostsHeld atorahov; 130'F. ' Containers" r ( 2Q Public Time as a Health Control 7-102.11 Common Name-\4rhnku;cC'o:uamers: � ( 7-_0... i r 7 Szparation-Storage" :i__101 i9 Time w a Fubhc Hcakh Ccutr lr 7-202.1 t Restriction-i'asencc and Ilse'° I 5'i0.ot"'hH) Varit:nceRequirement 7-20"_.12 Conditions of Use, 7-203 11 'Toxic Contain•r.: - Prohibitions REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-^04.11 Sanitizers Crvoioa-Chcmical,>T POPULATIONS(HSP) 7.204.12 Chemicals for Washing Produce,Ctileria" � � 21 1 3-301.'1(Aj Unpasheurued Frc-pacl:aycd fwee:and . 7-204.14 Ih Agents.Criteria' Bevei a',es with ctLarEnhri�nag` Lxibcls 7-205.1t Incidental Food Contact, Lubricants* , t aceu;i, le) - 7-_U - n)6.13 Recti iced Use Pesticides.G'itena r 3 801.11;D) Roat or P.utially Cooked A ot,ii Food and , Fav✓Seed Sptouts N'lz Scibed. 1 7-206.12 R<xinnt Bait Stations' ' .lJ(t'# Unon,_t a, 7-206.13 Tiac4 nig Powders.?est Control and I 'i ed Food Package Nor Re-served. Vtonito:vi„* CONSUMER ADVISORY TIMFrTEMPERATURE CONTROLS �-2 3-603.11 Cogwrncr Advisory Posted fir Cc•nsnmption of ,1naoal?'owl:: Thar tine Raw. Underc eked or 1fi Proper Cooking Temperatures for I No, F;theru�tse Processed to Eliminate PHFS 3-401.I1.4(I)(2) t:ggr LSi"F IS ties. Eggs-hnmediate Service 145"FJ Ssec" -392 13 Pasteurized Eggs Substitute for haw Shell 140111(A)(2) Comminuted Fish, A4eats,k Game -cs - Annual,s- 15T7 L wc. 3-401.1 I(B)(I)(^.) Pork and Beef Roast- 1301E E'_I ruin* SPECIAL REQUIREMENTS 590.0(19(A) -(D Violations of Section 590,009(A) (D) in 3-401.1 l(A)(2) Ratites,hyectedMcat:.- 155"F 15 ) seacatering, noluie food,temporary and 3-401.; I(A)(3) Poultry,Wild(Jame,Stuffed PRFs, residesthai kitchen eperatira,s should be Stuffing Curtaining Fish. vleat, debited under the appropriate s,re•tions Poultry or Ratites 165'F 15 see. £ above i]telaled to fatid€xirne illness 3-=401.11(C)(3) Whole-nmsele- intact Beef Steaks ituerventions end rick factor. Other 145°F* 590.009 eiolationF rel.aing to good rehtit 9101 1? Raw Anitao! Foods Cooked in a , tices si�oald !)?denited under 1129- It4icrnwave 16YF* Special Requirements. 3-401.1 l(.Ai(J)(b; All CRhor PHFS-- 145'F 15 sec. IT Reheating for Hot Holding VIOLATIONS R.ELATEO TO GOOD RETAIL PRACTICES 3 403.11(.A,&(D) Pi1Fs 165"F 15 tie,_. ( (Items 23.36) 3-403.11(5) Microwave- 165` F 2 Minute Standing; ( Graiud and non-rrili;.al iw)b7 ln.,, n•h4:rs do not relare to tfir Time" 1 ,foodbome ilinevs intetvenrtrn:;tore)ri.vF.,4rt,rs list' d above .nr,be 3-403A 1(C) Commercialk Processed RTL- Ri Kt- ' ,jatrnd in the fnl.4:H ink �tehon,i u(;he F'udd Cade roil/t)5 CMR 140'F' 590 00f). 3 dui 11(T,,) Remainim_Uw1wed Portions of Bcuf item Good P.et;du Fra-:tires FC 5911.00C ae �nt ::. Personnl : C-Fnasts" 23. Molts 2 .003 Ig Proper Cooling of PHFS I 24. Food and Feod Protection FC -"s :o04 ?.5. Ecuiement and UlaxIAs FC­1 ti05 -- ?-501 14(.4) Cooling Cooked PHPs from Iwo"F to 2G. Water, PLimbin.^and Waste j FC-5 1 .CO6 70'F Within 2 Hours mid From 70"F21, Fhysx:al Facility FC-6 I--- _ - '� .007 I to 41`FA50F Within d Hours. ` ?_fl Po:acnes:r or Toxic Mater:,3ts j FC--; .008 3-501.!4(13) Cooling PPFs Made-?ir.::Ambient. '9 Suecia:Requirer::ents I 009 Tempeiuture higredicnts to 41"F/45=F 30, Cthe• Uanotes rnucal item ni tho federal 1999(oW Code or 105 Ckll2 51)0 00o' r: CITY OF SALEM �-�, �//►► BOARD OF HEALTH ID n �r Establishment Name: rT ' 1.,.[L,.<�Ih-:E _ J �f Date: "? Z �C� Page: of Item Code c-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date f ) No. ReT ce R—Red Item ��i'' 'en/ �y t PLEASE PRINTICLEARLY 1 Verified /I< Cmr�cC (1) hu,d, 40o . In �'11i 12f 0_ .l "/YK'I/l}I hoY V02-S; figGoi-l-Iin YA" 1iw no //��i�or �✓Ll. J I �i� V F,�- �hhalc�2�eiv�ee,�� 1 1 `W - YC' f� � I ' D iscussion With Person in Charge: Corrective Action Required: I ❑ No Yes P 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-fives dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: fC'L1 t!r'1 PRFs Rer.;Ned n Temneratur'•; Violations Rolston!to Foodborne illness Interventions and Risk Aecwdm•*N Iatb Cooled.o Factors(Items 1.22) (Cont.) 41'Ft45 f'Within 4 Houn ' PROTECTION FROM CHEMICALS j 3-501 13 C:rx>ting Mellods for 1'17117, 1 V PHF Hrt and Cold Hald 14 j Food or Color Additives ( hig ' 3-;Ol.lo u) Cold PFIFs Maintained at or beirni- 3-202.12 Additives* 590 004((--, -01'1.15" F- 3 302.14 11:otection from Unapproved Addin iesi 3-501.16(4) '.i ^d!-lot PFIF> Maintain at or above 25 Poisonous or Toxic Substances ( !40't - 7-101.11 identitwnelnforntanuu-Qngurd 3-50i.1u(At *oasts Held at.,rob+vel;U'F'. " Containers, 7-1('2,11 f'nmmon Natne--Working Container:,* ( 2f) Time as a Public Health Control 3-SP1,it) Fime as a Public,Health Centra!' 7-2UL11 Separation-S1oiale-i - - - ' 7-20111 Restriction-Prr:;enr-r and Us& � � 590.004f H) Var.ancc_,equirement � 7-202.12 Conditions tit Use" 7-203.11 Toxic C'nntainem -P ob POPULATIONbitions" I REGU€POPULATIONS(HSP) FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitize,s.Criteria-Chcmie:ds^ ( ''04.12 Ciremieals for Washing Produce.Ctiiena" I '1 3-301.f l(?.) Unpasreur.;ed Pre- acY.aged hricea tinct 7-204.14I Diving Agents.Critetta' I N Becel:a,es wit`.t R'armng Iabets" 'r-205.1 ( IncidzmalFood Contact, Lubrn•ants* ( 3-801.11(B) UScofPastewiz.d `;'ees" j 7-'_06.11 Re.,aricted Use Pestic!das.Criteria* ; 3-01,11(t)i Rat� or Parindly Ceaiketl Animnl Food and R_i va Seed Sprouts% ,i Scrved.'- 7-206> 12 Rodent Batt tenons'' j 7-206 13 Tracking Powders,Pest Contr.,1 and =-SUI.I I(CjI Unopened Food Packagz- \',nt Rc-se, ed, i Monintring' CONSUMER ADVISORY TIME)TEMPERATURE CONTROLS 22 3-691 11 Consumer Adv!sory Posted for Consaniptiun of Aninad Foods'[Frit are Raw,Ilnderc yolked or 16 Proper Cooking'reorperatures for Not 0 r, PHFs a wrsr Proo_ssect to eliminate 3-40 L i i A(I)(2) Fgg,- 145'F 15 Sec. Eggs immediate Service 1'15"Pi Ssec' 3-302.1-, Pasteuure.;Eggs Subalitute for Rae Shell 3-401.11(A)(2) Comminuted Fish,Meas &(ittow I E92i* Animals- 155'F 15 sec. SPECIAL REQUIREMENTS3-401.11("B)(1)(2) Pork and Beef Roast - 130'F 121 min" j „ 3-401.11(A)(2) Ratites, injected Meat:. --155°F 590 15 009(A) D) Violallons of Seet;on 90.009(A)-f D)in sec, catcring. mobile food. temporary and ? A01 I1(Aa i) Poultry.Wild Cvine,Stuffed PHFs, TtNclontiai kitchen oporation;;should be Stn l ro,Corr.;ining Fish,odea,, debited under the appropriate sections Poultry or Ratites-16517 15 sec " above if related to foodborne iih?css 3-401.11(C)(3I Whole-muscle,Intact live(4leaks int: wntions and risk factors. Other 145=F^ 590.009 viol,:tions r-elating to good retail 3-401.!2 Raw?.ramal Foods Coked in a i pra,Lice,should be debited trader #29-- 1vlicrotva~,e ;GS'F Special Beguilement;. 3-401.11(A)(U1Yn Ail Other PIFs-- 145`'F 15 sec * j 17 Reheating for Hot Holding VIOLATIONS R,ef ATED tO GOOD P.ETA&PPACTlCEs 3-403.11(A)&(D) PHI., 165'P 13 sec.' (Iterns 23-30; 3-403.11(E) Micrn,cave- 1W F^_Minute Sumdine Corurat iv,d violations, i.hwh do not relate to the Timc' f rodb rn,81+ies.s intro ennon.c and i isA fin iorc listed above can be 3-403.11(C) Commercially Processed RTE Fiord- found in elle followine .rection c of the Ford Co*and 105 C'411t Ido"F* ( 590.UQ0. 3-403,11(L) P,ema'ning Unsficed Portions of Bccf i (item--- od--GoRetail Pcnetices FC 586.00(t _j Roa ts" j P3. Managomant and Person rail j r-C-3 .003 !8 Proper Cooling of PHFs I j 24. Foal ani Food ProtV_tion FC - 3 0011 j 25 Equpmen and t)ten;ils FC -4 005 3-507 14(AI Ctw4ns Cooked I'HFs from I40"F to26. Water ?lumbi-q and'Ner;te FC -5 .005 j 70-F W?thi:n 2 lmars and Front 70''F 27 Physical Facil:i•v FC-6 007 to 47^F/a5 f;Within 4 Hours. " 28 Poisonous or Toxic Material, FC--7 1 .006 j 3-501.14(81 Conlin,PHFs blade Froin Ambienti 29. Special Reauiresnents .001, j Temperature Ingredients h,41"F/45-F 30, Ciller j Within 4 Hours < • D a cies once al item or III, fadcoil 191)9 Fwst C-;de or 105 CkIR 500 Ouu, CITY OF SALEM, MASSACHUSETTS + i BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll www.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �AlaTfl �y 1S&"/i f-4- y-r}- 101JITEL# I JY - -7 —J7 0 ADDRESS OF ESTABLISHMENT l UE %1,1 G� +S I �n�L FAX# 3-7 f- — 7 Z-j MAILING ADDRESS (if different) I EMAIL--Business: V i�-6-0 L-A'✓41 0 rL(-['; L.� Owner's Ji?'"/?C/✓/f c� OWNER'S NAME17�L�1)(LTEL# {� av�3 ADDRESS IS' Gt/Z3%I�{1VOi l 7Z i`9/Q-jL(�LC1 •yt/� f 77�Fh"' STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) .301 -79S-2-- 7-( 79 $2 —Z-( Gv el G-1 77 r, ? (Required in an establishment where potentially hazardous food is prepared) [,7 G EMERGENCY RESPONSE PERSON Tt Z� t' l L�"") HOME TEL# '781-63( -i-q ? t _OAVSOFOPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION +M r!.'jP>A y /�i o A-iYj Please write in time of flay. 11 3C (for exampleltam-11pm1 30i'M // 30r�/ / +A4 /f1 s t ✓ L � 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 .... ... ...... ...._ ....... - fess... --th-a--an-...5-- -a- .sea.-t-s-- ...--- =-$-1.00...--- RESTAURANT �%ES NO 2 25-99 seats 0 more than 99 seats =$20 - -- ------------------ ------ ......... .......... .._ ........... - - - - .. .. ------------------------------ .... ...._. BED/BREAKFAST YES NO $100 .... .... ...... ....... ....._-...._-....._ I......... ._ ----------------- ..... ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT. SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fled all slate tax returns and pard all state taxes required under the!aw iz.-( y�L � tau L� � ( � y y Signature Date Social Security or Federal Identification Number - ----- ------------I------------------- ------ - ------ ---- ----- ------ ------- - ---- ---- ---- ------ ------ ------ --------- -------- Revised 11/13/06 FOODAP2007 adm Check#&Date l G s-3 ( [)-Lv`/' 0,6 $ 7/jj'U L At;u d - iwealtWof1Kassac1msetW 44 t�! ' Q "Dft SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Fantasy Island Restaurant File Number:BHF-2004-000138 516 Loring Avenue Salem MA 01970 LOCATED AT: 0516 LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions Notes FOOD SERVICE BHP-2007-0177 Dec 20,2006 Dec 31,2007 $200.00 ESTABLISHMENT Total Fees: $200.00 PERMIT EXPIRES December 31, 2007 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. 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'� 1�1� 6 f % ° �—Igo v? 3v 111 , ° X89° QU�Q 0 f7 n a 1 'o a wr D60 11 y og k #L' �41° 40 = a 3 a ,f -Y910 o — t3 —.Oy4 f 34Qo Dee tf7 '4' -34c 'Z.= Va° t' 4• -• ljryr J DCC �✓` a7 J9,4 i� 39a dK $62 i0 'd TZT6 0bL SLG QNH-ISI AS"INtld Wd Z0: ZO L06Z—Z0—Ntlf r , FRcm F.s/r7-4s ' JT;i.saNO AN Th NST D to IVNS r 5?b' • In, -0;43 yh°,j Tu Deily Temperature Report on Salad Unit vKur( /o--2 d°' /OaS_ Il/ //- d� N/ SL! 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It I! � a s 2 •�W a a � p �•°�' � a D a a � c� ° n o o x u o t'e o� eVe a �� ° ��. ro 4 a ¢` a C. � a ♦ . a c s (� O C a n r O Ne�� • w • + � 3 t. ,. `! 1 5! o St b V li }t M [Y 11 • }i I! k 11 Iv t 1 1 I N p 1 I� ;d `n A ° a a. c tro c i � d s e a g o ° C tr O a b ^ p • . rt o z o C p �. ° a ... I+ It S Il If \ 4. Qa s a p a w C`� w `R e p `� e W C �K o�� A� . e ° °� p • o �N,o p o e w rl ,1 >' 11 / /� q N ONO-"a a e c a o Q a e c o � \ a �, a o � N "'� iy q`0 4 p h• 1"a • a� n 04 I Sqi V4 L!1 tia W 10--4 C" O o n e tr s n n a a o q •, °(! 8 D r a 7 p„8 N i 2 Q h G XIE'S CO. 13 GROSSMAN ST. QUINCY, MA 02169 TEL: (617) 328-3720 INVOICE Date: October 20, 2006 Address: Fantasy Island Restaurant 516 Loring Ave. Salem, MA 01970 Job Location: Same SCOPE OF WORK: AMOUNT 1. Re-wrap air-condition unit. $ 50.00 2. Cement and waterproof the basement floor. 200.00 3. Remove pipes from the handwash sink. 250.00 TOTAL $500.00 Payable upon receipt RECE INIE® UCT 2 52006 BOARi- U 8437 DCJF 1 FANTASY ISLAND INC 516 LORING AVENUE SALEM, MA 01970 � 7 K60AJ C;K 3/� o 6 G-- �G- KEG- YoK G--- � f ... i rrn. _ .r� ^�4�''. •'a:':=d'. ��r :y,-^.n -aYi�. :;�:�.�3.;}.,.�.�.�''.'�'.3..C.-.."..S;c::1.'^.,3y.`'n�^l„,.'.-•.4`r, S�r- --4.:,^X„�PR.L-y_.,,:L::f.`.:�-,K•+�L;�:lr.:x�^.,/:�:,,bk'`.s,.:-n.:�.11`�+...� _�:'y-C°f.:'�S^-/te;�•.J-•'{.ti.:� _ _ . py-�. Rolm” 5�\ �. ..1, _.� M-+.v[+: 9r. ...JVG .y j,. •vim n 1. ., .nm :. Ile .- -. .C, .:? ,n:,� .�-4' COURT DOCKET NO. CITATION NO. ,F : ' g CITY OF SALEM PD C 0 C I VIOLATION NOTICE U J M Oi N,rA (LAST,FIRST,INITIA IIan�ASc! Slava STREET11DDRESS �^CIT)(lTOWN STATE ZIP 6) to LoQInqnV,{ e JCl/>°m, 77,6 — LICENSE NO LICpww '8N'P-760(,WNER'S NAM LAST FIRST,INITI ) I'M, boa STREETAODRESS CITY WN STATE ZIP REGISTRATION NO -STATE I EXP.DATE I MAKET' E ISE R CO�IQR ¢ ^ F o V .. o. „ yy¢ y I)T OF VI L/ATION TIME DATE`CITATION WRITTEN ?E +aL IU6 1 11 ����V t4 I I ❑PM IV"�U U O "'A `� ED LOCATION OF VIOLATION OIC1� 51(p Lu�r�g RC1 1Y►p +-a� O FJ�F via 1�yi r -f / `;e" iw C� ,-ffy' SECT FINES cc A'u a�aQY1 Ps/�A[dA{l Td�Aa. ego ovb rpN({�I COSTnx-r�mr d' IbKISr RJ(C Jwith Old inf"weL OS CTM2r€�!E. .dI– :c.lna�furJ-.' #Q binl(kA(J Au-MmAdrY Er JS L._ CiItICt_•rc res aaUy '�_. a CIA EC (t- f3k+6`__ LUNO TOTAL I O FINE ` •..^.—•9`I DUE r a ! OFFICER CERTIFIES COPY GIVEN TO VIOLATOR AN HAND • + ��..+� -� X �«�%�-��� ❑ BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: C m N j 1 CITY CLERK CITY HALL 93 WASHINGTON STREET C > W S SALEM,MA 01970 0< (D TEL.(508)745-9595 X 251 lD c Z1 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON 'E Q REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE yTJ E LL Q PAYMENT IN THE AMOUNT OF C'R Tn c W N O 0) CASEN LL i V SIGNATURE 'Cl SEE OTHER SIDE FOR FURTHER INFORMATION = ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL UU 3 HO d c t1 oQ O aO - to-r2-ore- _ `�-e---t��-I'h_�rv�.�_1�.�.__ a�--�_�i�tl�� 1��rtd_akx��-� =- - . . _ :�hd _sib-- -�� - �►�-{�,.c�c�_�aT�lNas _«Ue_c� - - -- . ._ ..u -- �� l�n� __ _ �-�-. ��..bpd�,t�_c�.t_�L��n h,�� I - - _ - -- � _ I _ City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Fantasy Island Restaurant File Number:BHF-2004-0138 516 Loring Avenue Salem MA 01970 LOCATED AT: 0516 LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions Notes FOOD SERVICE BHP-2006-0090 Jan 3,2006 Dec 31,2006 $200.00 ESTABLISHMENT Total Fees: $200.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 12 of 23 i � A CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH ' e, 1 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 o TEL. 978-741.1800 STANLEY J. USOVICZ, JR. FAx 978-745.0343 fid'/� MAYOR WWW.SALEM.COM "7/�j�Qfi .JOANNE SCOTT, MPH, RS, CHO 4 0 0 HEALTH AGENT y/4" s 2006 APPLICATION FOR PERMIT TO OPERATE �'A",FOOD ESTABLISHMENT �� NAME OF ESTABLISHMENT FA &--s A 1 -1S L*+-,1 ",PARIEL# 1"7d 7qr l?ob r ADDRESS OF ESTABLISHMENT A-&e7E.1 tyf A- 01 et 70 MAILING ADDRESS (if different) OWNER'SNAME )IW_9J) 4t--(- 1, +41 TEL# (P (_7 q —SIL ADDRESS CITY 7 Y! STATE H ZSP D t 1`r-1, / CERTIFIED OD MANAGER"S NAMES) V r?/1?'Sr 7,�' CERTIFICATE#(s) 1 6 X 7 ZSZ_ J--_G- (required in an establishment where potentially haz rdous food is pr pared.) EMERGENCY RESPONSE PERSON W, 004 (ice HOME TEL# HOURS OF OPERATION: Mon._/Tue. � Wed._✓ Thu. / Fri. ✓Sat. Sun. iI :3o — i�U1' It ''To - 6' IL- lz-c TYPE OF ESTABLISHMENT M uvA — r 0-7f FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ...... .......... .............. ... less s-s--t..h.an..---2--5 seat... e--a.is_ _-$-----.................. . ... .... 25-99 RESTAURANT S NO ///// 20 �ry seats =$150 more 77VV.• more than 99 seats /-=T2-0-0) ...N.....O...... ..................................................................'----...510.......-------*........ BEDiBREAKFAST YES 0 ---------------------------- .................................... ...----..........-----...-----*--------------............... ADDITIONAL PERMITS iJAKE (notjust serve) ICE CREAMI, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. 4— 12/ r/P � Loa I q 1V Signature Date ' Social Security or Federal Identification Number ----------------------------------------------------------- - -yy Re»sed 11/03705 FOODAP2.adm Check#&Date-- - -'/J5 ------------------------------------------ ------------------- ' CITY OF SALEM BOARD OF HEALTH Name of Establishment: Fantasy Island Address: 516 Loring Avenue Owner(s): Deborah Lam Phone: 978-745-170 Date: October J, 2006 The owner of this establishment was requested to appear for a hearing regarding multiple repeat critical violations observed at this establishment during a routine inspection on September 27, 2006 by Senior Sanitarian Janet Dionne. The owner, Deborah Lam did not appear as requested. Manager James Lee appeared for the hearing. Given the number of violations, greater than 40, 16 of which are critical violations, the owner is ordered to have the Head Chef and Second Chef certified as Food Managers. They must enroll in the next available class. The date of the class to be given to the Senior Sanitarian. In addition, there must be a "Person in Charge" at all times, even in the absence of a Certified Food Manager. This person is responsible to ensure that all sanitation techniques are followed at all times. Given the overturn of regular employees, there must be signs made up in Cantonese and Mandarin Chinese for employees to review every day upon entering the establishment to work. These signs must state the following: • Hands must be washed prior to work; following use of restroom; after sneezing, coughing or other cause of contamination; and prior to use of gloves. • There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used to handle such food. • Food must be held cold at 45 degrees Fahrenheit or lower; or hot at 140 degrees Fahrenheit or hotter. Therefore, food in salad units and other holding areas must be checked with a sanitized thermometer, at least once each hour. • All doors and windows must remain closed when not in immediate use unless a screen is in place. • Sanitizer must be used at each food prep and service area and for cleaning customer tables. This sanitizer must be made daily, checked for proper concentration, and the results of that test recorded. A ticket will be issued charging $25 for each violation that is a repeat from the previous two inspections. Mr. Lee understands, and will explain to the owner Ms. Lam, that if critical violations are observed again during a routine or follow-up inspection, the permit for this establishment may be subject to suspension or revocation. oar n n e Scott Date Health Agent /) � ��Uq�,�-�_ L� Ja es Lee, Manager Date f s + �� .,. j o � /.� �� z � � ♦ . J r � o '� 1 �K S � � _ `�' ::..F rye � � � r } �T l t� _� I �x 5s! y -F) i) \:1 1}. y 5 e is j S 0 ll ` t �' t ' .�� � r •R t •l } ,�µ '�f .f f y .. �. �� � I�fYr�;Y SSM ;� .� n. �` �'�, � � �; L' i�* 1 . , J� � � � ' � �;a ' � •1i �a fi � �, � � e S � ♦. r � , i �• .�. � . A .. ' Cl 3 COURT DOCKET NO. CITATION NO CITY OF SALEM �+�[ VIOLATION NOTICEPD [J 5J NAME(r�LAST,FIRST,INITIAL_ �SfQ�I� STREET AlD!DRESS ��{, �^CITV/TOWN STATE ZIP lva LICENSE NO J LIC EXP DATE DATE OF BIRTH OWNER'S NAME,LAST,FIRST INITIAL) Lam, hotot h STREETADDRESS CITY/TOWN STATE ZIP 61CoLov-in tAV, '-SAeYn'fy7)1o1 REGISTRATION NO STATE EXP DATE 0 DAYEIYES TE jOO'F-"�VIOLATION TIIIMiyEDAT//EE�CITAFT(ONON WRITTEN PERSONAL ( I2YIV ( ❑PM (V..tLj_VCLI 1� 2NO LOCATION OF VIOLATION Gi'�?Q EN-�,OORCING�DEPT.1 OFFENSE 4pr Vsak�"rK a(`.�I��lnx (?_ 1 CIA,CHAP SECT FINES IDTa[t.(bj,... AC„ ih1'1 BoQr�ssm.ned+Stw' �}. Jc �f0,�' h•,p}r,P74 r:1L:s tY6Y'i rA"1 a,' ,S, B ttaYls nt w.,th sulFkr+e,e(s Sc.'t+1aal�.a.L.7to-fA 17ulldµp.iscumvl0h�h-'s !+Isle wyes-tl�uwt-+4,hFcci� s— OFKiCER' "'°$'^' ""//"//r'""'-` °''1 D'NO TOTAL ( -SSI s 1 OFFICER CERTIFIES COPY GIVEN TO VIOLATOR IN HAND X ��ii./�IJJ�tL-.�.. ❑ BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE '- SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL JAN-22-2007 02 :06 PM FANTASY ISLAND 978 740 9121 P. 01 b-e NC re ,�r -'7��!''� OR ' , n OAJa' '''n = •O 04 e a 07P 7, `-�ate urn Pmes uo uodea Aln�eredwe�,.480 u' .HNiVO/4 (7A`W IV AWAW-4 WOW 0516 LORING AVENUE Fantasy Island Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE REINSPECTION Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-1700 : Handwash Facilities FAIL Critical ❑d RED Owner: Comment: The hot water in the upstairs ladies room insufficient. Plumber on site working on the problem. Deborah Lam Violations Related to Good Retail Practices (Blue Items) _ PIC: Water, Plumbing and Waste FAIL Non-Critical BLUE James Lee Inspector: Comment: Dishes and utensils stored under waste pipe in basement. Owner will be donating these items. David Greenbaum GENERAL COMMENTS: Date Inspected:ICorrect By: 383:AII other violations cited in the 11-15-05 inspection report have been corrected. 11/28/2005 Risk Level: Permit Number: BHP-2005-0069 Status: SIGNED OFF #of Critical Violations: 1 Time IN Time OUT Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2005 Des Lauriers Municipal Solutions, Inc Commonwealth of Massachusetts ( Rev. Nov 28,2005 ) 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®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 28,2005 ) Page 2 oft 0516 LORING AVENUE Fantasy Island Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection \ACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-1700 Separation/Segregation/Protection FAIL Critical RED Owner: omment:There were bottles of juice in the ice for patrons drinks in the kitchen and and at the bar. Do not store anything in ice for Deborah Lam atron drinks to prevent cross contamination. PIC: Food Contact Surfaces Clean 'and Sanitizing FAIL Critical RED .fames Lee nt:The inside panel of the ice machine has an accumulation of grime. Thoroughly clean and sanitize the entire ice machine. Inspector: Handwash Facilities FAIL Critical RED David Greenbaum Date Inspected: Correct By: ent: The new basement restroom is missing soap and paper towels. Provide wall hung dispensers for soap and paper 11/15/2005 towels. Keep stocked at all times. Provide a sign stating that"Employees Must Wash Hands Before Returning To Work" Risk Level: Check the hot water in the ladies room off the dining room to insure that the water is hot. Permit Number: BHP-2005-0069 Status: VIOLATION # of Critical Violations: 3 - Time IN Time OUT Urgency Description(s): BLUE' Violations Related to Good Retail Practices (Critical violations must be corrected Immediately or within 10 ,. days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 16,2005 ) Page / of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Equipment and Utensils FAIL Non-Critical BLUE Foodborne Illness Interventions and Risk Factors (Require �C,00mmmen heck all knives in knife rack to insure knives in storage are clean. immediate corrective action) ch' cooling unit across from the cookline needs a visible accurate thermometer. e reezer has an accumulation of food debris and grime. Thoroughly clean entire unit. microwaves need a thorough cleaning inside and out. silver refrigeration unit near back window has an accumulation of food spills and grime. Thoroughly clean entire unit. hews ant has an accumulation of grime. Thoroughly clean canopener. g- Estor accumulation of flour on a table in the back area. Thoroughly clean this table. siving ving in the back chopping area have an accumulation of food debris. Thoroughly clean these shelves. ein the basement meat and produce walkins has an accumulation of grime. Thoroughly clean all shelving in these Mina Water, Plumbing and Waste FAIL Non-Critical BLUE Comment:There are dishes and utensils stored under a waste pipe in the basement. Remove all items from top shelf under the ,-%O—' waste pipe. Physical Facili FAIL Non-Critical BLUE om nt:The back door found open with screen door open. Keep all openings to the outside sealed. I aIII Ge an accumulation of food spills and splatter. Thoroughly clean all wall surfaces including around all equipment and mk T re a missing wall tiles under the drain board. Repalce all missing wall tiles. i e s water damage on the wall and ceiling near the veggie sink in the basement. Investigate the source of the leak and repair. epair wall and ceiling. Thwk is a leak in the basement ceiling near the flour barells. Investigate the source of the leak and repair. Repair the ceiling as eede Ro t droppings noted in the basement. Have pest control operator exterminate as often as needed to abate possible rodent es on. r e holes in the ceiling of the old basement restroom. Seal all holes. ove the fly paper from food prep areas. GENERAL COMMENTS: 371: �C �U A �i City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 16,2005 ) Page 2 oft 0516 LORING AVENUE Fantasy Island Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency TelephonePROTECTION FROM CONTAMINATION 745-1700 Separation/Segregation/Protection FAIL Critical RED Owner: '�,/ Comment:There are metal collanders of produce stored directly on top of each other. Do not store collanders directly touching Deborah Lam food product to prevent cross contamination. PIC: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED James Lee Comment: Cutting boards scored and stained. Resurface or replace all cutting boards. Inspector. Brown cutting board not being used should be removed,otherwise clean and sanitize. David Greenbaum Date Inspected Correct By VSome food utensils stored on wste pipe. Clean and sanitize all utensils and store in an appropriate storage area. Not on the waste pipe. 2/27/2006 Risk Level: Knives stored between equipment. Knives must be cleaned and sanitized and stored in an appropriate storage container. Handwash Facilities FAIL Critical W RED Permit Number. Comment: Some dishes in the basement handwash sink. Handwash sinks must be used for handwashing only. BHP-2006-0090 Status: VIOLATION #of Critical Violations: 3 Time IN: Time OUT Urgency Description(s) BLUE' Violations Related,to Good Retail Practices (Critical violations must be corrected Immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 28,2006 ) Page 7 of? Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Equipment and Utensils FAIL Non-Critical BLUE Foodborne Illness Interventions and Risk Factors (Require V Comment: GE freezer has an accumulation of food spills and splatter. Thoroughly clean freezer. immediate corrective action) The silver cooling unit near the meat prep table has an accumulation of food spills and splatter. Thoroughly clean this unit. -jT%The same unit has door gaskets that are in disrepair. Replace the gaskets. \Ahe fryolators have encrusted grease around the top. Thoroughly clean the fryolators. VThe Bally walkin vent fan covers have an accumulation of dust and grime. Thoroughly clean fan covers. Physical Facility FAIL Non-Critical BLUE V Comment:The pipes above meat prep table have an accumulation of dust. Thoroughly clean all pipes. V The basement bathroom walls need to be be painted. A light over the dishwasher needs a protective cover. v The walls at the meat prep table need a thorough cleaning. V The wall and drain board near the dishwasher needs a thorough cleaning. A stall door in the ladies room broken off its hinges. Repair door. GENERAL COMMENTS: 502:Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Laurlers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 28,2006 ) Page 2 oft 0516 LORING AVENUE Fantasy Island Restaurant City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 745-1700 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:The silver cooling unit near the meat prep table has an accumulation of food spills and splatter. Thoroughly clean this Deborah Lam unit. PIC: The same unit has door gaskets that are in disrepair. Replace the gaskets. James Lee Inspector: David Greenbaum Physical Facility FAIL Non-Critical BLUE Date Inspected: Correct By: Comment:A light over the dishwasher needs a protective cover. 3/6/2006 Risk Level: GENERAL COMMENTS: 512:AII other violations cited in the 2/27/06 inspection report have been corrected. Permit Number. BHP-2006-0090 Status: SIGNED OFF #of Critical Violations: 0 Time IN Time OUT Urgency Description(s). BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected ` immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc Commonwealth of Massachusetts ( Rev. Mar 07,2006 ) 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®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 07,2006 ) Page 2 of rm OtTANT MESSAGE- FOR DA-W-1TEF_ �Z-L�O� TIME qN>✓ M RRti2t� 4 � cZ Low OF �l�l ^ 01-161 _ 5' PHONE AREA CODE NUMBER EXTENSION ❑ FAX O MOSII F AREA CODE NUMBER TIME TO CALL TELEPHONED l y„� ASE CALL CAME TO SEE YOU I I WILL CALL AGAIN WANTS TO SEE YOU I RUSH l RETURNED YOUR CALL WILL FAX TO YOU MESSAGE '^�� �'"1" l'Y�N T TI S K\23� oC tiS0\1.awJ _ 1) �a —S�IGNNED w Tops FORM 4009 MARE IN U.S.A. r L / Memo Date: 8/24/2005 To: File From: David Greenbaum RE: Fantasy Island: Food Complaint Based on a complaint regarding worms in Sesame candy at Fantasy Island an investigation was conducted and the following were noted, the sesame candy is sold on the counter in a small jar, it is purchased at a store in China Town in Boston. The candy in question was bought at a particular store and as soon as the problem was brought to the attention of management the remainder of the candy was discarded. I inspected candy that was currently on the counter and found no worms present. I spoke to Mr. Lee and he stated they would no longer sell the candy, and removed what was left in the jar. No health code violations were noted with regard to the sesame candy. 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 NameI, " . .. Date// // Type of Ooeration(s) Tyne of Inspection F 0111 A V V �rf-. _9 QlFS 1^AUNr t r 8 ARIJ r 2 Food Service ❑ Routine Address r Risk ❑ Retail Q-FI"e-inspection I Level El Residential Kitchen Previous Inspection Telephone 7c/fS� /70ej it44 ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation 09 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) J £_r 6 Time ElBed&Breakfast ElGeneral Complaint In: El HACCP Inspector/jq�dt/J e�r e M3AdM 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 Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH [:12. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS ❑ 3. Personnel with Infections Restricted/Excluded E] 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling i PROTECTION FROM CONTAMINATION PT9. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20. Time As a Public Health Control 0[[,9�food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board rl 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 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)(590.005) 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 500MVs lFoi 14 dO Inspector's Signature,:� it c .- / Print: PI C's Signature: i' ' Print: 3-� G� _ JI Page l of-2 Pages ✓i1 n A n .n Violatio,is Related to Foodborne fliness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT R Cross-contarmiation 1 15`)0.003(A) Assiutnrent of Recpnnsibdity' j 3-302.1!(A)ll) Rain ranirnal Foods Sepai Ikon I 590.003(B) I Demonsmi6on of Knowledge* Cooked and R'I'B Foods- 2-103.11 Person is chmge -duties j Contam,manor.from Haw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated frnmEach EMPLOYEE HEALTH I Othcr" j j 2 .ir)0.003((') Recpons+b+0ty of the per,on in mange to ( Cua7amlratior from the Fnvironmant j require r,-porting by tail employees and 3-302.1 i(A) Food Protection" applicants" 1 3-302.15 Washing Fruits and V-getables j 590.003(17) Responsibility Of A F(iod Employee Or.rut � 3-3(g.11 Food Contact with hfrapment and Applicant To Itzpon To The Person In Utensils Charge' Contsa rmalion from the Consumer j 590.003(G) Reporting by Person in Charge' 3-306.14(A)(6) Returned Food and Reseivi:e of FoncC° ( 1 590.003(11) Exlusions and Restrictions` Distrowticn of Adulterated or Corraminatad iW.003iln) Reun,v:d of Eschrions and Re>tr:ction, _� Food 3-101.11 Disc:wdutg rn Reconditioning l"ncafe FOOD F-iOM APPROVED SOURCE Fond" 4 Fuod and Water From Regulated Sources 9 ( Fcod Contact Surfaces 590.0f-)4(A-B) CutnplintnC with Niod Law' I 4-501 A I I Manual -Ii t Water J-20!.12 Food in it Fleinet'calle Staled Cominrer _ Sanitization Pemn.rdtures' 4-501 112 Mech 3-201A3 F'inid NI ilk and Milk Product," umcal Hut Rater W.u�uachity- 37.02.13 Shell Ern* i i Sauitizatior:'I"emper.;turesr 3-202.14 I,ggs and Miik Products. Pasteurized" i ( 4-SUI 1 Id Chzmica! Sanaizahnn-temp. pH. 3202 16 Ice Made Hour Potable Drinkirc Water" conern*ration and ( 4-601.11A) Equipmerd Frvld Contact Surf aces and 5-101.11 Drinkn^ Watcr from anApproved Ssen" Mens±ls Clens* }9OA Bottled Drinking Wetet* 4-602.11 u.-`. Cleaning..�nozncp of 8yuipment Food- 59l).006(1,) Water Meets Standards to 410 CNIR 22.0 Contact Surtatec and Utcnals* Shellfish and Fieh From an Approved Source 1 4-702.1 1 Preyurnc of Sanitization of Utensils and j 3-201.14 Fish and Recreationally Caught IVILIBuscan Food Contact S:uiaces of E•ymprnent` j Shellfish* i -4-703.11 Methods of Samlizatiun --Itot Water and 3-;:01.15 Molimcan Shellf.,h dour^sSSP Listed Chemical* Suurcer," ! Game and Mid Mushrooms Approved by Proper,Adequate Handwashulg . j Regtuatori Authority, 2-1.01.1! C lezn Con-1-Wor,--Hinck end:,ins E 3-202,1X Shellstock Identification Present' i i 2-301,12 Cleaning Procedure" 590.0,WC! Wild Musluuonrs` 2-301.14 Wien to Waeh" j 3-201.17 Game Anunals°' j 1 t Good Hygienic Practices S ReceivingiCcndition ! n--401.11 Gating„Drinking,or Using Tobacur 3_'U2 11 P}[Fs Rze.:ved::+ Proper Tempera++,ns'. j 12-40(.12 Discharges 1--tom the Lyec,Nose and j ?.202.15 Packa,,e hitegritvt ( Month': 3-101.11 Food Safe and Unadulterated3-:101.12 Prry?rniug Contemman+;n Ruts T:+sting' 6 ' TagsiRecords:ShelisYock 12 Prevention of Contamination from Hands j 590.0(WE) Prevcntin;Contamination from l 3.21;''-.1.8 Shellshwl:identification^ _. Empltlyees- 3-203.1.2 Shellstock Identification Maintained' ( 13 Handwash Facilities Tags/Records:Fish Products Conveniently Located and Accessible 3-402.11 Pairvite Destruction" i i 5-203.11 Number,,and Capat,iues" 3-402.12 Rerlreis.Crtation and Retention" 5.20-4.11 Location and Placement" j ,A)JAY1 1) Labeling of Ingredients' i Conformance with Approved Procedures ( 7-205.11 At,ce:c;1.+i lite, t)per,m,et and 1Yainten.ute.: j PrIACCP Plans I SuooGed with Seim and Herd Drvmg Ce vices 3-02.1! Specialized Processing Meth:lds� _ :i-101.11 Ilandwa,hing Clean,,ci :Availability 13-502.12 Redoced i-svgmr pac:k;o ing,criteria" 1 S-1(13.:2 Conformance with,approved Procedures' ' i 6-3,01,12 flora D'vin;1::^roncirn 1`ceo4.,ono":!flan in Inc Cedvrs7 1.999 Ford Cndc or 105 CN1R 590//.110 s CITY OF SALEM t BOARD OF HEALTH Establishment Name: F/wrw PSf4ola /l6r�—„��Jrcv�lr Date: Q� >7/is Page: 2 7a of 2 t Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date t No. Reference R-Red Item PLEASE PRINT CLEARLY Verified g O1 C cr m,kf �Sa.r>~nr Tlirtt34 n tt� s6x,t,..c3{! ^U&r rcr.m•/G- 4,0el«n /7) �rF I ort.nrs ks4- - - - ' I .• 57 ttirsoe e'-,b a ( I"a 5o a< oet fir. K c.�VN ,o- rlf' //YltrP a lF s t/�9t ni_-LR'7�1L- r/Id(NfYI/NS �'i RS4 ch/ Q �p sg� R,VS/6�CAoN R�/fJ � P L fVk�lr� tS 6/2.'j CI "ta o4t4 n- vza,r-.,,� Noir I I I I � I � 1 1 I � 1 I F I ' I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ 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 4 comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. _A/� A LiVoluntary Disposal LI Other: — r I E -SOL I�!?') FHFs Recen-ed,v-!.emperantrrs Violations Related to Foodborne illness mtewentions and Risk ! According to 1 a w Cooled to Factor.;(items 7-22) (Coni.? 4 Within d Huura. .' 3-501.15 Cooling RSelhods for PFIFS PROTECTION FROM CHEMICALS 14 I Food or Color Additives 14 PHP Hot and Cold Holding i-Sir:A 6(B) Coldd PF IFs Maintained at or below 3-_?O_.1._2 .4ddinv-edr 59j 004(F) .I '/45-P. 3-302.1-4 Protection frop.i Unapnrnsed Additives- 4 50 ) 15 Poisonous or Toxic Substancrs ( - u 1.16(A' tint PFIFS Maintained :r or abovr 7-101.11 lderditymctrf;)='m.:i:u::-On:nnal ( 140'P Containers" ! :,-5{)1 16..A) k,nets Hold at or nhnce 130'F 7-702.17 Common:Vaute -`<Korl:ingContain,W 21) Time as a Public Health Control 7-201.11 Separation-$tors=os' i 3 5i)1.19 Timc as a F ubhc Heedth Control* 7-202 11 Restriction--Prescuce and 1 ane^ ! ?')O.004(11) Variancz Requirement 7-203.12 Toxic C.o t i L;eG REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 1 7-203 11 Toxic CrS,Criteria - uhdntions, POPULATIONS(HSP) 7 2174.1 I Sanuizers.Criteria -�Chemic;4s* � 7-203.12 Chemicals for Wdshme Produce,Criteria"' I ?.I --801 1 l(=V Unpzsteurized Pre-packaged Jtocc;att([ Bevelages with W! r Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date� / T of 0 erasion s TyDe.of Inspection �t1 rr�P rI Sy �S[rf N/J I rL�t(�.g JN-yfN! ?�/d/s1� I Food Service ® Routine Address 7�d �0�, /4 t/� Risk ❑ Retail ❑ Re-inspection Level.. El Residential Kitchen Previous Inspection Telephone /`7 7y�� /7dd El Mobile Date: OwnerHACCP YM El Temporary ElPre-operation /J�ftle��rV x+4.0, I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint Inspectort;&NIO KAv1tlN I 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 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. revention of Contamination from Hands Ll1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities e_V 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 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 L�l"1'9. Hot and Cold Holdindl'2) P/8. Separation/Segregation/Protection El 20.Time As a Public Health Control Z 9. Food Contact Surfaces Cleaning and Sanitizing(_4 REQUIREMENTSFOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 21. Food ood aannd 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 CHealth. 590.000/federal Food Code. This report, when signed below Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 4. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations LZ 25. Equipment and Utensils (FC-a)(Sso.00s) cited in this report may result in suspension or revocation of 25. Water, Plumbing and Waste (FC-5)(590 ops) 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 grdql. 30. Other DATE OF RE-INSPECTION: S SOMVaTofm-Ndoc �J Inspector's Signa��_- Print: PIC's Signature: --/rCC�JJ^���, u- Print: _\ A M�, L 66 11 Page of Pages Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 K Cross-cnn'ar,;ins5cr, j 1 j .5')0.003(A) Assignment of Respon;i Lilitp": j I ?-?r?.I I(,A)(l) Ra:. Aoi=d Fu,.x!s Sep.u-:eed l our 590,003($) Demonstration of ICnuwledge" ( Cooked and R'E Fu:uJs' 1 Contamination from Rase tn-rodtents '2-::03.1 I Person in charge- duties ( � g ! 3-302 1 I(B)(2) Rat,Animal Food,S.psrat..d from Path EMPLOYEE HEALTH Dihei* 12 590.003iC) Responsibility of the person in charge to j Cvaraminalon from the Fmironmenr reyuire•aper ting by food empluvices and 13 902 11(A) Foots Prutrction' applicants ( 3-)02.15 Washnic Fruits and vregetables 590.0 Pa F) Respunmbltite Of A Food Employee Or Art 3-304.11 F„od Conlaet uah Equipment and Applie ni To Report To The Person In Utensils* Cha_e" j Contamination from the Consumer i'+O.003m) Reporting by Pers,+n in Chace" 1 3-306.1 1(A)(B) Retnmed Food and P,esevice -;Foix!°` 1 3 590 0031 D) , Esclu,ions and Re ti ictions' Disposition of Ad'uN,erated a Contaminated 590.003(F.) j Removal of Exclusions and Rcstiietion> j Food j 3701.11 Disc:rdin o RecoaditionineUnsafe FOOD F IOM APPROVED SOURCE Fond' 1 4 1 F.od and Water From Regulated Sourres 1 9 Food Contact Smfares 1 590 0041A-B) Complt;mce taith Food LaNO d-501 III Manual l Warewashing-tIot W,:ier 3-201.12 Food in aflermeticadySealedContainer Sanih,ad,n"I'en:perature:>° 3-701.13 - -- Fluid Milk.,rid bulk Produtl s" j 4-501.1 !2 Mechanical Warewaslring- [lot Water 3-20113 Shell Eggs" .t Sanit'crtion"Iempe-.nutes;: 3-202.1, ELusand NlilkPn:ttucts. Pasteurized- 5-501.111 Chemical Sanitizra:on-tomp.,pH, 1 conccnnstion and hardness. " 3-202 lfi ice Matte From Potable Drinkim; \6atc:'" `}-60!, 5-101 11 Drinking, Water from an Apptovrd Svsteru"" j !t`\l Uten'ro_Cr and Contact Sarfaces and ( Uten,ils Clean- 190,006;A) Bottled llrinkine Water` q 60^,11 Ch�aning Fre u-rw of E ui ricat Faxi- I • , y P j 5e+i1.006(B) Water Meet;Standards in 310{:MR 22 0" � ; Contact Encloses acid Utensils* 1 Snel9ish and Fish Froman Approved Source 14-702 11 Frequency of S.t ntization of Uten,i is and 3-201.14 Fish and Recreat:onalty Caught Mollw can ; Potx!Contact Surfncrs of I;yuipments Shelit�sh°^ ! 4-703.11 Methods of Ssmti:!atiun- 4-[ot lVah:r and i 3201.15 hkilla,cat Shel(ti;h from NESP Lrsroci Chenuc,d" Sources'% 1 S0 ( Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 1 Regulatory Authority j "2301.11 Clean Conditiun- Handsand?.:ms" 1 202.15 Sliellsoxk Identification Present* 1 2-301.!2 Cleanse• -Procedure.` j 590.004(") Wild MunhruomsT j 12-301.11 'When to Wash'` 1 3-201.17 Came Armua W' j 51 I Good Hygienic Practices Receiving/Condition 2-401.11 Eatmg,Drinking or Usme Tobacco" j 3-202 11 PHFs Received at Proper Tempel aturer` I '-40 i.i'2 Diselixrgec From the Eyes.Ruse and � 3-20'_ 15 Fa:kagehneerity„ I ` Muuih+ 3-Ioi.l 1 Food Safe and Unadultert+ted` 3 301.12 Preventive Contamination When Tasting^ j 6 j Tags/Records:Shellstock 1 ( 12 1 Prevention of Con'aminalion from Hands 3-2{)2.13 Shellsua;kldertdicaUnn^ 590.004(E) PreventingComannnation*rum ( 3 03.12 Sheliswck Identification Maintamed" Lin Handwaswas h Facilities TagslRecords:Fish Products ( 13 1 Convemontty Located acrd Accessible 3-1[12.1 I Pao asite Destrucdor.' j 3-402.12 Records5205.11 ,Creation and Retention* 203.11 Numbers aLtxa:um curd f9ecnrrnd Cason'nC a, 1 590 00411) Labeling of Ingredients' 1 1 - 9 Conformance with Approved Procedures2(15,1 t r1sc:+sibilitl:,t 1Pcrauu:and\4a:utcnarwr j lHACCP Plans Supalod meth Soap an.!Hams Drying 3502 11 Specialized Processing Methods: 1 Cevtces j 3 5102,12 Reduced oxygen packaging,cnreri,t„ j 6-301.!1 Handwashine Cleay.ta. A%ailabdity 8-103.i2 Conf'ormuncewith.ApprovedPtoceduies" ( 16-301.1_^. iIax7Drt'ing�F'rut!cian "Perotor,cm c[.I item u+un•federal JIM,Food Code or 105 C'hIR 500 00o CITY OF SALEM BOARD OF HEALTH , Establishment Name: 1si7t4ri4.rir I_V&4- P ~r.I6Y or' Date: 24045- Page: 2 of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date ' No. Reference R-Red Item Verified /� � PLEASE PRINT CLEARLY I We CXA At ,&44 . C XA 404 A0.19 I I P+If r_r J7��V�Et� P®.ur✓6' u✓,r sFr rf NO df �ili�M ��D Oa ug tJuco r2+in t o A°zri - .1re Ffewd ..I Sfshir� .radsr Ite±c eerg,�-�o. lei C `�P� g//!Yr/LGµA6T 4.4k rldsA F&A*1 /N IWa /hft i1&M" �At rot. 11j0r06% jW fIN�S fwUSl U�9� tiCf i3 f e.- /ItPW.1 evdA'Wf 11i d-NLSO es ��t -P 6l' [G�sr�7VNu1G s n/[LzCn .4 MoL j dr4e O Ar✓(-rr WrAO.Q 010Nf7 OtJf 1 � y WC - 4& F�Fs3 ec rz r,� .A4 r & -N rF�e u,r.qtr�i yt! df <o l�J /l rt./4.�it' . i2de�vCXi+✓�f F I C�'.GRe�NF.a.S S 2.2 rL. l9 r' 44E fof 4#100. rta,*,ox oC d-Asjsr 1 C' Of. 96 G�.r.n-tare rew��tif of M dRsR- o�f1�K[x tDe.✓ At✓i Ali mnwz l Ar *u- "_e*W minas -t 2Y N'�� �,e.��c a+x�, d.+�u� ��t✓,ve^ .rue`ai. -- 1 Discussion With Person in Charge: Corrective Action Required:—1-6 No I ❑ Yes b 1 have read this report, have had the opportunity to ask questions and agree to correct all E) Voluntary Compliance 11 Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension F 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. A1A� ❑ Voluntary Disposal ❑ Other: V L id(C) PHF,Received at Temp.rdturec Violations Related to Foodborne illness interventions and Risk AO-oldinc L,Iaw Cool: Factors(Iterns 1-2g) (Cont.) . 4!'(-1115F\L'i*lin d How's. PROTECTION FROM CHEMICALS I ill 15Cooling\'-cthu la for 1`ICFs 14 ( Food or Color Additives I 14 PHF Hot and Cord Holding 3-204.12 Addwcos;. I 3-30i.16(b) Cold PIIPs:Naim.:Lieu at or bc!ow _t90.00a,F) 4i'145'F". 3-302.14 Poisonous from Unapproved Su sta Additives" '3-501.IG(A) H„t PHF,. Maintained at or above 115 Poisonous or Toxic Substances ! 1-10!.11 Identifying Information-Oeiginai 3-51,1 161.=i; Roasts Held:u.or above i.'-,0'P. " Containers' 7-102.11 Canon n Nance Workinv Coot,wers ( ' ``'1 !I T'me as a Public Health Control { 3-501.!9 'rime as.a Public Health Control" 17-_01.11 Sco.:rat:un - Storage" ( Sop,t;Gdt H) ':;Iriarice Keuwrcr,nan 7-202.11 Restriction-Presence and Use'" 7-202.12 Conditions of Use, j 7-203.1 I 'Toxic Container.-Prohihitiom* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 17-204.11 Sa»itizers.Criter!o-Chemicals^ POPULATIONS(HSP) 7-201.12 Chenacals for Washing Produce,Criteria, I 21 3-801 11(A) Csraveunzed Pre prickagtj Juices and I Becet'age, c.i:h Manning I.abets" J 7-204.1.1 D,viae Agents.Criteria" l(H: U:e of PnS,eu:izrd Ea�_s' 7-205.11 ( hr(tdental Food Confirm Lubricants'^ I -g:?l.I II D) Raw or Partia!ly Ccaiked,4uimai Fmr;i and 7-206.1 i Restricted Use F'esimdes Cntcrin' awee RSd Snouts M 7-206.12 Rodent Bait Stations'" ( 4 t Served'" 3-SC 1.i:(C) Una ened Food Package Not Rc-sen ed. '7.206.13 '17acking Powders,Pest Control coil ( t R-ion:rorrnR CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603,I I Consurtet Advisor) Posted for Consumption of Animal Foods"flat sa ?Saw Urdeicooked of lb Proper Cooking Temperatures for I Not O;hc:v,'se Pn)iresed t0 Eliminate PRFs 3-401.11A(1)(2) Eggt_ i 55 F i 5 Sec. Fathu _nr..;' i Eggs-Immediate Service 1=45"F15see" I 3-303.L• Pacteunzetl Eggs Substitute for Raw Shell 3-401.!I(A)(2) Comminuted Fish,Meats&Game I Enis• Animals - li5'F !>sec,_ SPECIAL REOUiREMENTS 3-40!.11(13)(1!(2) Pork and Beet'Roast- 130'F' 121 min* I 59:J.OU4(A;-' r a 3-401.1 tiAH2) Ratites,Injected \teats-155"F IS D) �irlai.nos otSceiton 590.00}(A;-(ll)in sec. " ( c.:Ierino. mobil-ford, temporat.v aad 01.11(A):.3) Rmhry, Wild game, Slotted PH Fs, rre,deatial kitchen uperations should be Smlfing Comaming Fish, Meal, I debited under the appropriate Sections Poultry or Ratites-165'17 15 see. * above if refined to fot,c!)nrnc illness 3--401.1 I(C)(3) Whole-mn,rle Intact Beef Steaks interventions and risk factors. Other 145°F' 590.0,09 violation:' relaling to(rood retail 3401.12 Raw Animal Funds Cooked in a rnacttces siundd be debited under/729-- Micruwave 165"F* Special Requirements. 3-401 11(A!(1)(tr) All Other PH F,,- 145'F 15 sec. ' 1 17 Reheating for Hot Holding ( VIOLATIONS BELATED TO GOOD RETAIL PRACTICES ,403.11(A)&(D) PHFs 165'F 15 sic. ' ( (items 23-36) 3-+03.111 B) Miu'owave- 1650 F 2 Muune.Sutnding Critical and non-(,9t&al ;iuiatimu, n/n(h do not rlaa�to the Time" roodhorne!bassi hn,rveanon.+ and risn jou tm-.c 1<'5ted above, (on 6e 3403 11(C) Co)mnrrc:aih Processed RTF Food- uzwd in olio ollowing verba,:s ql the Food C(de and 161(111? !40`17* .5''ii.(iQf1 -403.11(17,) Rrnrnnme Unsliced Pnrtiunc of Biel I Item Good Retail Practices FC 530.000 Roasts^ 23. Management ane!Per3onnei FC -2 003 TTJ Proper Cabling of PRFs I '24. Food aro Fuor Praectiun FG-3 ON 25 E:iuipmerl and Utensils _ - -- _rC-4 _--.005 3-501.14(A) Coding Cooked PHF, from 140`17 to 5 •,Nate, Piumbino and tr{rite FC--S .006 j 70"1'Within 2l lours and From 70'F i 27 Pnvs:cal Fccilit), rC-6 Orpt to 41''F745`F Within 4 Hours. " 2E Poissrous or Toxic Iflalerials =C- 7 .00E 3-501.14!B) Coofin',PT: Madeloin Amb'ient I 29 I5;=ectr al Reou:iemr:n„ .309Tem;eranuehagredwntsu+41F(dS^ 30 Othe --_--1 � Within 4Ilours;' .•cr„ ,:;,,.:a.: Duwfes crawal dem m:hr f•dcral 1999 Fuud Code or 105 C NIR 1,90 000. CITY OF SALEM BOARD OF HEALTH r Establishment Name: r 4p4kre'1 IfUffO 1f4X rhfi4 ,vr Date: 2( G'J Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 1 No. Reference R—Red Item Verified PLEASE PRINT CLEARLY Sr AlflC Y^` d A ,ff& ..rd6/15 f IFV0A0okt/ Gc ga.r•nr� w+YA 1'.«n//!'i Zr�t g (� _r1V0,<j_Vp /SeFeWG wr1rjtao Ire roW PNlqucAs J7 ter Pl-e-VaCs rl"41 Aeds°r j Ct&Ar/&0 .Wo Se*J1 rYZj!&O /tt-10 u C&P crrt V ri Lr,1 TN NL�OcJd6` 9 AMY *4*1 Aec_ rm lev#rinN etc fam I&Akr .e..0 G+L++d.e . 177IW4•'E&MM / 1 get wile � v 1 9 �" a G,trfK� etil..ta� k � rc�,..� .aNl� .++ro J+rdKdFD .. e4sPc.Ecc� erm. lsa. s_ � �� �' �3�c y �,rr.�, ,� �u►.� v�uas .s cas,�vt-w i 26— k4l u(rf+ee efJ IG. r tSiNC Tlh�.,t+No,t.�ISr- • Pk�vloeF N ✓/fYAt6. vlcwlw.�" F.�� ,CaI�M�St"iliR- tN 6r.1-La /rt, 7 15A c(GiP P 4 (6 ^aril r f u eAce r�r►tDL.lf�ent d` fro lk&4 3 . VwOC8 dlmot r r ,tr( rs.N(zXer Pte/ v 74B & Discussion With Person in Charge: Corrective Action Required:To No (+o 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 C3 Embargo Ll Emergency Closure your food permit. n�j,,�,` // 1A ❑ Voluntary Disposal ❑ Other: \I% PHr3 Received at Ta:mer:our:s Violations Related to Foodborne Illness Interventions and Risk ,Accerlhrig to Lain Cooled to Factors(items 1.22) (Cont.} 4!'FI=tSP tyrthin 3 Hews. ' PROTECTION FROM CHEMICALS I 3-Srrl I Coeh.t', 9NIn hods for!'H 11's 1•l ( Food or Color Additives ( I 1° PH=Not and Cold 4olaing 3-^.O L Ib(B) Col:i PFIFS MJ.: ataiuc9 at or hc!nw 3-202,12 Addnivc>` 590.00=(1`) -0 P 115°F- -3;J2,14 Protection lnxn Unapproved AddioNes* 13-501.!6(A) Aot PHFs M:owdined at orabove 15 1 Poisonous or Toxic Substances 4WF 7-10(.1 1 lderutyw.-, :m Ormmi.-n-Ougtnai I 16(,-1; Roasts i-fe!d at or:-buse. 130`F. " Containers" 17-102.11 Common Name-Worl,inp,Container,` I ( 2t) Time as a Public Health Control 7-7()1.11 Separation-Storage, ( 1 301,19I•aro,a;t,6i:;. Health Contr-,0 7.2(17, I ( 500,,104(45 Varian:e Regmrement i l Restriction-Presence and li:e'� 7-:f .1Conditions nr Use' 7-2033.11 Toxicotaines-Prohibi8onsi REOWREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 7-204.11 I S:,nitizei:,,Criterm-Chemicals4` '-20't 12 1 v- .1, e .a. 121 r-XO:. 1(A) l,r;pa�ruru:ed P),,-pa:.kag:v Juices and f Chc::ncals for Washing.,u,. �c.c,( rn.ria 7-204,14 Doing Agents.CnteriaT Bev r',,es tri(h 14'arvne i ; r L.hels- 7-205.11 hteidental Food C . Lubne3-801.11(11) C7se of Pasteuized E,,*' 7706.1I Rescted Use Pesticides.Criteria*, -801 1Ron or Pstially C-x:ked Anent,,! Foo(I and Ra:r Seed Sprouts M1.,t Se:vel. '= 7 206.12 Rodent Bait 56tions'" ! ' C. I Unr-rend Pmnc1 Package Not Re-served. � 7-'_'Q6.C3 Tracing Puwdrrs, Pat Ct,ntru! and 3 Xi 11.11( � I Monitoring* I CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603 11 Coivu:net.Advisory Po,tcd for Consuiopo.un of .Animal Foods Thai arc Raw. UndercookedPHFs nr 16 I Proper Cooking Temperatures for Not Otherwise Processed to Eliminme 3-301.1IA(I)('I) E, s- 155`FIS Sec. Eger-hnntediate Service 145'1715sec, .3-302.11 Fasteun?ed Eggs Sub+ti[ute for Raw Shrli ?-40I.I l(Aa2,) Commmnted Fish, M.ats,k:Gana FggsT I Arnaud s- 155'F 15 sec. , 3-401.11(111(1)(2) Pork and Beef Roast- 130'17 121 min'` I SPECIAL REQUIREMENTS 500.009(A` i6) Violarions of f,R'tion 5'',10.009(A)-115)it, 3-4(}i.i i(AN2) Ratites. Iniccted *rats- 155'F IS sec. * catcrir,,-. mobile food, temporary and 3-401 11(A)(3) Poultry, Wild Game,Stull-ed PFTFs. residential kitchen operations .hould be Stuffing Coatamm.-Fish,Meat, dchitcd under the appropriate sections Poultry or Rutile,-165'F 15 sec. * above if related to focdbornc illness 3-anti1(C)(3) tWlale-muscle, Intact B:d'Steaks intervettion.a and risk factors. Other I 145'F' j 540.009 vi0lat Ions relating 10 good retail 3-401.i2 Raw Animal Fo,ids Cooked in a Ftacttces would be debited under 1129- Micmwave 165'F* Special RequirzrnetiO. 3-401,i l(A)(0i b) All Other PHFs-- 145`F 15 sec " 17 Reheating for Hot Holding I VIOLATIOVS R;":LATED TO GOOD RETAIL PRACTICES 3-403.11iA)&(U) PHFs 165T'15:sec. ' (lteinc 23-30) 3-403.11(B) Microwave- Itis` F 2 Minute Standing ( Ciila al and nun-chiral eiolatrme: icluch do nor reiate to rhe 'lime* fondbunte itha•-si drug:entions'and ns:'f(nn-r listed above, can be 3-403.11(C) Commercially Pnrccssed RTE Fond 7aaurd is rhe,totLn,•ing srrriunt q1 rhe Food Code anr7.'O5 CMI? 130'F'" 51750.000. 3-403.1 1(E) Rema iciui- Umficed Portions of Beef ! 'tem flood Retail Practices FC 590.000 Roast,* 23. Management and Perscnne: FC-2 .003 18 Proper Cooling of PHFs 24 Foexi and Food F:otecton FC--3 .004 25, Equipment and Utensi's PC-4 005 3-501.14(A,i Cooling Cooked PF!F,fivut 14(1`17 to ( 26 Water,P!urnbinq and Waste I FC-5 .006 70'F Wihw 2 Hour?and From 70'F ! 27 Phvocal Pacilih' PC--6 .007 J w 11'F/45"F R'gtnn 4 1-lorars. ( 25, Poisonous or'f ex;r,Matedais FC i .008 3-:501 14513) Cooling PHF:,Made From Ambient i ( 29, Special Roquoements ( 009 Temperature Ingredients t,:41`F)d5-F 110. Other I j Within 4 I four: i ' Uem ara cr t[Wl ileo:m 11W E''dera! 1994 Pond Cone or 105 UNIR 5')0000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Fr 'r.XUr y /Sz.nolf) Date: 2/fid/�� Page: t/' of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified • / PLEASE PRINT CLEARLY lf. ,mN fU l" 1 tY i�SherbSr ,si .xl r diJ�F 6 A-C U1f ue- I l/ � ClIk" Gv&eJI7&0kA*4, ht�sfer� tdrli vrXfzrc. I I "a tic iWoo f 1 1 I j I ' Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ 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 twTA'� five dollars or suspension/revocation of L3 Embargo ❑ Emergency Closure your food permit. �� l � p O ❑ Voluntary Disposal ❑ Other: XI / V A 1 I li "; PHFe Re ei%cti at Temparatutes Violations Related to Foodborne Ifiress Interventions and Risa .according,to 1-m Cooled W Factors(Items f 22) (Cont.) ! 41'Pr45`F 4Vitlnn 4 Hours. PROTECTION FROM CHEMICALS 3-5U L 17 Cooling Lkthcr,';for PHl e Mt) PHF Hot and Cold Holding 14 I Food of Color Additives 3-202.12 Additives' 3-51!.!b(R) Cdd Pf Mi,-Maintained at or below 3-302.14 Protection from Unapproved Additive:` 590(!U4(F) 41`/45" F" 1g Poisonous or Tonic Substances ! ( 3-501.I6GA) I-io: PHFs Maintained at or above 7-101.11 Identifying Information-Origmil ( 140'- ' 3-Su!.16(a) Roads Held at or abuse 130'F, a Containers" - 7-102.1 I Com is n Name Wnrkin_,rCott i ( 1 20 I Time as a Public Health Control ca nets` 7 "_'(11.11 Separation-Sa"rage` 3-501.1;1 Tim: as a Public Health Cuntro!* 721211 Resttiction-Presence,and Mine" 59J0(04(H) Variance Regnircr„ent 7 20112 Conditions of Use 7=203.1 I Toxic Co ita;ners-Prohibitions* ( REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ! 7-204.:1 Sanitizet'S,Criteria'- Chemicals^ POPULATIONS;HSP) 7-20-(.:2 ChenticalS for Wasbim_Produce,Criieria 121 j 3 :•;;1.1:1'A; Unp.tsteurized Prc-packaged Juices and 7-204.1-( Drying AKents.Cnreria* : Beverages with Rrarnine Uihels^ 3-i;01.1 i1 B) U,;C of Pasteurized L:,gs° 7-205.11 Incideniel Food Cooract.Lubrteanl's- 1 3-30 i.;l(D) Rav or Pattialiv Ccpoked Animal Fool and i 7-206.11 Restricted USr Pesticides.Criteria" ! kavr Seed Sprouts Not Sett-ed. 1 ?-216.12 Rodent Bar, Salines" ' 3-IiOi.i I((-') Unopened f'cwd Pack:i•=,•Not Ra-served. 7-305.13 '1'r;;ching Pov<drrs,Fe St Comm! and � ' Monitoring=` CONSUMER ADVISORY TIME[TEMPERATURE CONTROLS 22 60 ,11 Con.umer Advisory Posted for Consumption of 16 Proper Cooking temperatures for Animal Foads'Poat are Rav,.Undercooked or ! PHrs Not 011:er;.Ise Proc:sped to Eliminate f'athogeus." Eggs immediate Service 145°F15ser" 3-401.1 3 A(1)(2) Eggs- i m 15 Sec. 3-302-1:i Pwiteurired Fgg:Substitute for Raw Shell edI 3-401.11(A)(2) Communised Fish,Meal,&Game I Eggs* Animals.. 115'F 15 sea -401 I l(B),,I I SPECIAL AEOUiREMENTS 3-40L71(Ab21) Ra:rtes.lnjettedMcatl- 155°F 15 Pork and Beet Roast- 131"5 121 min"' SPECIAL �•iolanonc of Section 590.OJ9(A)-(D) in ) Sec.: catering, mobile food,teS tporary and ,3 401.11(A)(i) Poultry,Wild Gamc, Stuffed PHFs, res;dertial kitchen oprrativns should be Stalling Containing Fish. Meat, deNictl under the appropriate sections Pouhry or Ratites-165017 15 sec. a, above i1 related to foodborne illness 401.1 IW)(3) Whole-nulSele, intact Beet Steak, interventions and risk tactors. Other 145'5„ 590.40`9 violations relating to good retail 3 401.12 Raw Animal Foods Cooled in a Ftar•tiCCS Should lie debited under/129-- Microwave 165`F* Special Rcquirc:nentS. 3-401.1 I(A)(1)(b) All Other PHF:- 145"F 15 Set- 17 er17 Reheating for Hot Holding I VIOLATIONS R,:LATED TO GOOD RETAIL PRACTICES 3-403,1 I(A)&WU PHFS lbS'F L,;c C. " i (Itcnts 23-3€I) I-403.11(B)B) -Microwave- 1650 1 2 b5uuitr,Standing Cihicai and non-rrit4:al euilatiuns, mach do not relate to the 'Pulte too:lborne illness om-rwittions and ris'j,toorr listed aboi,.^, (at?be 3-403.11(C) Commerciail}Pvoce>sed RTE'R.xl- found in tka jallat:lag se eripres u(tha Food Code and I(/5 C1,41? AAF" .590.000. 3-413.11(I:) Remainim;_,Undiced Portions of Reef ! Item stood Retatt Practices _ __- ' FC 590_00.0 Roasts` 23. Managoriant and Personnel 1 FC - 2 I .G(3 _ 18 Proper Cooling of PHFs 24 Friedland rood Pro!ection FC-3 004 I 25. Equipment and Utensils FC 4 .005 3-501.14(A) Cooling Cooked PI-IF,- from 140'F to p6. Water, P!mnbinc and Waste FC-5 006 70'F Within 2 Hours and Frnm 70`F 121. Physical Facildv F-C-67 0o I to 4I"F/45"FWithin 4 flouts. ! 28, ao!sonous or Toxic Malcrittis FC-7 .008 j 3-51i.14(B) Cooling PFLrs Made Frv:n Ambient 29 Soecia:Rcouirerxanis .009 Temperature higredfentsfo 41"F/45F ! 30. Other Within 4IIours* "'"-' -Duitae,critical item in the fi,der,d 19901-o,nt Code or 105('kiR 590 o0r. f CITY OF SALEM, MASSACHUSETTS .�. BOARD OF HEALTH e w 120 WASHINGTON STREET, 4TH FLOOR o SALEM, MA 01970 .� TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Fantasy Island Restaurant Address of Establishment: 516 Loring Avenue Owner's Name: Deborah Lam Restrictions: Application Date: 11/16/04 Permit for Food Establishment 012-05 Frozen Desserts/Ice Cream 012-04 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. EALTH AGENT CITY OF SALEM, MASSACHUSETTS .v BOARD OF HEALTHA 9;C T1 s 120 WASHINGTON STREET, 4TH FLOOR �C' ❑ 11 flp SALEM, MA 01970 NOV u�ll TEL. 978-741-1800 6 2004 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOCITY OFSALEM MAYOR HEALTH AGENT ARD OF HEALTH 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT PA-k-fA,S # qOU ADDRESS OF ESTABLISHMENT 0 17 0 MAILING ADDRESS (if different) _G , OWNER'S NAME n r P 94-P' l/� TEL# ADDRESS I w�7M I S 1 �ti �lGt B L� 7' CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) .-f AiwVM CERTIFICATE#(s) _3 D 8 7 3Z 21 PV&II Ll 2zo x s y3 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON LAM HOME TEL# 7kl -63 11:3Do 1130 a3° 11 }11 1130 (13� IVVb HOURS OF OPERATION: Mon. 113 Tue. Wed. 1>�Thu. 11w Fri. 117") Sat. 10`' Sun. 13 0 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 XS NO \� " less than 25 seats =$100 V 25-99 seats =$150 V 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 jSUCh 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 owle ge and nbeli , have filed all state tax returns and paid all state taxes required under the law > axCiv l!lrrlo t9g7- �v = lggt `l Signature bate I Social Security or Federal Identification Number --------------------------------------------------- ----------------- --------------- - Revised 11/03/03 F00DAP2 adm Check#&Dale k6 iv-! I(,//A-/o l� ,off 1 CITY OF SALEMI, MASSACHUSETTS �. BOARD OF HEALTH 5S 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 I11, 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: Fantasy Island Restaurant Address of Establishment: 516 Loring Avenue Owner's Name: Deborah Lam Restrictions: Application Date: 12/18/2003 Permit for Food Establishment 227-04 Frozen Desserts/Ice Cream 012-04 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. 90L�"10� HEALTH AGENT CITY OF SALEM, MASSACHUSETTS �1/JTy 0BOARD OF HEALTH +•V 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 DEC 3 —2003 TEL. 978-741-1800 FAX 978-745-0343 Lily, CF SALEM STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTMOJ0 EL# 7 �-r-i 7 0-7-1 ADDRESS OF ESTABLISHMENT ✓�� L D VL % (� A-v s A-L ec> / M A 0/ 1 -/ 11 MAILING ADDRESS (if different) OWNER'SNAME �GZ!)n� *r L TEL ADDRESS CITY Mk7z' a L.1-pt� STATEN A- ZIP O( G F 5 CERTIFIED FOOD MANAGER'S NAME(S) -7+VI)e7, LZ-f! CERTIFICATE#(s) '�oYj ,9 3Z 11 Wld (Ll � (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON 1jz�3�' 't HOME TEL# 1171) -v 11�JJ'd ��'3 tt� !�_ t�3 tau HOURS OF OPERATION: Mon. /1 fdTue.� Wed. 1vu Thu.�Fri. ' "taCe Sun._ ' a� TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$50 1000-10,000sq.ft. =$100 p y more than 10,000sq.ft. =$250 RESTAURANT YES NO / less than 25 seats =$100 25-99 seats --$y50 more than 99 seats BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS —0 MAKE (not just serve) ICE C EAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Pleaaa pay total ::^:t" cne check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law., A4-- vcael f9 `f Signatureg,/��t,' Date 17./( '03 Social Security or Federal Identification Number -- .................. ---------------- Revised 11/03/03 FOODAP2.adm Check#&Date 1I0� IYj1 �U3 �z�� • J Massachusetts DepSartment of Public Health Salem Board Health M 124 Washington Street,4'" Floor Division of Food and Drugs , Salem, MA 41970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax (978) 745-0343 IName Date T f ODeration(s) Type of Insoection { 1'Aa)V'An/ A,S44- O 0?&P ' 18 F1Food Service ❑ R�9uttne i Address Ris Retail (�'Fte_inspection CIX !_d 4in/F _i AIJAX Level ❑ Residential Kitchen Previous Inspection Telephone I ❑ Mobile Date: 7HCr- 1740 ❑ Temporary ElPre-operation Owner [aFM HACCP Y/N , ❑ Caterer [ISuspect Illness QeSQr,�4/J Person in Charge(PIC) � 5 � Time 1 ❑ Bed& Breakfast ❑ General Complaint In: I ❑ HACCP Inspector Iv/4tJ,to F��� � Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Nan-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors, Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ II& Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS' ❑ 2. Reporting of Diseases by Food Employee and PIC [114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15,Toxic Chemicals FOOD FROM APPROVED SOURCE - - TIMEMEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19.Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices [122. Pasting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below �= 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.o08) 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 541nsp fro m614 dX s -_ ,- I( Inspector's Signaturem% �„�'/�.iICL ''F..., Print: PIC's Signature: //tt tri +vi U I Print: ,��`y(G..� � �j PageL of ages v v- Z. n Violations Related to Foodborne Inness interventions and Risk Factors(Items 9.22) PROTECT'ON FROM CONTAWNATID_N FOOD PROTECTION MANAGEMENT S Cross-comam:ration 1 500.-WNA) L+vgmneitt t:Rryr,vr�tbi(ity` ( ?-3,;2.i 1i.,th I) ; Raw An,n al Foods Separated from 590.003;B1 Denurnstr;;t:r»r ofKnnwie+igr" ( io0l:-W and RTE Gomp-rinaticn from Raw lnrred;'ante: n-103,i i I Person in cLirzc-duties i r -30211(AW-1) Raw Annu:d Ruxls Separated guru L•acn EMPLOYEE HEALTH OtherT 590.W3:C! Responsibility of the person in*hati!e to Conraminationirom?he E•rwitrnnrent reeuin. report;ra by foud employee.,anti 3-302.f l:.{) F,:nd Ytntettion' applieanni` 3 302.1; 1Wa.hintt Fruxs and Vet riai,le; j90 i)03(F) Respottslbdny QCA Food Gmp!uyee Or An ; 3-3(WA 1 Fo,i Contac•,with F(Impment :md ApnV,e ua !u Report To The Pers,-n In i)tens:ls" Cheree' Ccntamirei ion from the^nnsurrer 590.003(G! Repurtinz by Prrwn in Chnt'ge* I 3-3Ub I V A;dH) Returned Fora!am:R::,e, re o`'Fo)d" 3 590.0030) Exclusions and Restpoiomt I I Ui:.uusrSon o!Auullcratad of Contamnrated 990.003(7) Remota}of Bxclus:ons and Re,,rictions 3=7O!.11 Disan ding at Re.-onditiomng Pnssf,: FOOD FROM APPROVED SOURCE I'Wd" j d Food and Water From Reguhvtso'Sources 7 Food Contact Surfaces 590.00-PA-B) Compliance v.uh bund Law:` }-5!`1.i: : :V1er3::;I 4ti arrwa:shin!• -Y,;.1 Water 3 ?01.1? Food in a Horn;etrcuilt Sea;cd Cvnt,unrr=' 9.:r:it:zatiun Te:nperatums` f:lec:c:nicul V mewaslow- Hut t;Jatei +°OI 13 Fhtid&Llr. and Milk Ptoducts` , 3-20"2.1:• Shell Ep-gc'k ( Samtizr:non Temperatures" 1 3-202.14 F,rgs�.nd Milk Product,. Pasteurized* 1-:SOI.i 11 I C?tenticaf %with ttlu::-tc,ap..gII. 1 3-702.10 lcc Made Prom Potable })inking Water" I ccn:xuh'aben and h.:runcce.. r j i-101 I t 1 601 Urark ng Water iron,an,aper rued Systen " . i(4) !:q�I:)meat!'.-,()d C aaact Surface;, i.d DtenI Cle n^ 59'0.000,(A) Bottled D,wkin,.:Wmcr" u2ncy o`Equipment Food- a.-(1,7.11 Clrnninv rrcc ; - 590.WNB) W'alei Wets S;,mm 3 dauN !0 C14R 22 ti" ( - 1 I Shellfish and Fish Flom an App-owed.Source I ( Contacr Surfaczs and tensils'e -4-702.11 Frequency of Sanitization vi Uteusils and 3-20:.111 Fish:i:ad Rerreauonally Caught Mollosc:,n I Foodumtnc,Surfaces of Equipment I shellfish, 4-703.i I Alethods of Ser.:uz:rbon-!-lot Water and j 3-20 1.!5 biolluscaa Shellfish fromNSSP Ls,ted Chemical'. 400rces" Game and Wild Mushrooms Approv.^d by ( t0 Proper, Adequate Handw3shing Regulatory A•.thority i : 2-3(?i.!i Clean Coalition --Hands end Ann:.`. 3-22 IS Sheitstock identification ?resent' _-301.:2 Cle;lninc Procvdurv" p 1I 2-3!l.td When:o Masi;" 590.004i C'; Wdd Mushrc.omGoid F Practices3-20i.r7 Gamc Anirn.dsx -d0iEating,Drinking or icinT :"` Receiving/Condition 2 I c-2',2 11 PFF;Rece:,ed_�t Proper 9@nrperawit,-: 2-40 i.!2 Dis•:harge<Fro,,,rhe Eyes. Nnsv ,md 3-202, 13 Pa.kage imegrity` ( bfo:un� -3,d 12 3-101.11 hunt Saye and Cnadu!:e!'atcd" Prcvcnhng Cor;,nn.inatinn R9ten'hratinr:: Prevention of } : I : . CCcnfamin.atinr n tion•Hands( 7agsnerords:She;stock 3.20°, i;elktock Idenuti(abon rom 30. 13 ;°hrllsurck 'i Identification Afaintaiu:.d" I G,nplc^:e•._ex I 1 Mandwash i'arilities I Tags/Records:rich Products Conveniar:ly:_ecatai and,Ac•::essicie 3-102.11 Pu'xsite Destn:etiun^ I 5_i{)3.11 Numbet:.and Cap.:citierz 3.402.i 2 Records. Creation and Rcw,:bun" I . 1590.004(.f) Labeling of Ingredients* ' 15 2O`:.11 Location and Placement' 7 Conformance with Approved Procedures ( S_'105 11 ?.ucessibility.(?:,er.,ti�n and-Maintenance /HACCP Plans Supplied with S?ap and Hand;F)t y:r,( 3-502.1:1 Spceialved Processiaz X/rethrds' Devices LU €Iawdwashin£Cleanser,Avut'abii_ty 3-S(P.C Reduced oxygen packagin;t.cr:seri;; � � - . . , -10? 12 Confo,mance with:l,n. u,^Pr ocrclure>;" I E,-3;i1 t;. Hard C•rvmg > Prue-:arm I r: .Ler')Ls.rid"al ire n,huuc:cJm a1 1990 1ond Coda o: I0S C\IR 590.000. • CITY OF SALEM BOARD OF HEALTH t Establishment Name: )o9W#4rA -1v 1XII - ffND Date: I11d/r/ Page: Z" of Z Item Code C—Critical ItemDate No. Reference R—Red Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Verified PLEASE PRINT CLEARLY AU— V161-,+PL*U Grricf) 1a 8/uey i.J sP�er�an� f�tPdla- i�� I r7m-rrx Yee/ l eora . 1 v- ,.r 2.�c,�.K�nr0�ll cid Safi- ,e c-v✓��� ,�r.�-s�r..�c . �� 1 I I Discussion With Person in Charge: I Corrective Action Required: I ❑ No I ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct all ry p 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 t enty-five dollars r suspension/revocation of El Embargo ❑ Emergency Closure your food permit. ��� ❑ Voluntary Disposal ❑ Other: PHFs Recenved c!'1'emperatarr; Violations Related to Foodborne Illness Interventions and Rise According to I-aw Cooled to Factors(items 1-22) (Cont.) =tt`F45`F Within 4 Hour;. PROTECTION FROM CHEMICALS 3-3W.15 Cootine Mediod� for PH'r's 19 PHF Hot and Cold Holding 14 Food or Color Additives 3-50LIbfB) Cold Pf-IFsNSeinto,nedatorbelow 31.01.12 Additivc`F 59tinp.9(F) =:I"/45''F 3-302,14 Protection front tnapprovrd Additive;* ;-SOL I(d A Hot PS-IF% r - ) Maamiznudatorabove 15 Poisonous ar Toxic Substances 14017 7-101.11 klentitvme lntornwoon-Original ;-siil.16(.4) Roasts Held at or abo� 13017. '" Containers' - 7-102.11 Common Nance. - Working Containers'' 2{l Time asti Public Health Control ( 7-201.11 I Separation-Storage^"' 1 3-501 J9 Ti me as a Public Health Coatrul* 7-20111 I F;e�u ioiun--Presence and Use" � � Sc)0.(YJ4(F) Variance Requirement 7-202.1'1 Conditions of Use" 7-203.11 I Toxic Containers-Proiubmons* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizes s.Criteria-Chemicdti: ; POPULATIONS(HSP) 7-109.12 C'hemica!s for Washing Produce,Criteria* 121 3-801,11(A) Unpasteurized Pre-packaged Juice;and Bevel aleLs with Vra'rine f.thcls'. j 7204.14 ( Incidental Foo Criteria. 1 "-,eI.! t(B) Use vi Pantanized Begs` 1 7-205.11 Incidental Food Contact.Labrirantc` ( - ! 3-30 i.11(DRaw v,Raor Parn .4m ally Cwked mal Fucxl andj 7-206.11 Restrxctt St Pesticide,.Criterrn,` Raw Seed SPr,ats Not Seried. j 7-20Rod, ,tit R< nBt Bait Station'" ( 3-901.11(C) Unopered Fotxi Package Not Re-s:rved. " 1 7-206.13 Trtckmg Powder.,Pett Control and Monitoring* CONSUMER ADVISORY 22 3-603A I Consumer Adv lea Posted for Conswn tion of TIMEITEMPERATURE CONTROLS Y P Animal FOUC18'1'nat are Raw,Undetcooked or 16 I PHFs Proper Cooking Temperatures far Not Odlora ise Process<d to Eliminate 3401 I L4(1)(2) Fggs- 155'F 15 Sec. - - F..e'_s-hmmnediate Service 145°;'15sc:c; 3-30213 Pan ,teun;d Fgge Substitute for Raw Shell 3-401.1!(A)(2) Comminuted Fish, Meats&Game Eggs, Animeis- t55'F 15 see. 3-401.1 i(B)(1)(2) Pork and Beef Roast. 130`'7 121 min* SPECIAL REQUIREMENTS 5901 09(A�(D) `v'iola6ons of Section 590.009(A)-(D)in 3-401.1 t(A)t2) Kanter. Infected Meats- 155'7 15 i sec. * r4.erin,, mobs le food, temporary and 3-401.11(A)(3) Poultry, Wild G,me,Stutt'cd PHFs, residential kitchen: operations silould he Starling Contain:u Fish,Meat, debited under the appropriate sections Poultry on Ratites-165-1-' 15 sec. ' above if related to foodborne illness I(C;i,1) Whole-muscle,huact Beef Steaks tnten-cntiuns and risk factors. Other ( - 145-T* ( 5901009 v-iolatiens relating to good retail 3 =301.12 Raw Animal Foods Conked in a ( practtecs should be debited under 1!29 -- 1vCcrov.ace 165'F* Special Requirements, ! 't401.1�1(A)(t i(b) All Other PFIFs- 145°F :5 sec. ' j 17 I Reheating for Hot Holding VIOLATIONS R.ELA TED TO GOOD RETAIL PRACTICES 3-403.1 i(A)&(D) PHFs, I65`F 15 sec. " (Ztetns 23-30) 3-403.11([3) Microwave- !65'F 2 Mico lte Standing Critical awl or)n;'rirical violauone. ,.inch du rn7 relate to fire Time* j toodhorn<:iib< ;y nnei ventioua and rink(actors li,v cl above, can be 3-403.11((:;) COmmcrciallw Processed RTE Food- I umid III rhe fa&uwh;g sertion.r of the Food Code and 107 CLLR 14()°F* 590.(0(0 3-403.11(E) Remaining Unsliced Portions of Beef ( Item Good Retail Practices FC 550.000 Roasts* 1 23. Management and Personnel FC-2 ; 003 j j (g Proper Cooling of PHFs 24. Food and Food Pro'ection FC-3 004 I 25. Equbment and Utensil; FC-4 ,005 j 3-501,14(A) Cooling Cooked PHF. from 140`F to 26 W atsr.'Plunibinq and Waste FC-5 .005 70"17W:ifur'2lioursand From 70'F j 27. Phvs:ralFacihty FC-o" .007 1 io 4 i"F1a5'F Within 4 Haws. W 1 28. Poisaicus or Toxic Ma:edals FC-7 .008 3-501.W(B/ Caolina PRFs Made From Ambient ! 29 3pec:ial Peoul erneras ong j Temperature In,sa-edienh to 41°F145`P j 30. Other Within 4 Ilotus* •^•roe.,,,, ------------ Denote%entlud item ut Ili:tatual 1999 Food Cod,,or 105 CNIH 57u 000 �. .. .._ -..,, .. -.-.- - -�... ..c....+.rr.-.wr-.nNlw�v^'.T'Msgow.�..+rT},�,M•+A/M..e�l.e+ev+.m.. -.a".s..s.:rve,.. -..-.,-.--� -. 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 ,d n� Date Tvog of Ooerattonls_) T i n Fi4N`4f l/ IS�n /KLf r 8/S Of� Food Service O Routine Address �'6 t ,��/N� 1„tf Risk El Retail ElRe-inspection s-!/ 1Wv Level ❑ Residential Kitchen Previous Inspection Telephone -7q5 - ,,,y,a _.t 7 De) M El Mobile Date: Owner HACCP Y/N El Temporary EJPre-operation 4<6v iM It GArtt I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time El Bed&Breakfast E1 General Complaint In: ❑ HACCP InspectorDhutf) 6�dtffv CAdM Out: Permit No. 111 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 ❑ 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) El 4. Food and Water from Approved Source El16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements ❑ 17. Reheating El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8�Separation/Segregation/ Protection L_y.."/9 ` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) . Food Contact Surfaces Cleaning and Sanitizing`�� ❑ 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 (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 �~ 4. 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 ✓,L,,,26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order, you &,/ V 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: A U6- f 3 ZOLI r/ �I.�saren-+ Inspector's Signature_ r-/ ,�„__ / Print: PIC's Signature: � Print: /11 Page of Pages FORM 734A HOBBSa WARREN - BOSTON 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) 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 I 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) Bottled Dnnking 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.]1 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Game and Wild Mushrooms Approved by 10 I ' Proper,Adequate Handwashing Regulatory Authority _ 301.11 Clean Condition-Hands and Arms 2-301.12 Cleaning Procedure* .I 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* ]1 I 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 I 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(7) Labeling of Ingredients* 5-205.11 Accessibility, Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Cntena* 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision - *Denotes critical item in the federal 1999 Food Cade or 105 CMR 590.000. CITY OF SALEM // � / / BOARD OF HEALTH Establishment Name:�LZ/tYZ�SL/• I�an6 �eSTll v��12 f Date: 8��,e// Page: a of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 11 tri C ^ ( `c t DOBIL t tj o Phi/ PertrI.6 J_ A-(I - -GSrF/NGJ G^^ vwf 6A V-X_*1 A-- I /3 tilt- -.�M&L Nr0+J( &JA_7# 171iNiC " 11A"6&vAv41W6- cw6y_" 2,5- t•/le- '- r' v A4 ie LArv,teldr 14-,Wr£ A44 rr n.r ✓a �� r.w�aJLRf ®� ri�r� s(�!�`fr6A• L& N A+.rO XAJ. trez,< 6o" / rrnD& AHQ ei tir, I I I 26-- I e Grf+�at6 Oa,,s . sv cN� ��ie u��£ /d,a ArjAcevtitdcsna� oP I ��ire,or�E ,errtJ Funs 06f3�,s. G"'i�nRvr.+FNu� Ctdarr .iic- Ci,r�..�S�s RtNs, V7e Ori CWAWrs ej./ cx�,C Sle"&A "AeW-tiI/ RsFrtrs�tr+.� /ft�r•' .4 40e"M L)LA-r eJ9 .3P OI.ar' AA 6V-414d. G /Fa itvu6!!u0 eek nr OII4.*6 r� co mi,/Q- ev A!/tD S` 4w-.0 t3,tWW sF;4i u 4 0 hu0 Scu tka, Fr tvr,F /Ml /1+J FcaJ Q` dEbJiJ: j oew e 1 C LaiA4 inrhtW_I tJ F&O10 4f. j Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: J PHFS Received at Teumcratures Violations Related to Foodorrne lliness interventions 2nd Risk ! Accurditu,to taw Cooled to Factors(Items 1-22) (Cont.) j 41''17145°F`.S'iihin 4 Homs. ' PROTECTION FROM CHEMICALS ( 11 01.15 tin ASedvxis for PHF J4 Food or Color Additives ( 34 I ; PHF Hot and Cold Holding 3-202_ 12 Additivc:r' � i ,_501.16(8) Cold PI FS Mla:ni mm' at o, belov; ( . 3-302.14 ProtectiontProtectionfront L?appn n -ed Additives* 59(1.0114{17) 41'145'F, Additives* I 15 Poisonous ar Toaic Substances 3-501. Hot PHF.Airintatned at or above 7-101.17 Identitymg Information-Ungina! C'or,rainers' -')I)! 6{A) Rnast,held at or above 1309-. .e 7-102 11 Common Name--W'rrkias Container," j i 20 I Time as a Public Health Control 7-2(i 1.1 l Cem¢ation-Storaec" -5t�1.(9 Time as a Public Kalth C'ontroP � 7-202 11 Restriction-- Presence and User, j '`)0.001 H) ( Variance Rrgiirem::ni ',-2(}2.12 Conditions tit Us,": REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ;'-203.71 Panic Containers - Proinhi POPULATIONS(HSP) 7-204.11 Sat»tizert.Criteria -Chemical;' i i-'.04.IChemicals for W'ashnu,Pr(Klu:e.Criteria" i I P.J 11(4) Uupasicurized Pre-packaged Juice,and 7-204.14 Divirs Ascots.Criteria" Beverages tenth Warning I.tbrlsT nt)t.i1(L,) I.,,ofPactennzedlessT 7-205.1 t Incidental Food Comact.Lubricant's i i 1.801. !, j 7-206.1 Restricted Use Pef torides.Criteria D} Raw or Yatt,a. t C x`.1;ed Animal Ftx xl and 7-206.1 Rcxi.nt Bait Stations" ( Raw Scot Sprouts Not Set',ed. '^ '7-206.1 3 Tracking Powders,Pest Control and I j 3-SOI.11.C') Unopeueet Prod Package Not Fc-served, " Y?:,r,:t •ria•t CONSUMER ADVISORY %i 3 603.1's C'ansumar Advisory R%;ted I'or Consumption,tf TIME/TEMPERATURE CONTROLS Animal -r.eds'1 at arc Kr.w, Undciconl:ed(it1h Proper Cooking Temperatures for ( N;8 Otherwise Processed to Eliminate i PHFS 3-40L11All (2) Egg,- 155`17 15 Sec, j 3-+02.73 Pasteurized Eggs Suhstitute for Raw Shell Eggs- fnnnediu.e Semite 145°Fl5sec- - 3-401.11(A)t2) uxnminutadEsh, bleata&Game EY"sW Animals- 155'F 15 sec. " j 3-401.1l(B)t 1)(2) Pork and Beef Roast " I30'P 121 titin* SPECIAL REQUIREMENTS 3-401.71(.A)(2) Fames. fnjected Meths- 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D) in Fee. catering. mobile food,temporary and 3-401.1 !(A)(3) Poultry, Wild Game,Stuffed Pffl=s, r:sideniia) kitchen operations should be Stuffing Containing Fieh,Moat, debited ::,tiler the appropriate s cion Poultry nr Ratitr,-165°F 15 sec. '° above if related to foodborne illness 1-101.11(C)(3) Whole-n:nseie,hitact Beef S,,aks nterv_otions and usk factols. 01 let 145`F" 59().009 violat-,ns relating to good retail 3-401.12 Raw Animal Foods Choked in a ora,hcc; should be debited under- - Mictowave 765'1:h Special Roc,dreutents. 3-401.71(A)(7)(6) A]I Other Pffl` - 145'F15sec, ` j 17 I Reheating for riot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)K(D)' PH Fs 165'F 15 sec. (Items 23-30) ?-403.11(B) Microwave 165°F 2 Minute Su:ndin^ Ciittrat urr<I roar rinco7 V.,Mrtrun e. ,:0icfr d:,r,nt!slut,'if,the Time* f,odborne dines.;intovcntleni and riskja,iters listed above am be, 403.1 h C) Conttneiciall}Processed 117E Rx-rd- found in the;•17nn w;;.e::rtioer;l!the,Foe;l Corte and JOS C'AfR I i4WFt 590.000. 3-403.1((17) RentaininO,3nclit-ed Portions of'iicel I I item Good?•e.'aii raracflces FC 590.000 Roasts' 23. Maozgement and P^tunnel FC-2 .003 13 Proper Coolint)of PHFS ( -'a Foal and FoW Protection FC-3 ,004 j 25. Equir.,nent and Ulonris FC- 4 ,005 j 3-_iOi I;(A) Coolint Cooked PHFS from 140OF to 26. Uhler, Plurnbine:and Waste FC -5 C06 j 70"F Within 2 1Infers and From 70`'F 27 Phvsk al Fac:lit`/ FC-6 .007 ue 4l'F/45'F Within 4 Hours. re j 28. Poisonous or I oxic Maten�ls FC-7 .008 3-501.1-'.(B) Cooling,PFIFs Made Frolli Ambient 29 Soc.;ial Rec,uirements _ 009 - -- Tempetanue Ingredients it, I I 'F/4i'P f 30. Other ---_-----_� Within 4 Hourrr < `i)cnotd,erne d don m ihr fc oral 199)wood('Ode or 105('NIP.590000, CITY OF SALEM z BOARD OF HEALTH ` Establishment Name: Fle�/G'r� !t ! N'L,Qr%() Date: ��S/�</ Page: 3 of Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R=Red Item Verified PLEASE PRINT CLEARLY 2'7 ZrN �� t c_ &z44-&Cr tsWd+l!T n,40 SVII'l car NLACo N#!1XeJd6-ii I 9 G . /camc011^P r%►1 r-o P nr /C& tit hC N //✓ifi . IckreoeP /.P Q) ` /G a,✓cO A"0 S'At'r 1 ,7c O OGar.gO in/ lex *A-Nola rrnbf t!P e!'K .S J&N#VtZ*_V r-eili 'Alva,[_- (./a'136"_n � ICE. .Penne nw-Y-• I 7 !' C„4,le oP" /d-,48 A.W 4ec_wA4uz.Aj,*#t aG l4.4ir- f iantauar,Fct� Sc�uc I =, I cAti ens"&A- ANn .F I _ 27 a le- Y -n✓Cr&*r A.so G4,erA N Bea s6.• re>c,�F' �4io�. 9 C 6 CC,,4�f u P A0A~ N ctd£ Ra r&MC►ta— .A0,C 4U0tj sOC,ics a AWO �Am of" . 12<rt.4 e&. A t C.- in,4-s-.N� off* �r � I / 211 C V eE&fq-w Q U4o &G PL/Pf4PL t3 t w .rt /s Arcs r4r&ar ZS W~ 11/ MYiJ4 4N 4Ce_0H1Jt. - 7e_W OF AOtn 01 9AIP. S tC / A.Wn f,MT/ili- r .Dik.. I 'z�s �f/C., � �0�►t6 u✓M.l� �►,( FtLta�I4` Ns�OS Sw�6P1'��. Dlscussion With Person in Charge: Corrective Action Required: I ❑ No ( ❑ fes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. `-r ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk 4(Ct PHFs Received at TenmcmnaresAccording to law C-) ted to Factors(Items 1.22) (Cont.) i 4:'l/43'17 W'a±iris d Hours. x PROTECTION FROM CHEMICALS 3-50:..5 ( C,xtlirg R4etbo:I G r F'i lFa q4 ( 14 Food or CoPHF Hot and Cold Holding inr Additives ! l WE) Cla nld PTIF:,Maintained at or bc ,a- 13-202.1_' Additive>' 154U9(i4tF) 111'4 ' F' 3-3(12.id Ptotecnon front htappro?ed Additives, 13 501.16(A) Hot PHFs Ntaintau?ed at or above IS ( Poisonous or Toxic Substances ( t40 F x 1-101.11 klentil�ut):Information ghial ( 3-501J6(A) Roasts Held at or above 130'F. * Container," 7-102,11 Common Name-W urkin^Containers! i 20 Time as a Public Health Control 17--201.1 1 Seoarotion-Stca'aee" -501 19 Time as a Fublic Health Central" .OIU 1 ) ( 7-202 !1 Restriction-Ptc Bence and Use'" � t Vaiian: CITY OF SALEM r7 BOARD OF HEALTH Establishment Name: r-A rI_ —Ary /,71 ,40,3 Date: ��Sr �D �/ Page: of Item Code C-critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 1 No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 27 W/'ifs /jr avrilN/S IV60. T&At- FL�Jf 6a ?� C 67ZdtC Vh§4 ,Nr: /S' GLOW/a/Cr Hu �tO /3 Oltif s � 1I I 2y C S'�i,� ,..,at.�c /,✓ /.�[� (LcJtf�O Me�Pa4L Cev��s d,� �u4C��'$ d/°" I j �vv0. udA-/ter,-£ 6.-)t'4Ar AZAT i'c, dX- 01.7eOSMC& 60t'WXi ✓� 77 /r V- /�3 c,� /3As&M&#,rr Orcavre A- 15- 0IIJr- a1-rIALO- r-UMO e'v I / 1 I 2-7 ti//c_ ItGtlO��_ &Arlo 400 rcnef.4r.Xr Alk&I) A r7de,ec3&444 64!c fAed � 26. C Ar.6 At_VMd1ad- ANO 41AYM A,P&S u0uev6i0140 otgA- 1* Aftill' 1 CA -AeX P/ s art frzd k c.4CiL4A16- eel, is r-VVSX r'frP6 Q,; c - s , �-, u�,,6- sucvnord� /.Ivy K.�ao,��► rw►�a-,Nir.�s A�— au. wonut� 1 u.tt. 9A-ts,r,Z,,46 J1X_k-/vrl o 6^ A?JPtf-tt CvNc6Nf FATio,/ Me�ST 89: (R-.CAO/LY A-fn41c..94.r. Af Alt_ wed .TT*i',M-P Atc. 97MS3 Discussion With Person in Charge: I Corrective Action Required: I ❑ 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 L3 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: J j-50! 141C) PHIS Rec.ived at'(emt rerature, Violations Related to Foodborne illness Interventions and Ris?: Acaadmg to l,:uw Cooled to Factors(Items 1.22) (Cont.) I 1"F14"'F Within-Hours. ' PROTECTION FROM CHEMICALS I 50;,i5 Chnine Mcdmds tur PIiPs 14 I Food or Color Additives ( "� PHF Hot and Cold Holding 3"2(17.12 Additive;* .`:OI FNt B Culd Pi IF,, Maintained at or below I - 590.004!F; 4i'i�t7•' F' 02.14 Rotection {tom t:nappto•:etl Additives! }_tip;,;fi(A) I lot PIIFs Maintained at or above 15 Poisonous or Toxic Substances 7-1C!.Ll ldent!fpm�"mforn::n:on-Original 3-567 I6(A) Roasts Held at or ah.ne 13C`P. " Coutain,r ' ! 7102.1 1 Common Name -Working Contain'fs* 120 "l ime as a Public Health Control 17-201.I1 Separation-Sturtee 3-501.19 Tinx as if Pub':ie Health Control* 7-202.11 Restriction-Prescnc'and Use" ( 59(1.00-Ii H) variance Reyaircnnc:)t 7-202.12 Conditions of Use' 17-203 11 Toxic C'onttin-:s " 1'roh,bdions" I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Senitizers.Criteria--ChemiadPOPULATIONS(HSP)s^ I I 7-2U-4.12 Chruucals for R'ashutt•Produ;e,Criteria'' I 121 -8'?t 1 If A) Unpr,tcur-?cd Pte-packai cd Juices and I7-204.14 DieingAgznu.C'r;teria° I C-�:eeitleeswnl. Warnnug!,abols^' ' 1,11(B) Use of Pasteurizers 7-20.5.11 Incidental Food Contact.Lubricants^ -501�:._es l.i(illi Raw ordtiall Cked:inimaiFood and "7-206.1 i Restricted 1_ise Pecticudes,Crites;e^ Ya Raw Seed Sonxns tint Trackiberved. '. 7-206.12 t Ban Stations- 7-206.7-206.13 Trt;ckiny,Powders,Pest Control and 3-KM A I(C( ) Unopened Food Packa)'c Not+ot Re-served. � Yl�mtx m.,� CONSUMER ADVISORY TIME(TEMPER4TURE CONTROLS 22 3-6.t; 1 I Consumer Advisory Posted fon Consumption of Animal Foods"fhat are Raw, Undercooked or 16 I Proper Cooking Temperatures for N,a 0d,erter+se Processed ro Elinnnate PHFs v:2r.,.:,•iron. 13-401.11 A(U(2) Fggs- 155'F 15 Sec ( Psiho;.ens. Eggs-Invnediate Sena,-e ids'PiSsec* I 3-'02 13 PasteurMd Egg,Substitute tar Raw Shell F 3-401.11(A)(2) CotnmmutedFSsh,Alcat<F.zli:uuc ' £", Animals- 155F 15 se,_ 'x 3-401.11(B`;,1 2; ()- " 2 SPECIAL REQUIREMENTS 1 ){_ Pork and Bret Runs, 13 P I_I nun s9O.009(A)-(D! Violations of Section 59(LOOJ -(D) in A 3-d01.11(A)(2) R<rtnes,injedeti Meats- 155°F 1.5 ( ) ec,- catering. mobile food,trrnporari and - (11.1 1(A)C3) Poultry,Wild Game. Staffed PliFs, residential kitchen operations should be Stuffing Containing Fist;.Meat, debited under the appropriate sections j Poultry or Ratites-165°F 15 seg. above if related to foodborne illness 3-40LI1(C)(3) Whole-muscle,Intact Beet Steals I interventions and tisk tactors. Other 1-45`F a 590.009 violations relating to good retail .3-=401.12 Raw Auunal Foods Cooked in a ( practices should be dcbiied tinder Yr 29 - Microwave 165'F* Spx ad Requircmunts 3.101 ll(A)00) Alt Othcr PHFs- 1-19"14 15 sec 117 Reheating for Hot Holding ( VIOLATIONS RELATED TO GOOD RETAIL.PRACTICES 3-403.11(A)@(U! PHFs 165 F 15 sec. 1 lleris 23-30j 3403.111 B) M;Lrnwave- 165' 'F2 Minute Standing I Ctilo<d and nr,,r-slits at violations. Bio irh do not roltnr to the Tune' ; todborne d/rrsv into�enfionv and risk/iu tort iisted above, can be 3-403.1 I(C) Cotnmerciallr Fiucessed RTE Fail- ( lnund i;r die following:H(.1rons of the hood Code and Itis C1-IR 14p`I-* 590.0u0. 3-403.1 t(,E) Remaining Uns!iced Portions of Beef Item Good Retail Practices FC 580,OW R,;.!y;�- 23, klanauement,:nd Personnel FC-2 003 J 18 Proper Cooling of PHFs °d. F,),--d aril Fgcr Pr o:echon FC-3 ! .004 26 E4ciptneni an"Utensils FC-4 . .005 3-5u 1.14(A) Cooling Cooked PHFs irom 140`P to - -------006 26. 'JJa!er.Piumbinq and waste FC-5 � 005 7WF Within 2 Hours and From 70'F j 27 PhYs cal F.zci!ity FC-6 007 to 41"F/45`F Within 4 Haus. 28. Poisonrus or"I eric lfaterials F,',;--7 1 .002 3-50L 14(B) Cooling PE4Fs Made Front Ambuent 29, Specie!Requirements 009 TeTemperatureTemperatureIngredientscnts n,11"Fl45`'F 30 Other:-------_ -- � Within.1 l lourc:x Deuo;r,muud nam In iha Cod,sal 11)94 Frahl(-ode or 10S CRIR Yd0 000. CITY OF SALEM BOARD OF HEALTH Establishment Name: F/4"I— ry /.rte fi. Date: 8 oy Page: '� of item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I 1 1 1 1 1 . l1 Ien Fr --t-M /l6jt*41 ICA rK A_o4„ire r7un/ It,�OoA rsrL,n - I • S,arr�rzer.I� rNCfr/!-a0S I " 4 re &A-4- FoaO$ �nvrroa�t � I i pFr4SoA /rr !�N,4Mr� 1 I 1 S Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ 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 y/ ❑ Voluntary Disposal ❑ Other: • � - r , 3-501.1 1k-) MIFs Received of Temperatures Violations Related to Foodborne 9fness interventions and Risk Acondi ng to Law Cooled io Factors(items I-22) (Cont.) 41'F/4 51T Within 4 Hour;. PROTECTION FROM CHEMICALS 3 101.15 C ilii Methods 8.r PHFs { 19 PHF Hot and Cold Holding 1J Food o:Color Additives 3-501.16(6 Cole! 3-202.12 Additives." PNFs Maintained at of below 3 302.14 Pmtcction from 'Unapproed Addtlivea* 5901)04(F) 4E"145° F" ' 3-501.16(A) Hut PHFs Maintained at or above 15 Poisonous or Toxic Substances t 140'6 7-101.11 Iden:ib-irw Information-Original ! 3-501 16(.1) Roasts Held of or above 1.10`6 (lmtainers" 7-102,11 Cnmmon Name- l'+'orkin:;Ccnriiner,< { 2J I Time as a Public Health Control 13-501.19 Time as a Public Health Control` { i 201.11 Sit), 7-202,11 1590.004iH) Variance Requirement 7 ?.02.(1 Re;trictinn-Presrnce mid LJsc�' t 20°.12 Condrtiom u;l se" j 7-2011.11 '1-oxic Contain?r<-Pr:»i,hihons REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 j Sariiitiets.Criteria --Chemic ls^ POPULATIONS(HSP) 'call .o r i.hire Produx.Criteria" I 21 3-801.11(.A) Unpaste rived Pre-packaged Juices and 7-'04.74 1 Drvini Atent�:.Cr'tzria" Beverages with Wilmine labels" ,, 1-SOLI It B) Use of Pasteurized E:egs' I 7r-1-05.1 1 { i estricta7 Used egicidet.1_uhricant 3-501.110)) Raw ca,Partially Couked.Animal Food and _06.11 Restndrd Use Paaicide..Crirer� Raw Seed Sprouts Not Served. 'r { 7-206.12 Boxiest Beit S;,-,'ons" 3-901.1 I(C:) Unopened Food Package Not Re-served " 1-206.13 'rrackiug Powders,Pe,t Cowrol and --- bienitorina" CONSUMER ADVISORY TIMEfTEMPERATURE CONTROLS 22 3-603 I i Consumer Advisory Posted for Consumption of nint:d Fuods That are Raw.Undercooked or (6 I Propel Cnnklrq Cenrperxtu•es fee ANot Otherwise Processed to Eliminate i PHFs ,-:rrera:re"""Pool -401.I1A(1)(2; Eggs- 755`1 15 Sec. I pathogens.* Eris-hlmtedi,ite Service 145"F15sec* i '--102.13 Pasteur.ved Fggs Sub:.Lautc foe Raw Shell 3-401.1 NAY2) Coinnunuted Fish, Mee.�&Gane I E92r* - A:ustall;- .55'F I S sec. ( SPECIAL REQUIREMENTS 13-401.71(11)(1)(2) Pork and Be-!Roast - I-')T 121 nein* { 401.:1(A)tT? Rattles. l::iected Meat,-- 155`F 15 590.00o(A)-(D) Voaadons of Section 590.009kA)-(D) in rc. * catering. mobile food,temporary and 3-401.11(A)(3) Poultry, Wild Game,S udHed PfiFs, residential kitchen operations should be Stuffing Comainine Fish, Meat, dchited under the appropriate sections Poultry or k,.tite::165°6 15 sec. " above if related to foodborne illness 3-40L1;(C')(3) tNliol--muscle, Intact T, SU:aks interventions and risk factors. Other 145°F'' 590.009 violations relating to,00d retail 3-401.12 Raw Animal Foods Cooled in a practices should he debited under.7129 - M ciowave 165"F" Special Requirements. 3-40111(4iii)(F?) All Other PfiT's- !4Sr' 15see. '' j 117 { Reheating for Ho-Holding { VIOLATIONS R?LATEO TO GOOD RETAIL PRACTICES 3-403.111A?&(D) { PHeis i650!- 15 sc.. ' { (Items 23-30) 3-.103 I1(B) Microwave- 165`' r") Minute Stending Critical end non-erith al vrolutionv, which,do not relate to rite Tinier' foodborne illness interventions and risk fu(tors listed above, eon he 3-403.1?(C) j C:rmrncrcially Yircessed RTI- Food- found in the forlowing sec lions of the('ood Code and 105 CMR 1141)'6.. ! 590.000. 3-403.1!(F?) Rimming tridw-d Portions of Beef iItem Good Retail Practices FC 590.000 sts Rou * 23. Managernent and Personnel FC--2 .003 I }tf Proper Cooling of PHFs 24 Food and Food Protection FC--3 .004 125 Equipment and Utensils FC-4 005 I 3 501.14(A) Coining Cooked PHFs from 140 F to 1 29 Water Plumbinq and Waste FC-5 006 70"F Witn!n 2 Sours and From 70°F � ( 27 Pf:ysica!Facility, f-C-E I .007 j to 41"F145"F Within 4 Hours. '" i 2n Poisonous or Toxic Materials FC -7 j .005 3-501.1 B i Cooling PHFi,Made From Ambient ( 29 Special Requirements 003 -?'emperaoirc Ingredients t,-41"F/45-F 3o. Other a a41M1nGdn:.0< WnitlR 4[-IUi1CJ' Denote..,crimaI item in thz f:&i al 190°Fwd Cde or 105 CNIR 590 n00 ( IMPORTANT MESSAGE ) FORi .LC{',+rY-�� DATE 'a7 'fl� TIM E,2 ff"3 �� M OF PHOIVP AREA CODE NUMBER EXTENSION Cl FAX O MOBII F AREA CODE NIIyHER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU I RUSH RETURNED YOUR CALL II WILL FAX TO YOU y MESSAG G(.- SIGNED 'PS MDAOE N4U 5 AA NOTESIN I � CITY OF SALEM BOARD OF HEALTH Fr i4 � /SEstablishment Name: 4"'W X'S:sr-,414tl — Date: / 114 Page: / of � Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY eATM e--v%( k co.94104 a.,1r_ / v,r, MJ10 r1 -17 ,9,� �tn�2�Nf2-�v !'vo✓Y�,firms 9 t ,rr �S '9ui'te.- r'- 4W&q79: I CrP dNp QvAe�.rT' p. �7`�t�`ilL� /F ✓✓C) �I%G��/JLS G�' /A'J"� /�t� '�N ssAI-t c-fa-s.r.Il'tr I � I 1 I 1 I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ 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 Lyour food permit. ❑ Voluntary Disposal 0 Other: 1+;(:) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1.22) (Cont.) 41+45T F W;thin 4 Hours. ' PROTECTION FROM CHEMICALS 3-301.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hat and Co!d Holding 3-501 16(B) Cold PIIFs Maintmned at or below 3-202 12 AddiLiVeS* 590.004(P) •41`715" F" 3.302.14 Protection from Unapproved Additive: I Poisonous or Toxic Substances A-501INA) i-lot:'HFs Maintained at or above IS f lot F. 7-1(11.1 l Identifying b formannn-Original 3.504.16(A) Roasts Held at or above 130'F. ' Containers' 7-102.11 Common N:mte'-working Containers' 20 Time as a Public Health Control 7-201.11 Separation-Storaee" -- - I J-501 19 Tim--.is a Public Healih Contro:r ! 004(1-1) Variance Rectuirement 7-202.11 Restriction-Presence and Use � 590., 7-202.12 Conditions of Use- 7-20' se" 7-203.11 Toxic Containers --Prohihitiom* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitiiev-Criiens--ChemicaW POPULATIONS(HSP) 7-lila 12 Chcnitcals liar l4'ashmg Produce,Criteria' 'P 3-801 11(A) Thlpzstew'ired Pre-packaged JUILTS:alit 204.13 Diving Agents,Criteria' Bl-wia#;es with Warnine Label, i ?-5U 1.11(81 Use of Pasteurized Eegs" 7-20$,11 Incidental Food Contact t.0 brtcants* 3-Y01.1 I(D) Raw or Pa.tUallq Cooked Aniu al Food and 7-206 11 Resnictedl"se Pesticides.Cnieria* Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations'. j ;-g0!.l i(C') Unapem:d Food Pac}:u:e Not Re-served. 7-206.13 Trackma Pov.ders,Pest Control and -- ` Monitorinax CONSUMER ADVISORY TIMEJTEMPER 1TURE CONTROLS 22 3-603.11 Consumer Advisor} Posted for Cousumptiun of 16 Proper Cooking Temperatures for 1 Animal NxKl>That are Raw,Undercooked or PHFs Not O:h-r leisr Pn,cessed in Elinwlate 3401.IIA(Ir..) Eggs- 155'1715sei. Pathogn s', -i-302.13 Pasteurircd E<, s Substitute liu�Raw Shell Eggs-hnmediateSersice 145'F15sec* =g' 3-401.11(A)(2) Comminuted Fish, Meats&Game I Eggs* I Aninwk- 155`17 15 see. 3-401.11(1)(1)(2) Pork and Beef Roast' 130'F 121 nIm* SPECIAL REOUIREMENTS .;-401.1 l(A)(2) Ranter. Injected Meats- 155'F 15 590.009(A)-(D) ViCilaliOtl3 of Section 590.009(A)dll) in sec. 'I ' I calcrin„ mobile trod, temporary and 3-401.1I(A)(3) Poukry, Wild Game,Stuffed PITFs. residential kitchen operations should lie Snuffing Containing Fish,Meat, debt ted under the appropriate sections Poultryor Ratites-1657 15 sec. above if related to Ioodbornc iIlness 3-401.11(C)(3,1 Whole-muscle,Intact Beef Steaks ir,:er:entions and risk factors. Other 145'F r 590,009 violations relating to gond r;.tail i 3-401.12 Raw Aninod Foods Cooked in a practice,should he debited under#29- Microwave 165'1' Special Requi;emelt;. 3-401.1 1(A)(1)ih) All other i'lIFs'- 1.45"F 15 see. , 17 Reheating for Hot Holding ' „ VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.iI(A)&(1)) PHFs I00F15sec:4 ]ltems23.30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Crituoa and nor:-rrit;at!twkrru;;:;, wha.h do not reb.re to 65c Time* foodborne illness 6urrrenlions and iiskjacia•-v lW,d ohne, cxrn be 3-403.11(C; Commercially Pi ocessed RTF Food- i fount in the jrtl,„+inr sections ujtrye F',>rr<t C'adr and Fit-i 0,'1112 140'F" s90.00'o. 3-403.t 1(F) Remaining Unslieed Portions of Beef Item Good Retail Practices FC58(7.(J00 k.asis" 23. Manat ement and Personnel FC -2 .003 (g Proper Cooling of PHFs ( 24. Food and Food PaZsctioo FC'-3 .004 25. Equimment and Utensils FC -4 _.005_ 3-5t}1 14(,4) Cooking Cooked PHFs Iroin 140°F to 1 26, Water, P!umbinq and'Naste FC-5 006 700F Within 2 Hours and From 70'F 127 Physical Facility FIC--6 : .007 to 41"F/45`P Within 4 Hours. - 1 28. Posonous of T-Ar Materials FC-7 ! .008 1 3-501.14(B) Cooling PHFs Made From Ambient29. Soee,al Requirements 009 Temperanue hreredicnts to 41°F/45'F 30. Ciher ----- i Within 4 floor," .•°�mn:ar-z a. *Denotes cimcal item mum fiaieral 1990 Foal Code or 105(AMR 590 000 , i'-r. CITY OF SALEM BOARD OF HEALTH // Establishment Name: FArr`�a� 1JzAtW I9&Sfi@Ldv"r— Date: ��n /ay Page: / of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY far A Gomlokpcw — Iues;/wio / wri o rfT essril rri+,+fsN1' j R66Af4rt✓F Ind�r6� �K�s,�,,u�u,�-`s�✓ Peuc<1 . nVc3 Foo t�/iN� 1�✓Y�* . crs kl RM,rrirFr� .3 WiTW4M n�fs�,¢.It_ v�f� ✓ ' 1 ro-�-� �,.�..� ��r v,mac- s���•� �-t,��� �- .N��rn►: 1 I r 4 dM 40WX&CJ -P AAM X-vr96nrc& al; ,ary �NFs�v�9f�N` I d� A-rr-f rwt-f" 4rrr t7PeS r21�S , I I I ^ I 1 1 Discussion With Person in Charge: I Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all LlVoluntary 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: ?.'Ci !=4{<'i PHF's Received,n'Iemn:rnlures X Violations Related to Foodborne Illness Interventions and Risk Aaard�ng to UCooled to , Factors(items 1-22) (Cont.; a1`F145-h Within.4 Hnnrs. • PROTECTION FROM CHEMICALS ( ,>01 )` ,^.00!irly Methods :'or PHFs j 14 Food or Color Additives j F 9 PHF Hot and Cold Holding j i ( 7 at� i[I1.1(i(B Cold p F- M 1-.. . ii w below 3-202.)2 Additive.' F :1.o;,u.inc .VF) 41`4t745"F^ Fi 4l" 3-302.14 Protection from Unapproved Ad590.00 VF)! 1-50i. Pi-[Fs Maintained at or above 15 Poisonous or Toxic Substances 40,t. x t . Contrainer; 7-101.11 nail glntormallun-CA igw'al 3.501.11:(Al Rom is Hrid:¢�,r above 13(`F. ' Co j 7-1012.1 t Comwor:N.mte - Working Container:'' 2P Time as a Public Hea Control 1 3.101.!9 Tim:a,a Public HealtIt h C'nniro'.* 7-201,l i S-paratiou--Storagtr" 7-20111 Restriction-Pr_sincc wid Use" 59t).O:kti H) VarianceRdumremem � 7-202.12 Conditions of Use" ',-^_03.11 T(16:Container!,- Prol, b:'ions" I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizes>.Criteim--("benticils' i. POPULATIONS(HSP) 7-'_0-?.12 Chemicals for\\'ashore Produce,Critrria* I 111 3-801 1 I(A) Urr(cnteuriz,,d Pre-packaged Juices and 7 204.14 Drymg agents.Criteria' j Bcveragc; with Warmine, ts:hels^ j 3:�Ci.11(B) Useuf Pasteurized E,tgs* 7-205.1 ( Incidental Food C'untact, Lubricants'* ( 3.9W 1 i{D) Raw or PaaialP,Cooked Asim:[: Ftxxl>:nd 7-206.11 Restricted Use Pesl:cides.Criteria` - 7-20(}.12 Rodcm Bait Stations" Raw iced Scrums-kat Se: -SOI.11 1Ct Unopened Food Package i`',n,)t Re served. " 7-206.1-4 'PnteKing Powders,Pest Control aced A2nri:uring* CONSUMER ADVISORY 22 3-60 I I Consumer A.dv;sory Posted ror Consumption of TIMEREMPERATURE CONTROLS Annn,:i Fonds That are Ravi,Undercooked ur 10 Proper Cooking Tempzr?tures for I Nor{)diet case Processed to Eliminate1 PHFs 3-401.IIAO (2) Gggs- Iii�Fi5Sec. ens. E gL- >� housed-':ue Cerriee )rt5"FlSsrc* 1 102.13 P,:ateunzcd Rags Subsutute for Raw Shell 3-401.11(A)(2) Comtmnuted rr;h,Meats&Name Anirnals- 155"F 15 sec. 'r 3-401.11(6);1)(2) P.,rk :aid Beet Roast- 13i;'F 121 mins j SPECIAL REQUIREMENTS 3-40L1ICA ..) RaIwe;, )njcctcdbh'ats-- 155''F IS 590.00- -(D; Violation,of Section 590.009(<a)-(D) is sec. catering, inn;,ile fund,ternporary and 3-10 IA I(A)(3) Poultrx Wild Game Stuffed PH;•s, iusidenttal kitchen operairons should be Stuffing Containing Fish. Meat, debited under tite appropriat,scctiolts Poaltry or Ratites-165°F 15 se.. ' rbove if i elated to foodborne illness 3-401.1 I1C)(3) Whole-muscle,huact Beet Steaks interventions and risk factors. Other 145"F,* 59-'1009 violations relating to good retail 3-401.12 Raw Anins:l Pods Cooked in a practices should be debited under - Mociowave 165`."' Soccial Requirelnenh. 34M A I(.A)(1)(b) All Chha PHF,-- 1;5'F 15>ec ' j 17 Reheating for Hot Holding VIOLATIONS RELATED t'O GOOD RETAIL PRACTICES 3 403.11(A)&(D) PHFs 165°F IS sec. " (Items 23-30) 1 3-403.11(B) Microwave- 165'F 2 Mmote Standim� Critwrd m;d nun,"ifleal vi.,tu!ruxs. which aro,rot,elerre to the I 1 ime' ,j,wibornd-'lines.;inter wwtion„ and risk fa<iors listed above, con be 3-403.1 1(C) Com norcial ly Processed I2TE Foud- found in the fo!hm ung so lium of the Fond Code and 105 Gl1R i a0"F* 500,000. 3-403.11(L) Remaining L'nsliced Portions of Beef I Item Good Retaa Practices FC 590.000 Roast * 1 23. Manacen:ent and F'aisunnei FC-2 .003 j IS Proper Cooling of PHFs 1 1 24 Food.tnd Face Pcoiection FC--3 .004 125. E'auioment cad I"r-nsDs FC - 4 .005 3-501.14(A) Coonng Cooked PHFs from 140`1-to ( 26, Water,Plu:nhinq end Viaste FC-5 e10E --1 70"F Wilhm 2 1Iourg and From 70"F ( 27. Physical Facility PC-6 00? Lo-4 i"`std "F Within 4 Hot::v. " 126. Puisunm:s o,Toxic Materials FC-7 .008 3-501 la{B; C oliw*PJ[Fs`v1::de From Am:lent 20 Soe'ciai Requirements 009 I Temptiatw- inrredientsiodl`;dd;'F X, Other \\%tibio 4 Hours:: ameal weir 11'!h-federal 1994 food C'A' or!0`.CNIR 51'U 000. �. - --._..-....--... .+, .. , -. n... .�..+.-.ori'�--�-•�qr-.. rya�w.®V"+.+u4/).�"pti.V�Y+nr•'^'�r'.r-.'s-^.-n'Y-.+'T„-'.-.+w-s-- ..�v^.).p•'- 1 THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM BOARD OF HEALTH Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 I FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Y Name Dat I / T f r n Tvoe of Inspection 1 F110-41Y � u4 10-4ry ,r , -17 (4tESr,,,� ,fAAA,F-� z_ /s/ P� pod Service ❑ Routine AddressRisk [IRetail ©inspection �'le Ldrt,Mt, X yr Level- ❑ Residential Kitchen Previous Inspection Telephone 978 - -7 VC'_^17 0(� le_/II ❑ Mobile Date:f Jl--'t re-{ Owner HACCP Y/N ❑ Temporary ❑ Pre-operation /OEJ1d/AN [.Mm ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) ;/mM✓ LCA Time ElBed 8 Breakfast ElGeneral Complaint In: ❑ HACCP Inspector G4V- () Fri.&N00v1 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 - El 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 426. 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: sppe tor'S, igrAtu,%4 /�.� Prin _2J1/ �j4 Inn G,c11..,�, PIC's Signatur'e: / Print: c� Page�of�- Pages FORM 734A HOB\5 9 WARREN - BOSTON�/� R Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION S Cross-dontamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 1590.003(A) Assignment of Responsibility* Cooked and RTE Foods* Il 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) 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 I 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- Ho[Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 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* 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 7 I Conformance with Approved Procedures Supplied with Soap and Hand Drying it /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 16-301.11 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 CbIR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:/-_AA/�/ rtsy / S"lvf) Date: 2-/710 l Page: Z" of Z ` Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified � PLEASE PRINT CLEARLY , 7 -7 IV C_ '&oV)9C (')f o1 �L)IV€ ('O ,i.^�ti-P X072'. I`!a1x r.G€G ,/✓r� C�VL rSt�S nv6rii I - I AR- -,fl oL-A T-1OW Ci IC T-r✓ I 1W 5417oAer--j.,r✓ .2CA'W4— q I �✓� QF_ ae.N CaRiag'C'r1sr�_ . I p I ,r I i I I I I 1 r � I I 1 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ fes i I have read this report, have had the opportunity to ask questions and agree to correct all LI Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P El 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. M til_ t ❑ Voluntary Disposal ElOther: I IMA Pi \/ 3-501.11((') VHFs Received ItTenlpei:i-jvs 111013tions Related to Foodburno 11.1ness Interventions and Risk A-Lrdiv.-it,Law coled 1+, Factors,(items 1-22) (Cont) 'F/4S'lF� 'Witjj+' PROTECTION FROM CHEMICALS 65cthods "i.,r PH F:: 14 Food or Color Additives 19 PHI:Hot and Cold Holdino 1 20', 12 i 3 .01 16(Fi) Cold P - HTs v below Addit��es I C - 1 90.0040 t 5 1 '/a5'F, 3 Pi otect i on bout Unappj m ed Add i Li e" 16(A) Hot P1 IF,T0,-jnt,,.i nc c! it o ahm j 15 Poisonous or Toxic Substances 140'i- 'I-I()1.11 litntilp),,Information-Originei 3-5ffi I"tA) 7 2o Time as a Public Health Contra! -102.11 Common Nzqne-W;skirt,L,Coalaort is 7-20 i.I I Separation-Storage" J-501 1?' liar: ')- -..,. �- . '-`rev-. �.w-..�ry^-�T,..�.gM,.�.o.- Me.--�-••-• .. v��•...+.rv^-.rv+^Y-z^rr.-,r.�...:.-..i�w+-.a.''.n,�.a,,,. 1 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 Tyne of Oneration(,Q Tyoe of Insoec i n <�Sy ZA ,_,L _c?9i ,cod Service EVRoutine Address Risk LJ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone /g�/ ;74� /'70Q [1 Mobile Date: Owner f ' HACCP Y/N ❑ Temporary ❑ Pre-operation Tko 65ea_ ❑ Caterer ❑ Suspect Illness Person In Charge(PIC) Time El Bed&Breakfast El General Complaint /"/ In: ❑ HACCP Inspector����� / �/ S"`y/YI S 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 ❑ 2. Prevention of Contamination from Hands El 1. PIC Assigned/ Knowledgeable/ Duties 13. Handwash Facilities EMPLOYEE HEALTH -❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ' ❑ 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures F 5. Receiving/Condition El 17. Reheating El6. Tags/Records/Accuracy of Ingredient Statements r ' El7. Conformance with Approved Procedures/HACCP Plans El 18. Cooling ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control 2(6. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 9. Food Contact Surfaces Cleaning and Sanitizing ❑ El10. 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 C 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: (?n qctori nrilf": Print: PIC's Signatureq /.. Print:�-R SEE Page / of-3 Pages FORM 734A HOB HSS&&WARREN - BOSTON /7 L + Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-clintamination _ 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 o/Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces 4 I Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H, 3-202.14 Eggs and Milk Products, Pasteurized* P g@ � 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 l3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 51 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 3-402.11 Parasite Destruction* Conveniently Located and Accessible 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 7 I 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* I •Denotes critical item to the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM n BOARD OF HEALTH i Establishment Name: iy,2 x,�� 1�c��PiwrP. Date: /- R 9- a'l Page: of Item Code C-Critical Item V DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - Verified /� PLEASE PRINT CLEARLY 13 /�iP n� a /�cf S/N,/l -Liii3eL J� G/UlJSf G7/G� 9 All rc' A41_w"'P v 11*'Or y/ Gt�SGin9 /St it-/ 9 I 9 /Ve /.scn�Pc —,��psvFe/AcE o,2 �eFCc�c I a7 ✓��.o,Np c�eyr t('�'U/.off Gir�/if f%xT�� �✓P.� ,U,F�� 77 ' �P cL�'c�u2� i I M � e �v — r,l�:�) t 1 IX/ i /Prt�;.v,c: P:'cc lfir�C`�iiN9' ,�S2U+�?G/'2/,v '—G'c-..s�cJ` c• a � f�.�'_cc �' �-- � q4S '�r; S a7 Z/9Af Qc y��s 9 SQA✓2 e P/f-ZFt lt' '7 Z_ crK'oG it,0 rr I I �' I � h'ti� �� /-�r�'P.� - �C��.� /���i��.e s��.- -also ��,r✓e� I a� 1'L GLS "Maas/ I I 4 lr�?SKP ,rle cLPlzwn/L,9 '-___ /CG J Cao A 7�1. Gto "• I I oK OLac' 11b n girl yzr�!C�.tj�Gn2!� �t(jaG��c( " /Ce Scca,o d�GL/ t Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all LI Voluntary Compliance ❑ Employee Restriction/ violations before e next inspection, to observe all conditions as described, and to Exclusion ilth • p :3 Re-inspection Scheduled LI Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars orrsuspension/revocation of LI Embargo ❑ Emergency Closure your food permit. �/c, ❑ Voluntary Disposal ❑ Other: V (li i 1 3-Sul H(C1 PfIrs )Zeceived�:Teupentmmrrs - Vrolalions Relaieci to Foodborne Illness Interventions and P.isic Accu.C;n¢1"t,a++ Cooled to Factors ftterns 1-22) (Cont.) 41'F/45 F\l,l hum 4 Hours. ' i PROTECTION FROM CHEMICALS 15 Ooliae Glethods for P11,P1 14 Food or Color Additives ' 19 PHF Not and Cold Holding 3-501. 6(B) C.;d PI-fFs Maintained at or below 3202.12 Additkes: 1500.9:.)-1;F) 4`'A: F`* 3-3o2.14 Prutecoon from Unappr,,ved Additi%es ( 3-501.16(A) HI;t PliLs Maintained at o; aboec 1; ! Poisonous or Toxic Substances 7-101,11 Iden0lumg information -On,iml 3-501 HdA) IZnac,-I-ICiu at e:above 1 ?(i'F Containers" 7-1C'2.I i Common Natne - N'urkut�,Conlin nee,: 20 Time as a Public Health Controi ! 7-201.1 1 Separation-Stoi aec` 3-501.19 Time as a Puld Fkalif,C.mtr:,:' 1 59G.004(!i, Var,:rice Requirement 17-20...1.! Restriction-Prescnc. and Ike''' ' 7-202.12 Con:ntnns of l ice',. 7-.!03 11 lox;c Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 17-204.81 Sanitizes Criteria ingPro Produce. 121 3-801 H(A; UwMsteurized Pre- kae x Juices and 7-204 1'_ ChanieaL for Wadming Yrochtce.Criteria': I P`.- •_^"i. Bc%etaces with W"arninR L.:b�Lr` 'T-204.14 C)I}in};A;;eats,CSttetis ;FDLI I(B; Use of Pasteurized 17 205.11 Incidental Food Cmtnct, 1_ubricants* - I I I(D) Ram or Parti-do Cuosed Animal Food aad 7-206.1 i Restrirted Use Pesticides,Cr!6_tia� Raw Seed Sprotns Not Semted. " 7-10 12 Rodent Bait Stations ?-SGI 11(C) Urut. nd F.,-,d P ex, acl:aeNR e Not ; ! 7-206.13 Tracking powders, Pest Control and { f,, c•rved. " MomlorinR ( CONSUMER ADVISORY '? ?-603.11 C•.,nsurrwa Advrsor}'Posed L,r Cnnstlnmpnt,n of TBME(I EMPERATURE CONTROLS Anim.d F(x:ds'That arc Raw-, undercooked 36 I Proper Cooking Tempavatures for I PHFs TJ:t erv; Othise Processed to Elhm nale 3-40i.]I A(1 n 2) Eggs- !55 F 15 Sec, 3-302.13 Pasemrze ' td E ,Substitute for Raw Shelf Cess-Immediate Service 145`F75sec+ gg 3401 1 I,,A)(2) Comminuted Fish. Meals&Game Animals- 155'F 15 SPECIAL REQUIREMENTS � 3-d01.11(B)(I)('i Frnkand Beef Roast- 130'F 121 min-' 590.009(A)-(D) Viol.,ionsofSectunt59Q.009(P.)-(,L>tin 491.1 U,A qt) R,ti as, Injected Meats- i 55'F i 5 see, calermng,mcb:k food. temporal} and 3-401.1I(A)(3) Poultry,Wild Gamc.Stuffed PHI-s, residential kitcben operations should be Stuffing C]„laming Fish.A4eat debited ued:! the appropriate sections Poultry or Ratites-I05'F 15 sec. ' above if related to foodtmorne iihtess 9401.11(C')(2) Whole-muscle,In:act Beef Steaks interventions and risk factors. Other 145'F” 590.009 violatit,n, relatine to g:wd retail =401.12 Raw Animal Foods Cooked in a I practices should be debited under#20- Microwave 16x97 Special Requirement... 3-401.11(A)(1)(b) AtI (Aber PHFs - 145°F' 15see. ' 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-1C 3.11(A)8:.(D) PI-fFs 165'-F 15 sec. * ijtems 23-30) I I(b) Microwave- 165'F 2 Mnmute Standing Critical ui,d i a-Erika(rb,i,irions, n-Lich do not refire+o the little* ;r;rnhorr.°t,hent s itrternc:::i:,:!.c and risk fac?on hsfcd Ohmv, rr!n he 3-.103.1 l(C) Cunnuerually Ptecessed IZTE Food- A and to 21 llw ho,l Code uvd 105 L:.ixK 1-70"F* "ti'.Ot10. ?�U? II(E) Remaining, (htchced Portions of Ficef Item 111 Good Retail Practices FC 550.000 Roasts,_ 1 23. 11 Management and Personnel FC-2 .003 1g Proper Cooling of PHFs ! 24 ! Foos and rood Proiertion : FC--3 .004 25 1 Equi-mon!and'Jte?sils FC-4 005 i 1 501 14(A) Coling C okcd PHFs stunt 140-F to 26. Water,P,cmbin4 and Waste I FC--5 .00O 70'-F Withiit 2 Hours and From 71) F ; 27 Physical Factl1v ( FC-6 .007 to 41'F145'F Within 4 Hours. ' ', 28. Puscnous or Toxic tdatelials ( FC--7 .Otis .3-5ul.14tB) Cuoling PHFs Made From Ambient 29 Special R1 Quiren.ents ,009 Temperature Ingredients to41`F/45`F 1 30 Other Within 4 Hours' `Denote.rril,onl tion m tl,e federal 19(x)Feud Code o, M CMR X90 COU. CITY OF SALEM BOARD OF HEALTH f t Establishment Name: �tA'V_ a Date: /— a 9/- `! Page: Of 3 Item Code C-Critical Item V DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY ' � s tC� 7 ) /1eze /a✓I r vR,,, 'e/ae'L'tikZ ai ZlN/ f N°PS Yis/r3ke Qccuifa ��rl�/ry Pi �iI.7� �7l BP CGZP�P_e�- # / f /3 Li f-�n�1riGLt,�as`i .�iivx ,c/exr tO Aeda/vice 64' E-XyP,era't a/�- Sc,��%L'/ Gr�G�.F' �YrG�eGS I /3 f dies ?�/sSiIV rePf� PP� j` `�/ �eI11��fCLe Q Ci LGr lJi�� GL`D/f/S /v I Ak�Pdra)SC'ptt'Wh- &C' e/s --owa )yJc kx-ek nc� riC�r r ,�tL >Cod� '?iZv „ na,,elee�/ Sce,�r7i -e/- Co Pair ira l�/1",em 7 � I _ ff FLNt7r 9k,-t q I I !/ E mrn�o/�� -G('/a0/it'-✓.mac vrt�inr�a•- I s - q a rRsri c .417` rL kG Amu/S`czc/ /J x Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion LIRe-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that . F noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure r your food permit. ❑ Voluntary Disposal 11 Other: _1-501 12:C) PHTs Received at'iniilreratii%t; Vio:aVons Related to Foodborne Illness Interventions and Risk Accordins o0 7 aw Ccoled to Factors(items 1-22) (Cont.) 4I'Fi45'F\l::hm 4 Routs PROTECTION FROM CHEMICALS ( ".`.•'Jl.li Coolin)t Methods tot PH Fs 14 Food or Color Additives .9 r HF Hot and Cold Belding ?>01.16f81 C•ad P!Ts Maintained t or belu:r i-202.12 Addurves ! S90.004(F) 41";'45"F' 14 Pr,nection irom Unapproved Additivos' 3.501. 1W A) Hui PHFs Maint.titied a: u:abov is Poisonous or Toxic Substances 7 tOLil hlenhh•i r.,', (ntorntdbc,n-Original 1'13-.N)i.16(A) Roasts FIeid a! of ahcr.e i 30'1-. " Cuntauiers` 2('i Time as a Public Hearth Control ! 7-102.1 I Cuninun: Nano Working Contamza' 3-501.19 Tine as a Public Health Conic,": 7=301,11 Separation-Stotntec" 720211 Resirietion-Presence and Pea � 590.001(iii fan.:ace Requirem..nt 7'm.I) Condnionc,,f:Tse' ( REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203 i l Toxic Conta ners-Prohibitions' i 7-"204.11 San:tizers.Criteria-Chemicals, ( POPULATIONS(HSP) I 7-104.11 Chemicals for Washhte Produce.Criteria' I 11 3-801 110?J Unp„steutiied Pre-pa,,kaged Juices !end 7-204.14 Di}ine Agents.Crn:riu" ( ; i;c;erage, with Warning Labels' 3-801.1 UB1 j Ilse of Past u:ized.e¢s' 7 1;)i I I Incidents! Focd Contact,Lmbiicants' ! 13-801 IIID) ! Rae. it Partiollq Cooked Animal Foal and 7-2(16.11 Restricted Use Pesticides,Criteria" ; Aar;Seed Suroute.Not &c-r'.ed. ' 7-166 12 Rodutt Bait Stations" ! i 7-206.13 Trackitn�Powder,,Pest Control and =-801.1 llC;: j tinoouted Foul Pacl:aet Not Re-served Momtonne° CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 V)3.11 Consumer Adr,oty Posted for Consu:nplion or 16 Proper Cooking Temperatures for Amnicl Foods`chat are Ravi. Undcrc,eked ur j I PRFs Not Othera-i,r Poxessed to Eliminate 3-40!.11A(1)(2) Eyes- 155"F 15 Ser ;-zi,?.'3 +*> Lgg;- linmedtnte Set vice 1.1"F7 sere' - , Pasteun�cd Eggs Substintle for RauShall 3--40;.11(,0(2) Comminute" Fish.Meals A:Game E^ys Animals- 155''F 15 sea. '" 3-401Al(B)(I)(1) ( Pork indBcefRoast- 130"112! min' SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratite:.. Injected R9catn - 151°F 15 590.009(A)-([)) v4dation:ol'Section '590.009(A)-(D)in sec, catering,mobile f,tod, temporary and 3-401.11(A)(5) Puuhiv' Wild Carne. Stuffed PHF< :estuendal kitellen operations shauid be stulfing Contauune Fish, Meat, dehi,ed tender the appropriate sea ons Puultry or R2titcs-1,65"F 15,sec. " above if related tU fcudll orne Illness 3-401 A HC)(3) Whole-muscle. lntaci BeefSteaky interventions and risk Factor~, Other 145'F* 590.009 violations re!atrng to game retail 3-401,12 Raw Anitrtul F,cods Cai!.ed in a I pra:lic.,should bo debited uudet ff29- Miero,tave 165"F* Specrd Requirements.. � 3-401.11,A0(1)(b) All Other PHF;-- 145'F15see. x 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403 11(A)K(D) PHFs 165'F 15 sec. * atoms 23-30) 3-403.i I tP) Microwave- 165-F 2 Minute Standir , Cnticul ur,d non-craicai 4olatilins, tilos/+,to not rrlow to the Tinto" joodhorae illneos inhrrenrions un.l ri,vk(solo,:s !Wed above, oar be 3-403.1 I(C) Couuuerdally Puxessed RTE Food- jound in the f-,!Pn,irrr se:tiom,y'dre Food Code aril 105 C:MR 140'F" 59o.000 3-303.11(E) I2emuininc Unsliced Portions of Beef ltam j Good Retail Practices FC 590.000 Roasts'. 23, vanagemort and Personnel ( FC--2 _.003 fg Proper Cooling of PHFs - - - -'•} Fond and Food P-otection ! FC-3 004-- __-- 5. E moment an-::Utensils FC--4 .005 3-50114(A) Cooling Cooked PRFs from 140"F to 26. . 'Wafer. Phu mb'nq ane\:t94 aste ! FC-5 .006 7WF Within 2 }lours and From 70'1 27. Physical Facility F"--6 .007 to 41 F'(45"F Within 4 Hour::. i 23. Poisonous or Toxi:Matenais FC--7 .008 3-501.141 B) Coolmy PHFe Made Ftrnn Ambient '-0. Spec+a!Requirements .009 Temperaturc• Ingredientc to 41`Fl45"F I i 30 I Other Within 4 Houis" Daaoic,cridcnl neru in;tic federal 1999 Food Code o 105 CMR:'90.000. . 6 �axo1T CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR ` SALEM. MA 01970 ARB 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 : Deborah Lam Name of Establishment : Fantasy Island Restaurant Address of Establishment : 516 Loring Avenue Type of Establishment : FOOD SERVICE Application Date : 12/16/2002 Restrictions : Permit for Food Establishment 91-03 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. P HEAGENT r co USETTS CITY OF SALEM, MASSACH BOARD OF HEALTH m i • 120 WASHINGTON STREET, 4TH FLOOR DEC 132002 1 SALEM, MA 01970 TEL. 978-741-1800 CI I7 vf- J„LEM FAX 978-745-0343 BbARD OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Fa.,,, ��COuaf llc�iF«^ i TEL# I? S �7/1 S'I 7OZ� ADDRESS OF ESTABLISHMENT S l (� G 6 kw - Y MAILING ADDRESS (if different) OWNER'S NAME L0. c p TEL# 7lP1- 43( -9'tq / ADDRESS lug G1JGe T�rou��c'. Kd CITY STATE M4- zip D(94' CERTIFIED FOOD MANAGER'S NAME(S) <A � - CERTIFICATE#(s) 1kwVT'7 1 &k.- `S°,�'] K (required in an establishment where potentially hazardous food is prepared.) �Ll 22 oq,)-qj EMERGENCY RESPONSE PERSON HOME TEL# '7V"�3 HOURS OF OPERATION: Mon. -'Tue. ✓Wed.v Thu. Fri. Sat. dun. C� 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 RESTAURANTES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 1/ BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL h'0!V: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 kngwledge and bglief, have filed all state to returns and paid all state taxes required under the law. I�-X.tr7 z�l. 7n- Z 1 vl 9 /o Z--- �U til, �( I e 1 }� Signature Date ' Social Security or Federal Identification Number // /}—/-3---------- Revised 11/25/02 FOODAP2.adm Check#&Date F6`9 19 114 C1 $ a60 . r ...-.,�,-.-.-�.� .,..--.. ..-......--v... e :y-w,yl2Yf �+�^Y" m.,...�:hxF"^+4...rv�-.n.✓w.HrY".'.'-^ter .o's j THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date T fOperation(s) Tyneof Inspection / Food ServiceS-Routine Address .. Risk - ❑ etail 9'❑ Re-inspection �_Xb <�Clr '4 JfU Level// ElRes(dential Kitchen Previous Inspection Telephone C"lV _ ( � ❑ Mobile Date: Owner (' ,.., ' HACCP^.Y/N ❑ Temporary ❑ Pre-operation❑ Caterer ❑ Suspect Illness Person in Charge(PIC) �� / Time ❑ Bed &Breakfast El General Complaint t �-( In: ❑ HACCP 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 El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El 14. Approved Food or Color Additives El3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures 2.. ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/ Records/Accuracy of Ingredient Statements / El7. Conformance with Approved Procedures/HACCP El 18. Cooling Plans .1 k✓/ ❑ 19: Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control 0.8. 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 4 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 123. 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 ( 4 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address o / 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: JJJ r A Inspector's Signature: ! Prim /Lr-7C 611 c_/- ,/I C'I PIC's Signature: P� Print: f'7 `� .I Y 1 L��?"T Page /or_�_'Yages FORM 734A HOBBS(&WARREN - BOSTON 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 AnimarFoods 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)I Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 I _ _ Food Contact Surfaces 4 I 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* _ Approved b 110 I Proper,Adequate Handwashing Game and Wild Mushrooms A PP y 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 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* 6 I Tags/Records:Shellstock 12 I Prevention of Contamination from Hands 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 I Handwash Facilities Tags/Records: Fish Products 3-402.11 Parasite Destruction* Conveniently Located and Accessible 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 7 I Conformance with Approved Procedures /HACCP Plans Supplied with Soap and Hand Drying 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 CN1R 590.000. CITY OF SALEM OARD F HEALTH ` Establishment Name: F���77 �� /� ��� Date: / C Page: z of 2 Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I c� Q - S4 -1ar SLI I �S ��✓—lca l? .C�c SCUc]� r�CY15YA�� 6/7 Cwt L-1-/ / BSc YCFIr �nRl - �°. T Discussion With Person in Charge: Corrective Action Required.—ru-No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that * noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure r your food permit. ❑ Voluntary Disposal ❑ Other: ,i r G 3-5ULL:-(C:1 PI-Rn keceived::. empers*ares Vic'ara:w5 Related to Foodborne fHness!rite:vendcns and Hisk Accord rw, :. Ian,Caroled to Factory(items t-22) (Cont.) l T/47'F V;itl•.:o 4 Flows. " 3-ti01.1 Conlin!Methods tin'PRF: PROTECT 10.4 FROM CHEMICALS .A 14 Food or Color Additives ( 19 PHF Hot and Cold Holding 1.0'.12 Additives'^ .Ii.(Q, i'old PI-fFc \.1 a:a:arra at or IfJow i-tW I4 Protection front Unappnn:d Addrmcc' 1,161 Ai Hut Pi IFt. Dsainiained at or above 15 Poisonous or Toxic Substances 40 7-I01,13 (dcntdnuns;inlixn}ahon-Original ofA) R::a;:> Helactorabovt ('30 F. Contaitteri" 7-10111 Conunuu:Name- R'urkm;:Concriners„ 10 Time as a Public Health Control 7 20 i.l t Separation-Storage` ' 3-501 1't Time:tae Public Health C:miroi" 7-202J i Re>triumn--Presence and 17;e I 5?O.OU{tH, V.rtaaia:krquiremenl 1 7-202.12 Conduion;of I„e, REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-20:.11 Toxic Containers-Prohibitions^ PO.-ULATIONS(HSP) I 7-104.11-7-104.11 Sanitizer�.C'nseieria--t:'hetnicnis^' j -7_204.1'_ Chemicals for Bashing produce,Criteria` 123 l 3-801.1 I f inp.:steurized i're-paclsec,i.Toile.:and ?-204.1? Dnyin},Areuc,Cuteria' j Pic^crate;with i taa.11(:''.} I (.,e of Pucseur!zed l�,s' -206.i 1 Incidental Food Gxrhu.t, i.uh06.i 1 Rstrded Use Peptic;des,Crnor 'a", 'a",r11(,D, kaw nr Partiali) C'ouked Animal Fnoct and Ra",Seed;;prouL Not Set,rd. 7-206.12 Radcnt Bait Stauuns�" 2-Fdil.l i(C) 1Tin-peued Fond Package Not Re-served ' 7-206.13 Traz1ant Poodet., Past Control and n9oarturina'" CONSUMER ADVISORY 22 ;"6,0 1.11 Consumer A&Jsory Posted fly i:onsuml,tion of TIME(fEMPER4TURE CONTROLS - 16 Proper Cooking Temperatures for Annmal Food:: ilt:u are P.aw.lin:i.;rcnnked o PHFs I Nnt Otherwise Pmt-escocj to Lii now!- 3-401.1IA(l)(2) Eggs- 155°F 15 Sec Patho;,ens Eeqs- Inmednne Service 145=F1"s-c , ) 3-30'_.1--. Pa,,,tetn i and Egg> SUbntill11c for Ram Shell 3-401.1 I A)(1) Comminuted Fith. YtcaiS X Game FKgs,t <lninnals - 1551 F 15 sec. SPECIAL REQUIREMENTS 3-401.11,Q)tl)121 Pork:nni Qcrf Rna�r - 13tT'F 121 mill' 590.(lU4lA)- ,: lir . '- -401.IItA!(2) Ratites,Injected Meats- 155`F I ( x rti of Section 590.00, A) (U) in ee ' e arenng,mobile food, temporary and 3-401.11(A`(3) Poultry, N91-1 Game.Sniffed PHi=s. residcnual kitci,;n operations should be StufRn,Curtaining Fish. Mew, debited undcl the appropriate sections Ponttry or Radios-165''F i5 ee( "' above if related to foodborne illness 3-401 11(C)(31 Whole-muscle,Intact Reef Steab's interv':ntions and rtak ftitot s. Other 145-F" 590.0(}9 vtolatitms relating to eood retail I ;_401.12 Rat,Animal Foods Cooked lit a ' • �� -es ehdel-fired � ,t � ptact .e, _.roulct i)e undo: rY_� INT:c mvave 165-F )pCCl1l RCC}Ulrefllelltu. 3-401.11(A)(i)(b) All C!iner PFIF:; - I45'F IS sec. 17 ! Reheating for Hot holding VIOLATIONS RLLATEU To acoL RETAIL PRACTICES 3-403 1 l(A)3r(D) P1417:. 165'F 13 sec. * j (Items 23-30) 3-403.11(Q) Microwave- 165°F 2 Muuue Siandine• Crilaa!ce:d wn-r rifical violations, nthh h'n no(relate to dee j I line* ,Fnerihorile rihiess inrenlw;;rions and rW.fi m"t Irsred aP��:r, eco,he ' ?403 1 1(C) Commercially Ptucessed RTE Food - ;ounce in flufoRunzng ser lions q!the food Code and 105 CAIR 140'F' 560.00(( 3,03.11(E) Rennaininy Gnchced Portion;of Beef I 'I teem ; Goad Retail Practices FC 590.000 1 Roasts: 23. M1nanacemerit and Personnel FC- .003 1 is Proper Cooling of PHFs ' 1 24. Food and Food Protection FC"-3 .004 25. cqu.t}insnt and Utansiis FG-4 .005 3_5r)1.14(A) Cooling Cooked PTITs lion: 140`F!o ( 26 I th'ater Plumb.noarcWaste i FC-v .006 70'F Within 2 Hours and From 70"F ' 17 ah'csical FaccitY Fr_6 .007 to 41'F(451f')Within 4 Hours '* I 28. Poisoncue,or Toxlr,Materials : Pl- t .008 --5111.!-1(11) Cooling PHFs Made Flow Amhtein 29. _ Special Requirements .009 Tcmperawl-c Ingredicnt.to 41 Thli F ?0. G'.her ---- Within 4 Hours* i):nolcs aaical nru;in till tcdc,dl 19991-000 od.01 ;a5 CSItt.90.W00. �.� .... ,...r...,ww'-.r,- �.a:�,4.- y.-•m--..-.-r--�_--��ti-.-.^�..'^w.^-.vrn+,s,rix+n^^^rrr,.v-w.�^r^r.,rnn.y,.+,,.�-�- •+�.- ,.+..:M _ 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 / -fJe� /. Date Imp of Ooerationts) Tvoe of Inspection ��7r/3 Food Service ❑ Routine Address 3/� /Q/i Risk ❑ Retail ©'fie-inspection Level ❑ Residential Kitchen Previous Inspection Telephone NL _ �� /717 171 Mobile Date: Owner p�a� ��� HACCP YIN El Temporary ElPre-operation6 /,aJ I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) �j /i Time ❑ Bed& Breakfast ❑ General Complaint In: El HACCP Inspector --7'=sem lel2 Out: Permit No. El Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) Violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 4. Food and Water from Approved Source ❑ 16. Cooking Temperatures El 5. Receiving/Condition ❑ 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/HACCP Plans E] 18. Cooling ❑ 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 ❑ 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: Inspector's Signature: Print: �1 PIC's Signature: `' - Print: Pagejof,�­Pages v - FORM 734A HOBBS&WARREN - BOSTON Violations Related to Foodborne Illness I . Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION f 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 1590.003(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* Applicants*nts* require ng by Food Employees and 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Contamination from the Consumer Charge* - 3-306.14(A)(B)l Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE - 9 Food Contact Surfaces 4 I 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 to 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 4-702.1 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- Ho[Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301 11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 5 � Receiving/Condition � 2-401.11 � Eating,Drinking or Using Tobacco* 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 I 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 7 I Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashmg Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* - - 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Z Establishment Name: Ski S��v> >+�cs�. Date: /'�1.3 Page: � of ez Item Code C—Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R—Red ItemJPLEASE PRINT CLEARLY / Verified I I t I I I � I I k I I t I I r I i I I I Discussion With Person in Charge: Corrective Action Required: I 1:1No I 1:1 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. ❑ Embargo ❑ Emergency Closure r ❑ Voluntary Disposal ❑ Other FORM 734B HOBBS a WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures ' /I Factors(Red Items 1-22) (Cont.) According to L'w Cooled to 41°F/45°F Within 4 Hours.* . PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I 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* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original l40°F.* 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-Storaee* 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 13-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing;Produce,Criteria* 1 Beverages with Warning Labels* JI 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 Parially 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.* EHechm 1/12001 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 I 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(13)(1)(2) Pork and Beef Roast- 130°F 121 Min.*I catering,mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.*1 residential kitchen operations should be 3-401.1 l(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 3-401.11(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 I Reheating for Hot Holding (Blue Items 23-30) 1 3-403.1 l(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 Cade 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. 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. ( IMPORTANT MESSAGE ) FOR J/ A DATE �/� /O3 TIME M � OF r/�(Om �i2rT PHONE AREA CODE NUMBER EXTENSION O FAX O MOBII F 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 /azo/C.✓i.v5 _ 7?l� l�iim/ r! o IP r -SIIGGNED 7}opS FORM 4009 ) ffii MADE IN U.S A. NOTES - - ---- -- -- CITY OF SALEM ��^^ ) 9 BOARD OF HEALTH Establishment Name: f' w f 14// S r n rJ Date: / /,ham/i13 Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R—Red Item Verified IPLEASE PRINT CLEARLY 9,4 I I I � I I � I I I I I I I I I I I Discussion With Person in Charge: Corrective Action Required: I ❑ 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. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other FORM 734B HOBBS &WARREN - BOSTON 14(C) PHFs Received at Temperatures I v Violations Related to Foodborne Illness Interventions and Risk 3-501. According to Law Cooled to Factors(Red Items 1-22) (Cont.) 41°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives G 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* 15 I 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* 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 13-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* - 7-205.11 3-801.1 I(B) Use of Pasteurized Eggs* 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.* Enecnve 111,201, 3-401.11A(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.*1 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#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 3-403.1 I(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 J 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 1 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility I FC-6-1 .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. CITY OF SALEM '�.�•, BOARD OF HEALTH Establishment Name: f ., i�sy/ Ss�rr/ Date: / /Z if3 Page: of Item Code C-Critical Item / DESCRIPTION-OF VIOLATION / PLAN OF CORRECTION I Date No. Reference R-Red Item Verified PLEASE PRIW CLLEARLY '�z/i////J/ T'/✓P``_ L7 e,/� /n��r/,flrtP(_/ �i/E ./"/./J//I'rY �" /-YP/�.�,� . I d /J //.14Z<"zt u/) i,�✓� fy/., lfiC� >/��.c f i/rc'rr /tea � �l e � j 1 -1• 1 I DigCussion With Person in Charge: Corrective Action Required: I ❑ No I' ❑Yes t ❑ Voluntary Compliance ❑ Employee Restriction/ have read this report, have had the opportunity to ask questions and agree to correct all Exclusion F violations before the next inspection, to observe all conditions as described, and to comply ❑ Re-inspection Scheduled ❑ Emergency Suspension with all mandates of the Mass/Federal Food Code. I understand that noncompliance may p g y p result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure + Ilk- f ��, 'y ❑ Voluntary Disposal ❑ Other i 1 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 Lew Cooled to 41°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives 119 _ 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* 15 I Poisonous or Toxic Substances I 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°E* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* I 120 I I 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* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 13-801.11(A) Unpasteurized Pre-packaged Juices and 17-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 17-204.14 Drying Agents,Criteria* I 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.* EHechv 11112001 3-401.11A(I)(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.*I 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 3-401.11(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 117 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 FC590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. I Food and Food Protection FC-3 .004 18 I Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 I 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 I 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. I Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590 000 -,-, -,...-,.�-w-. .^.^--_..,,�„--.....r.._.-.n.:r-�. .s.T.d.-•,--•-�.�.-....�...y,_...._....-..-.raw,-w.-.-.-�a�,,....±�. ..�..-..--:- e s � • 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 J �e��. Date / Tvne of Onerationlj) =0 f In i .�l/s��s,(�// '/R r �; I�Pood Service Ct]� outi�� Address / Risk ❑ Retail ❑ Re-inspection .S woH'-/O_ .-v/ e- _ Level L1 Residential Kitchen Previous Inspection Telephone , /��d ❑ Mobile Date: Owner // / HACCP Y/N ❑ Temporary ❑ Pre-operation I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector "'T'ss -e- f,'1���� I Out: Permit No. [IOther 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 (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 ❑ 3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE E-1 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)El 5. Receiving/Condition �� M t6. Cooking Temperatures - . 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 El 20. Time as a Public Health Control V8. Separation/Segregation/ Protection V9. 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 3 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 o 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 i26. 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: /_ / / i Print: �dtX ! / / PIC's Signature: �j A, Ary �/_ - "/ 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 8 1 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Ammar 1 1590.003(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 3302.15 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)l Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces 4 I Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 11 590.004(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 Samnzation-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 Sanmzation- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Game and Wild Mushrooms Approved by 1 10 Proper,Adequate Handwashing 2-301.11 Clean Condition-Hands and Arms Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* - � 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating.Dunking 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* 1 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placemen[* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility.Operation and Maintenance 7 I 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 ChIR 590.000. i CITY OF SALEM BOARD OF HEALTH Establishment Name: /i.,. 1i7 s f ?_t ,, o/ �P_� �• Date: f X /L�3 Page: of Item Code C-Critical Item / DESCRIPTION OF VIOLATION ! PLAN OF CORRECTION Date No. Reference R—Red Item PLEASE PRINT CLEARLY / Verified J( A)& 1 /6J//ir /�J/Y/�I/PY /I✓JL�fY///9� /.+>Q� Cl/1/4 lily /x! /�!I//P �,� r /UA /T/fi e /�/l//l //CP CLS _/1 O`7 _///�J_/i,i/.1///7✓i _�J_/1 �_irY/A.re /7/7 r.oi. /�� i.j//_, 41'h_ �o_ S I LIli o'er /.3 ZIA /1/H// (]fl�i.•S�i/ !)A�•�///i,_�rvs /J.iJ`irrr /.,/ii-P/�/i>i�.f•f //irP_ _;f 1 /Ire d� 7� a7 .v/ / Discussion With Person in Charge: Corrective Action Required I ❑ No ❑Yes i I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ t Exclusion violations before the next inspection, to observe all conditions as described, and to comply ❑ Re-inspection Scheduled ❑ Emergency Suspension h` with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ilk result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other 4 FORM 7348 HOBBS &WARREN - BOSTON f Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont.) According to Lcw Cooled to41°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* 15 Poisonous or Toxic Substances _ _ 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°E* 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 13-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 11 7-204.14 Drying Agents,Criteria* -- - 3-801.11(8) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact.Lubricants* 3-801;11(13) 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.* Enectme 11112001 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.1l(A)(2) Comminuted Fish.Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.1413)(1)(2) Pork and Beef Roast- 130°F 121 Min.*1 catering,mobile food,temporary and 3-401.11(A)(2) Ratites,Iniected Meats- 155°F 15 Sec.*I 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 3-401.1l(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) I 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 rhe 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 3-403.1 HE) Remaining Unsliced Portions of Beef 23. Manaqement 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, Plumbinp 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 .006 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 J 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. CITY OF SALEM / BOARD OF HEALTH I Establishment Name: sr e-1 Date: i 1/ Page: of .3 Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date t No. Reference R—Red ItemVerified PLEASE PRIMCLEARLY 1 0�7 Al J/- 4 i_.sol batJ/i/�f 17 AJ !//1,.i 7 SIJ IG Z15�/ Js//_s / 7 j"10 n2 1l//L ._ .moi 1�5�1� „> /�/1_il�✓ ///JVPP/t -41 Dis&ussion With Person in Charge: Corrective Action Required: ❑ No I ❑Yes 1 i 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 L) 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 FRO N CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives 119 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(6) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41*F/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original140°F* Containers* 3-501.16(A) I Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* 120 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) Vanance 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 13-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce.Criteria* Beverages with Warning Labels* 11 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 17-206.11 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.* Eneoboe 11112001 3-401.11A(1)(2) Eggs- 155'F t5 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 3-401.1l(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) I All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 I 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 rhe 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 590.001 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 I Proper Cooling of PHFs 25. I 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. IMPORTANT MESSAGE ) FOR lY e c/ A DATE b TIMESa M OF PHOriIF AREA CODE NUMBER EXTENSION U FAX U MOE311 F AREA CODE NUMBER TIME TO CALL TELEPHONED II PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN YOU WANTS TO SEE YOU RUSH RETURNED YOUR C��A,,LL WILL FAX TO Y MESSAGE SIGNEDW� IIyyII��/I r �� MAAOEIM 0009 1 � I NOTES --- - - - i p CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: 27110 (0 Page: of t Item . Code C-Critical item DESCRIPTION OF VIOLATION/PL'AN 00 CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY Yan ' rw [� ri� /)7)' L//r f?j �1/, A./.P -f7/l i.L_ (l�_-il(a�!yl/1/L2W'1 i C� .Gc iri��Lir�S ���/i/Ito : i'>C j7i�T0Yrms - I S lomat ✓a,S lvrc�� �u /��. it vie �l �(o ;50 n-7atl 1 ,-eslor6�07' 6f se rnk=e 6, E —+(41- I ,� • �S� ( � 1� I�. q !-741 - Skov �- ev q0 rv\ I LA, 0 1 K')'t rm 1��F ane ' eA a I Discussion With Person in Charge: Corrective Action Required:-I ❑ No ( ❑ Yes If7 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 P comply with all mandates of the Mass/Federal Food Code. I understand that ❑ Re-inspection Scheduled ❑ Emergency Suspension 1F noncompliance may result in daily fines of twent$-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. r �/ El Voluntary Disposal ❑ Other: I r U , Pl-?b;,Recet ed it Temperatw-es t'iD:2S;n:'s Related to Fondbome A+nsss tntorvertionz and Risk Accordi ug to tar.+G wiled to Factors(Items 1-22) (Cont,) I1`Fi4:i'F 4r'u hin 4 Hours. ` PROTECTION FROM CHFMiCALS I Jl IS C.Aiur Nledioc;s fol j I E Food ur Color Additives ' 114 PHF Hot and Cold Holding 3-2o2.12 Addinve�." ( 3-5(;!.I6W) Cold PHF,\3 aintained o, n,'beloir ! 'I 5gQO0VAj 41>/45'F:< 3}30}2.!A protection from lhtapproved A•.'ditive� I 3"i01.i5(?) Iiut PH F:Maintanc:d :u or::ix,ee i 15 Poisonous or Toxic Substances 7-H)L11 klentrfjmg latrrcm:mnr-Ori;;u:at Roasts I eld in orabore 130`R I Containers' ! 7 1 17,1 1 Cmm�ton Nanto- Workire,Container.* I ( 20 T"ime as a Public Health Control 3-501.;n 'rime a,a Pubti,_Iieai,;,Conuel" _ j 7201.11 rienaration-S;haa'e" 590.0(40i) %'ariar,ce Requirement j 02 11 Re>tri-nun--Fres,rice and U e" 7-202.12 C'ondahons ut I rs, I I 7-203 11 Tniic :,,ntaincr.-Prohitritiona" REQUIREMENTS FOR HIGHLYSUSCEPTISLE Sanitizers,Criteria-Chcuticals" POPULATIONS(HSP) j 7-201 12 Chemicals for Washing Produce,Criteria" I 121 j ,3-SOLI!(A) Unpastutoized Pre-packaged Jui,,er.and f I Bevraee-swit?W:uIIIngIebels^ 7-204.14 Drtiaa?:il!ents.Cnreria" t_ 7 205.1 ! Incidental Fu:xl C'nnract,Lubnranls13-501.i?(P) Use of Pastemiced Eels- _ -1{OLI I fro Raw rr F'at?icily Ctwked Ain rlal Find anti j 7-206.11 Restn,,ted licr Praicrdes.Ciiterir° I kaw Seed SprotrtS Vol Servzd. 'x 7-206.12 Rodent BudSuninns- 13-?i01 II(C'l I (4mpene9Rice! Par-ka>;eNet Rc-eerved. 7=Of, 13 'Iraekimg Pmcders.Pest Cluarni and Monitoring- CONSUMER ADVISORY TIMFJTEMPERATURE CONTROLS }2 3-603.:1 Consumer Advisory Posted for Con,u:nption of 1:4 Proper Coakng'lemperatures for i Anneal P,xoas'1?ra arc Paw.Undcicookzd o� ! ' PHFs Not(tthercvitr PrncesszQ:n Eliminate 3-30!.11A(I)(2) Fgga- 15i'l-15 ec. 3-302.13 PaSeUMCd E891 Substitute Raw Shell Et:es-humediatz Service 145`FlSsc:: t 'bstitute f ";-401,11(Ai;2) C'omminatedFis?:, Mews,EGame F^asx Animal:- 155-F 15 sec. _" Pnrk anrll;ecf Roust- 130°F 121nilu SPECIAL REQUIREMENTS iI auous o{TacoO3"dii.11(A)(2) Ratites, 590.:K,9(A)ID) Violn . 09(A)-(D)in ec, W cz rine, mobile food, LemporioN and 3-401 1 U,ANa) Poultry; Wild Came, Stuffed PHF_c, residential itehen uperations should Ix i Stu'Trig Contein:n_,Fish kleit, debiv�d under the appropriate sc.tions Poultry of Ratitee-10'F 15 sec. '" above i1 related to foodlinme illatxs 3401.1;(Cit i, Whole-raucle, Iaract Reef Steaks intervention, and rick fa,:tois. Other 590.009 violallons relating to good retail ! ?Ji,1.:2 Raw Animal F(,:.[:;Cewked in apracticer.<,otdd be Crnte„d uneT "')- Mieioceave 165"F 11 Special Requirements. 3401,11(A)(I;Ibt Al? Other PHF,- 145'F15scm )z Reheating for Not Holding VIOLATIONS RF(-ATED TO GOOD RETAIL PRACTICES 13-403,1 F;\)&,D) PHP:, 165'F 15 we. :" I ((tors 23-30) 3-401 I 1 t B; Mi;ro•.v;n,e- 165` !t 2 14umte Standing Crib,ai awl noe-rriti,.al cio6ailms, ehirh do not relate l,.the T:me' I Jac",Irne dlt:ess hm r,euiions.;nu ri::n item;rs lialed abov., an be -103.11(C) Cummuremlk Prace>sed RTI- Food- /Mm",it theol/mrh,,c sedimu uj the Ar„d Cb,lc and IiiS ('AQit' !40"F* I 19:7.000. 3-403,11(L•,) R.anaining Lnshced I'ortioae of Beef j -Item Good Retail Practices FC ( 5°0.1Ke0 j F.:'ats<�:; ! 23. fdanawrnorit and Personnel FC-> i 003 IR Proper Cooling of PHFs I 24. Foon and road Prt'cctim FC - 3 004 J 25 Equipme-D and Utensils FC--4 ! 005 Conbng 0)iiKed Pi-IF, from 1,40'F to `6. Water.P!umbing and'✓la:Oe F( -5 ! .00, i 70=1-Within 2llourS and From 70'T' 27, Physical FScmty FC-o" 007 to 41�Ft457 Within 1 Hours. ' 28 Po;mous o:1,=klarenas FC--7 LOOS 3;01,140t) Cooling PHFs Made From Ambient29. Sp?cia!Requirements 009 ! i eunt-white Ingredients to 4loPk15'F ! 30, 0111w Witiin 4 Hours' 'Lfmot, ;rnr,ca!item:n c!:r:ALlfxsl !990!'ond Co.'e or Inti''NIR JIM0(FN. CITY OF SALEM F , BOARD OF HEALTH # Establishment Name: Date: ZvGb -Page: of _ Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF 41IRRECTION Date f No. Reference R—Red Item Verified PLEASE PRINT CLEARLY tS a I (C 1AjA A-P ✓ V�A 5 I l�eA�^ ��s� r� • . I I I I 1 i Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes 1 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 comply with all mandates of the Mass/Federal Food Code. I understand that L3 Re-inspection Scheduled LI Emergency Suspension r noncompliance may result in daily fines of twenty-five �rs or suspension//'revocation of ❑ Embargo ❑ Emergency Closure „ your food permit. ��D,,y / . ❑ Voluntary Disposal ❑ Other: ��..II.��ii r f ��J !J/ I � 6 I;!r.; frit`!.Receive,:at Temperatmes V;otations Relatea'In Foodocrne Illness interventions s.^.d Risk ^;.nru�n�:o ;w Cculed to Factors(iters 1-22) (Cont.) 4!=F/;5'F Within 4 Hours. 3-.SOI,i 47j Cooling it"ec'ttcds for Pt-ths PROTECTION FROM CHEMICALS 39 PHF Per and Cold Holding i 14 Food or Color Additives j 3-501 16lB) Cold PfIFO Maintaiuod al or-=iov% �-20"S 12 Ad-,.iiuw z 59CU.:(i-1(F) 4l'',/-15° t 3-302 14 Pwtcctmn from Ui iappio vd 1ddgrve:` ! I 2.5(1 . Ib(A; 'lot Fl-iF;. Maimatued at or nbo;e j 15 Poisonous or Toxic Substances � 140,E 1 10 1.1 l Colica ere lm�n'u:eLou "-(ingi°S' 3__ ' (`) Roasts Field at or ah,-, � . 5(1..16 :, e ;3U°!�. Container;^ I 7-1011 ! C'ouanon Natne- Wl ,Ain;,Conoiincrs' ( j 20 ( Time as a Public Hemith Control "0€.!1 Separation-5knare' I, 3-501 11) Time as a Public Iie.tlih i'onr,ol,: 7-202 If R,sh iction- Pn•aenc•.and Use i j 591i.004(H) Variance Requirement j 7-202.12 Conditions of tlac" j 7--"u? 11 Toric Crnnainer,;-Prohibitions,; j REQUIREMENTS FOR HIGHLY SI ISCEPTt£iLE 2(i4.t1 S t:uzris. :rlt: i:-Ch:nrcals^' POPULATIONS(FISP) 7-2(rl.i2 Cheur,cals for Washing Produce,Criteria" 2t^ 3-801.11(A) Unpiisteia i7od Pte-packaged luimc and Breuure•s with Ikarnin_Labels' 7-104.1-( (hying agents.Critena' i-Rl:1.1 1(8) Use of Pasteurized h^r,s' I 1 7-205.; I incid.m:t3 Food C ta,wi. I.unricants� L! ;(D Rae'or PattialN Cooked Arammi Food amt 7-206.11 Rcetricted Use Pestit ides.Criteria" ) Raw S---ed 5prcuts Not Sect-ed. 7-206.11 Rodent Bait:it:mons" 7-_t16.13 Trickl1w Powders.?est Conhnl and 3-90i.I I(C) Unupe�cd Food Package No: Re-scrvzd. " Monitoring` Cu?VSt;PnGR AI?V€SOFTY TIME17FMPERATURE CONTROLS 22 603.11 Consumer.Vb,i,my Posi•-d n,:Consumption of i ^.nim:!Foods That arc Raw.Uw&rcovked u, 16 l Proper Cooking Temperatures for PHFS f. :.Giter:: li;hm otiae Processed to untc j � P 3--101.11A(1 q,2) (ices- 155'F 15 See. nc Padloq ns. Fg!_s-lnuu-dime Service I45"FiSsec+ ;-30'_..13 Pesteefizeci Eggs Substitute for Roc:Shell 3-401.11(AI(2) Comminuted Fish,Medu.&.(;nine Arai=.,!als- 155'F '5 sec. SPECIAL REQUIREMENTS j 3-401.11(B)(1)(1) Pork and Reef Roast - !30"F 121 min'" 3-401.11(P.)(2) Rallies, Injected Meats--155'F 15 590'009(A)-(D) Violations of.Section 590.0091A)-(t)) in sec. , I catering, mo-le food temporary and 3-»01.1 i(AYa3) Poultry,Wild Game Stofted PHFs, j te;adential kitchen opera)ions should ii. StuRlnc Containing Fish. Meat, dcY�ited under the pproprinte sections Pnultrvor Ratites-165°F 15 sac. .. I above if related to roodborne Moos 3-!0(.11(0)(3) Whole-nn::de,intact Bert Steaks ( intw entions and risk faclor,i Other 145"F ii 590.009 violaiions relating to good retail 3-401.12 Rat, Animal Foods Co, ked in a inacaecs should be debited under 4/29- Mic,owave 165`F " Special Requ:remcnt.. -4f)lAUA)'I)(b; All Other PHFs- 1-}5"F15 :cc. * t7 Reheating for Hot Holoing j VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3 a03.I I(A)&W( PHFs. 165"F 15 se,:, (Items 23-'0) 3-403.t I(8) Microwave- 165'F 2 Minute Standing Ciitk:d otid nen-rririt'al rink;nn„s, nvl,icn rr,not ieL<-t In Nae Tune; toodhnrte illness oitervenho^s and risk-tat inns fisted ahovc, ecn be 3-403.'i(CI Gvnnicrcialty Processed RTE Fond- ,linin in rhe;'ol4uo ing ,ec ion::or''h:I'ruJ C'odr au<1105 CIOR 140'F` St10.UU0. 3-403.11(F) Rrumrtdng Unsliced Pv,vions of Beef Rem Good Hetai!Practices FC 590.000 IVIsts, - _23_ Manacernent an7 Personnel j SS Proper Cooling of PHFs 24. j Food and Foal Ptot-stion FC -3 004 25. Eomprnent and Utensils FG -4 .005 3-51')1.14(AI Cooling C)okrd PHFs from 1407 to 26. Wa'.er,Plmffiinq and 4Naste FC-5 '' .006 70`F Within:2 flour:;anti From 70"F' 27 FhV-ical Fecdity FC-6 .007 J to 4!`F/45"F Within 4 Hours. " 28. Polsonovs ti'i=r,btatenals FC-7 j .006 3-501 14tB C'oohm Pi-IFs Made From,-AmbientL29. Special Hernurements � 005 f Temperatnre ingredienes to-41`'F/4S'F 3Q Oltur j 'A:i!a n 4 Flom;" s a oi.mo.,.k. ':. 'pe-n:ae:erica(item m Thr IMaal 1999 1ood('ods or 1:15 C'NIR 5 W)000 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"'Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax(978) 745-0343 City/Town of (::�Atp/YY\ Address: FOOD ESTABLISHMENT INSPECTION REPORT Telq W n LR l Wc(p Name( r1� /� D e Typ f0 eratiorro T�ype,efInspection Food Service LJ Routine Address L ^ /\- . _ Risk ❑ Retail M Re-inspection Telephone ti�C� Level ❑ Residential Kitchen Previous Inspection el'T,trl! (� ❑ Mobile Date: Owner ```'� � ,, a HACCP YM [I Temporary [I Pre-operation �()VAI � ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) ! ) Tim ❑ Bed&Breakfast El General Complaint 1 J" i.lM.� In: �!I,(((,,///�y�, ❑ HACCP Inspector O � 'l1l lr Permit No. E]Other Each violation checked requires nation on the narrative Pagel) a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD PROTECTION MANAGEMENT'S __ __ I0 (Se2. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties Q 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 FOOD FROM APPROVED SOURCE . 015. Toxic Chemicals ❑ 4. Food and Water from Approved Source _ TIMEfrEMPERATURE CONTROLS(Potenttally 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 _ n - _ I ❑ 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 HIGHLYSUSCEPTIBLE-SUSCEPTIBLE ```��� ��IEl21. Food and Food Preparation for HSP ❑10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMERADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the Items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an IiE23. Management and Personnel (FC-2xs90.0 ) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-4x590.0044) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-axs9o.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5x590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6x590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7x590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of pislorder. 30. Other DATE OF RE-INSPECTION: Inspector'sS;Ihire Prin PICs Sigaad Print: -� L .1� rr r�,.�-...._ . -` �- � ti .. � . . ._-,� � .r......`.r"....-rte'. .. "+Jw.. .-�'••`~-'�1i� e .. .. .. . .� r . Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT I8 Cross-contamination 3-302.11(A)(I) ' Raw Animal Foals Se crated from I 1 590,003(A) Assignment of Responsibility* I Calked and RTE Foals* 590.003(B) I Demonstration of Knowledge'" I Contamination from Raw Ingredients 12-103.11 Person in charge-duties ( 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* I I Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 13-302.11(A) I Food Protection* require reporting by foal employees and 3-302,15 ' Washing Fruits and Vegetables I applicants" 4-304.,11 ( Food Contact with Equipment and I 590.003(F) Responsibility OC.9 Fad Employee Or AnI 1 1 Applicant To Report'1'o The Person In Utensils*( I Contamination from the Consumer Charge* 590.003(G) I Reporting by Person in ChargDsposrtionofAdufferaced e* I 3-306.14(A)(B) Returned Food and r Contaminated of Food* 131 590.003(D) I Exclusions and Restrictions* I tedor Food 1590.003(E) I Removal of Exclusions and Restrictions I 3.70 1,1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fad* 14 I Food and Water From Regulated Sources I 19 Food Contact surfaces j 590.004(A-B) Compliance with Food law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container'" I Sanitization Temperatures* 1 3-201.13 Fluid Milk and Milk Products* I 14-501.1 t2 Mechanical Warewashing-Hot Water 13-202.13 Shell Eggs* I - Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized14-501.114 I Chemical Sanitization-temp.,pH, 13-202.16 I Ice Made From Potable Drinking Water* I concentration and hardness. 5-101.11 I Drinking Water from an Approved System* I 14-601.11(A) I Equipment Food Contact Surfaces and 15W.006(A) I Bottled Drinking Water' utensils Clean* - ,� �� 4-602.11 I Cleaning Frequency of Equipment Food- Shellfish I Water Meets„G-ndarda in 310 CMR:_.!, Contact Surfaces and Utensils`" She!Aish and Fish From an Approver Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recrealionaily Caught Molluscan Foal Contac[Surfaces of Equipment* She1L'sca I 14-703.11 I Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from^!SSE l.i,ted I Chemical* Sources* Game and Wild klushrooms Approved by 110 I Proper,Adequate Handwashing Reoulatoy AuthodtV I 2-301.11 I Clean Condition-Hands and Arms* J 3-202.18 Shellstock idenfificatron Present` 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* ( 12-301.14 I When to Wash* 3-201.17 I Game Animals* I 111 I I Good Hygienic Practices 15 Receiving/Condition I 12401.11 I Eating,Drinking or Using Tobacco* 3-202.11 ! PHFs Received at Proper Temperan res* I 2401.12 Discharges From the Eyes,Nose and 13-202.15 I Package httegrlty" I I I Mouth* 3-101.1 i I Foci Safe and Unadulterated* I 13-301.12 I Preventing Contamination When Tasting* 16agslRecords:ahelistoek I I l2 I Prevention of Contamination from Hands 3-202.18 I Shellstock Identification* I ( 590.004(F) Preventing Contamination from 13-203.12 Shellstock Identification Maintained* I Employees* j Tags/Records: Fish Products I 113 I Handwash Facilities Conveniently Located and Accessible 3-402.11 IParasite Descmetion' ( I 3-402.12 Records.Creation and Retention* I 5-203.11 Numbers and Capacities* I 590.004(J) + Labeling of Ingredients* I 15-204.11 Location and Placement* I 7 Conformance with Approved Procedures I 15-205.11 I Accessibility,Operation and Maintenance I !HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialimd Processing Methods,* I IDevices 3-502.12 Reduced 1oxygen packaging,criteria* , 116-301.11 Handwashing Cleanser, ,Availability 8-103.!2 Conformance with Approved Procedures' 6-301.12 Hand Drying Provision I 4 DenoW critical item in the federal 1999 Fait Code or 105 CMR 590.00). I ' `3` CITY OF SALEM BOARD OF HEALTH establishment Name: 'FOA-VA- AAA A,1J_, v A_. Date: IJ Page: of A Item code C-Critical Item N3 DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item P --t'� Verified - EASE PRINT CLEARLY A�� 441 0 LW Wa�k 4c) I 0,10-PE a Q'6 „r' -ter 4 /1 A J D/1 inn.0/U PkIl it t[.- _�-'DC7-Y.i�' - c�\J tl Cil I 11v (h wLAL rnn P� \ /� U 1.�)AlulV l (j d_;1 0 01�1Sl � nciM0l - I g I -EU �a�d a,, �l�r R rrly cA IYA ()J 1 044 u Discussion With Person in Charge: -1'0( Corrective Action Required: 1 ❑ No I es I have read this report, have had the opportunity to ask questions and agree to correct all M'.-Voluntary Compliance ❑ Employee Restriction Exclusion violations before the next inspection, to observe ail conditions as described, and to 0-"'Re-inspection C3edul�� Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that i(�I r�I noncompliance may result in daily fines of twenty-five dollars or su ension/revocation of ❑ aryv ❑ Emergency Closure your food permit. q/f /��� tN� it ❑ Voluntary Disposal ❑ Other: r 3-501.1 ` 4(C) PHFs Received at Temperatures Violations Related to Foodborne Alnesslnterventlons and Risk According to Law Cooled to Factors(hemi 1-22) (Cont.) 41=-'145*F Within 4 Horns.* i PROTECTION FROM CHEMICALSI 3-501.15 Cooling Methods for PHFs S19 PftF Hnt and Cord Holding 114 { Food or Calor Additives f { I j 3-50 L 16(13) Cold PHFs Maintained at or below 13-202.12 Additives*' { 590.004(F) 41'f45'F* 3-302.14 Protection from Unaporoved Additivesie 3-501.16(A) Hct PHFs Maintained at or above { 15 Poisonous or Toxic Substances { 140 * 7-101.21 Identifying Information-Original 3-501.16(A) Roasts Held at or above,. DOOR i Contmnen* { 20 Time as a Public Health Control { { 7-102.11 Common Name-Working Containers* 3-501.19 { Time asa Public Heath Control* r 201.Il Separation-Storage* 590.004(H) { 7-202.11 .Restriction-Presence and Use* I VarianceRequireet I { 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* I POPULATIONS(HSP) 7-204.11 Samtizers.Criteria-Chemicals'* { � 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 17-204.12 Chemicals for Washing Produce,Criteria* { Beverages with Warning labels* { 7-204.14 Drying Agents.Criteria* I 3-801.11(6) Use of Pasteurized Eggs* I f 17-205.11 Incidental Food Contac,Lubricants* { 3-801.2 l(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* S { 7-206.12 Rodent Bait Stations* I { 3-801A I(C) Unopened Food Package Not Re-served. ! 7-206.13 Tracking Powders,Pest Control and Monitoring' CONSUMER ADVISORY { T4MEl6EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures far Animal Foods That are Raw,Undercooked or Not Otherwise Processed to Eliminate PHFs 1Pathogens.* n,c vv2w�r { 3401.lIA(1)(2) Eggs- 15S'F 15 See. Eggs-Immediate Service 145°1`15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3.401.11(6)(1X2) Pork and Beef Roast- 130°F 121 min* I 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in i sec.* I catering,mobile food,temporary and 3-=401.11(A)(3) Poultry-,Wild Came,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Ment. debited under the appropriate sections 1 Paul"or Ratites-165°F 15 sec. * above if related to foodborne itmess 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks ( interventions and risk factors. Other 145°F s` 1 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a ( practices should be debited under#29- Microwave 165°F* Special Requiremenrs. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec.* { 117 Reheating for Hot Holding { WOLA7I0NS R LATED TO GOOD RETAIL PRACTICES I 3403A I(A)&(D) PHFs 165°F 15 sec. * ( (Items 23-30) 3-403.11(B) Microwave- I65'F 2 Minute Standing Critical and non-criffcal violations,which do not relate to the Tics* foodborne illness interventions and risk factors listed above, can he 3-403.11(C) I Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140*P 590.000. L 3403.1I(E) Remaining Unsliced Portions o£Beef i Item 1 Goad Retail Practices ! FC 159tT.QdO j ( 1 Roasts* ! 23. 1 Management and Personnel j FC-2 .403 ! i 24. Food and Food Protection ! FC-3 .004 ! 18 { Proper Cooling of PHFs I 125. j Equipment and Utensils I FG-4 005 3-501.14(A) Casting Cooked PHFs from 140°F to 26, 1 Water.Plumbing and Waste I FC-5 .006 ! 70017 Within 2 Hours and From 70°F ( 27. 1 Physical Facility FC-6 .007 to 41`F/45°F Within 4 Hours.* i 28. Pasonous or Toxic Materials ! FC-7 ! .008 f ti 3-501.14(6) Cooling PHFs Made From Ambient129. ( Special Requirements 009 ! Temperature logriahenot'o41*Ff45°F 30 1 Other 1 Within 4 Hours* s �u•�_ "Ihrrous critical r4m ir the fedora) 1999 Food Cate a 105 C.MR 90.000. } 1 CITY OF SALEM �1 BOARD OF HEALTH �( Establishment Name: Date:. 3 Page: _3 of�" Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, No. Reference R—Red Item Verified � PLEASE PRINT CLEARLY _ S - / n ( _ v �TfJn JI/11/1 Sc 11 o�.Q ��U/1 V NJGtiI dv` L�ktkkw_❑' UvLa -41) ril' L.Q. *CtAr­�' Yap l .tc r 11-.a-- fir, `N 01A �S1a. ,�. 1�I rim a r ,>< P M Q3 A n 4,101A, ( �DA14,n4 Q�- , Discussion With Person in Charge: Corrective Action Required: I ❑ No I %-Yes I have read this report, have had the opportunity to ask questions and agree to correct all Ctl�Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P Re-inspection Sch led ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand thatA, -� noncompliance may result in daily fines of twenty-five dollars or pension/revocation of ❑ bargo �& 1-3 n/ ❑ Emergency Closure your food permit. �� ❑ Voluntary Disposal ❑ Other: I i 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 Ft45°F Within 4 Hours. t I 3-501.15 Coolinf-Methods for PHFs PROTECTION FROM CHEMICALS { 1 119 PHF Hol and Cold Holding 4 Food or Color Additives { 3-202.12 Additives* 3-%1,16(B) Cold PHFs Maintained at or below 590.004(17) 410145*F* 3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hot PHFs Maintained at or above { 15 Poisonous or Toxic Subefances ' I400F. * 7-101,11 identifying Information-Original 3-501A(i(A) Roasts Held at or above 1300F.* { Containers* f 20 Time as a Public Health Control { 7-102.11 Common Name-Working Containers* 3-501.14 Time as a Public Health Contras* I 7=201.11 Separation-Storage* I 7-202.11 Restriction-Presence and Use* { 590.004(11) Variance Requirement 7-202.12 Conditions of Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ii 7-203.11 Toxic Containers-Prohibitions* I POPULATIONS(HSP) i 7-204.11 Santrizem Criteria-Chemicals* { 21 3-801.il(A) Unpasteurized Pre-packaged Juices and 1 7-204.12 Chemicals for Washing Produce,Criteria` _Revetages with Warning Labels* { 7-204.14 Drying Agents,Criteria* + 3401AI(B) Use of Pasteurized Eggs* I { 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and { 7-206.11 Restricted Use Pesticides,Criteriat Raw Seed Sprouts Nor Served, * 7-206.12 Rodent Bait Stations* { 3-801.11(C) Unopened Food Package Not Re-served. " I 7-206.13 Tracking Powders, Pest Control and Monitozing* CONSUMER ADVISORY t TIMEITEMPERATURE CONTROLS 22 3603.11 Consumer Advisory for Consumption of 16 Proper Cooking Temperatures for Animal Fraise That arere Raw.Undercooked or PHFs � � Na Otherwise Processed to Eliminate Pathogens.*Ern"`rn.7m!r i 3-401.11A(i)(2) Eggs- 1550F 15Sec. t Ego-immediate Service 1450P15sec- 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game 11 Ems. Animals-155°F 15 sec. " 1 SPECIAL REQUIREMENTS j 3.401.11($)(1)(2) Pori:and Beef Roast- 130°17 121 min* ! 3401.11(A)(2) - Ratites Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and I3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be j Stuffing Containing Fish,Meat, � debited under the appropriate sections I Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 1 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a ( practices should be debited under#29- Microwave 165F* i Special Requirements. 3-40LI RA)(1)(b) All Other PHFs- 145'F 15 sec. { 17 ( Reheating for Hot Holding VIOLATIONS R FLATED TO GOOD RETAIL PRACTICES 3403A I(A)&(D) PHFs 165'1715 sec. * I (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Foal- found in the following sections of the Ftvd Cade and 105 OUR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef i Item 1 Good Retail Practices J. FC 590.00 Roasts" r 23. 1 Manaaament and Personnel FC-2 .003 I 1g Proper Coating of PHFs i 1 24.. i Food and Foal Protection FC-3 .004 12S. Equipment and Utensils I FC-4 .005 i 4 3-501-14(A) Canting Cooked PHFs frtmt 140`17 to 26, 11 , Water.Plumbing and waste a FC-5 0% ( ArF Within 2 Hours and From 70`F i 27. 1 Physical Facllity 1 FC-6 007 to 41`F/45'F Within 4 Hours. * 1 28- 1 Poisonous or Toxic Materials FC-7 .008 3-541.74(6) Cooling PHFs Made From Ambient 129. 1 Special Requirements i .owOth { Temperature ingredients to 41°F/45°F 130, I ! { Within 4 Hair's"` s_�ar.•,-m�-x.�xc: •Dmores aiticat isni in the i^deral 1999 Food Code ur 105 CZAR 590.004. 1! R CITY OF SALEM BOARD OF HEALTH r Establishment Name: M .O, t_J_�X�n Date: Page: t Y of Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified � PL^EPRINT CLEARLY u A I li�0046 A\ I /IA0A (/ AI��dlZZ� U �f _ �—�O17 i 11 �i — No �onJ . � PA) Apvx�4-0JL _ -nom 4rj G cam_ ONX 1A I - v I I 1 I I I I 1 Discussion With Person in Charge: Corrective Action Required: El No I lye .'es 's 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 R inspection Sc eduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollar r suspension/revocation of bargo ❑ Emergency Closure your food permit. M 0 Voluntary Disposal 0 Other: 3-501.14(0) PHFs Received at Temperatures Violations Related to Foodborne Illness Inter✓endons and Risk - According to Law Copied to I FactorsQtems 1-22) fCont.) 41'F/45'F Widna_4 Hairs. ' ( 3-501,15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS l 19 PHF Hot and Cold Holding 14 ( Food Color Additives 3-50L16(B) Cold PI-IFs Maintained at or below 3-202.12 ! Add tiv e�*' l E � 590.004(F) 4i't4S`F* 3-302.14 Protection from Unapproved.Additives" 3-501,16(A) Hot PRFs Maintained at or shove no j I'i5 Poisous or Toxic Substances 1400F. * 7-101.11 idemifying Information-Original 3-501-£6(A) Roasts Held at or above 1300F,* f Containers* l 20 Time as a Public Health Control 7-102.11 Common Name-Working Containers* ( 7-201.11 Separation-Storage* I 3-501.19 Time as a Public Health Control" ( 590.004(H) Variance Requirement ( 7-202.11 .Restriction-Presence and Use° 7-202.12 Conditions of Use* ( 7-203.11 'roue Containers-Prohibitions* ( REQUIREMENTS FOR HIGHLY SUSCEPTIBLE (HSP) ( 7-204.11 Sanitizers.Criteria-Chemicais* 7-204.12 ( Chemicals for Washing Produce,Criteria* I 2t 3-&41.11(*} Unpasteurizedrn,ges t Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* ( .Beverages with Warning Labels* ( 7-205-I I Incidental Food Contact.Lubricants* ( 3-501-11(6) Use of Pasteurized C Eggs* I ( � 3-$01.1 I(D) Raw or Partially Conked Animal Food and ( 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served* ( 7-206.22 Rodent Bait Stations* G ( 3-&01A I(C) I Unopened Food Package Not Re-served. ` 1 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY T{MEIE EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of fl6 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.* 3-401.IIA(1)(2) Eggs- 155F 15 Sec. m«e ,n2ee ! Eegs-Immediate Service 145'f lSsec3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game { Ewe Animals-155`F 15 sec. * 4 ( SPECIAL REQUIREMENTS 3.40LII(B)(1)(2) Pork and Beef Roost- 130°F 121 min* 3-401.11(0)(2) Ratites,Injected Meats- 155'F 15 590.009(*)-(D) Violations of Section 590.009(*) D)in 1 sec.* catering, mobile food,temporary and 34011 RA)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be t Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec " above if related to foodborne illness 3-401AI(C)(3) Whole-muscle,Intact Beef Steaks interventions and tisk factors. Other 145`F* 590.049 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'F 15 sec, ° y ( 17 Reheating for Hot Holding I VIOLAT1ON3 R:MATED TO GOOD RETAIL PRACTICES } 3-403AI(A)&(D) PHFs 16ST 15 see.* ( (Item 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be ! 3403.11(C) Commeremlly Processed RTE Foal- found in the following sections of the Food Code and 105 CMR ` 1400pv 590.D(t0- k ! 3403A I(E) Remaining Unsliced Portions of Beef % Item Good Retail Practices I FC 590.060 i III Roasts* 1 23. : Manacterrent and Personnel FC-2 .003 ! ( Ig Proper Cooling of PHFe 124. Foal and Food Protection ' FC -3 .004 i i 125. I EquiumeM and Utensils I FC-4 005 I 7 3-501.14(A) Cooling Cooked PHFs from 340`F to 1 26, ! Water.Plumbing and Waste I FC-5 '006 ! t 70'F Within 2 Hours and From 70`F 27. 1 Physical Facility FC-6 W7 to 41`F/45'F Within 4 Hours. 28. Poisonous or Towc Materials FC-7 .008 I 3-501,14(6) Cooling PHFs Made From Ambient ! 1 29' Special Rectuirements '009 1 Tetnperature lugredients to 41'F/45`F i ! 30, i Other ! I Within 4 Hours* f q �ll.ntttes critical nu.m in the tMo�ra1 1999 1w:4 Code w'105 C:N(i 594.000. ii r