The URL can be used to link to this page

FILIPONO VARIETY STORE - ESTABLISHMENTS 4 �o� Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name ffHACCP Type of Operation(s) Type of Inspection G/L( f_ ❑ Food Service outine Address [Retail Re-inspection Telephone _ ❑ Residential Kitchen Previous Ipsppdion ❑ Mobile Dater //3 Owner ❑ Temporary ❑Pi pe Uon f AJ a ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) ` t Time ❑ Bed 8 Breakfast ❑General Complaint In: ElHACCP Inspector ' Out: or Permit No. ❑.Other Each violation checked requires an explanation on the narrative ages)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) El Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. rFOOOPROTECTION.MANAGEMENT_ _��.= ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties . .._ ._ _. .- .� ❑ 13. Handwash Facilities EMPLOYEE HEALTH. .._"�.. - `� �PROTECTION FROM`CHEMICALS_ .._-i _ __-. ❑ 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 IITIMEREMPERATURE CONTROLS(P.oteMlalty_Hazardous F.00ds) - ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved ProcedureSIHACCP 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 iREQUIREMEyTS FOR,FiIGHLYSUSCEPTBLE=POPULATION$'_(Fi$P), ❑10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP ❑ 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. Non-critical (N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. C N 590.000/federal Food Code.This report,when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-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 6. Water, Plumbing and Waste (FC5X590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6X590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: N S 6t/dec �A / Inspector's Signature: Prin : PICS Signature: Print: ,H VolPage�of�'Pagea Violations Related to Foodborne Illness Interventions and Risk Factors(Nems 1-22) PROTECTION FROM CONTAMINATION ,R FOOD PROTECTION MANAGEMENT 8 Cross-contamination I I 590,003(A) -Assignment of Responsibility* 3-302.I I-(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 590.003(6) Demonstration of Knowle e* Contamination from Raw Ingredients 2-103.11. Person in charge--duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302-15 Washing Fruits and Vegetables applicants* 3-304.11 FoodContactwith Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(.B) Returned Food and Reservice of Food* 590.003 Cr) Reporting b Person in Charge* Disposition of Adulterated or Contaminated 31 590.003(D) Exclusions and Restrictions* Food 990.003(E) Removal of Exclusions and Restrictions 3701.1'. Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ Fes* _ Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Com fiance with Food Law* 4-5()1.171 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Seated Container* Sanitization Temperatures# 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-HM Water 3-202.1.3 Shell Eggs* - Sanitization Temperatures*. 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking(Eater* concentration and hardness.* 5-101.11 Drinking Water from m Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water` Utensils Clean" 590.006(,B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food - Shellfish and Fish From an Approved Souse Contact Surfaces and Utensils* 4-702-11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Moliusa�a Fotx1 Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of SanitizationHotWater and 3-201.15 Molluscan Shellfish f om NSSF Lasted Chemical* Sources* 1© Proper,Adequate Handwashin Game and Wild tv7ushrooms A g Approved by Regulatory Authority2-301.1.1 Clean Condition-Hands and Arms* - 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590M04(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1, Game Animals" . 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 -Eating,Drinking or Using Tobacco* 3-202.1.1 PHFs Received at Proper Tem ramres* - 2401.12 Discharges.From the Eyes,Nose and 3-202.15 Package integrity* Mouth* 3-101.11 _Food Safe and Unadulterated* 3-301.12 Preventin ContazL_ation When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shebstock Identification* 590.004(E) Preventing Contamination,from 3-203.12 Shellstock Identification Maintained* Em plo es* TagslReeords:-Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction' ---- Conveniently Located and Accessible 3-40212 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(n Labeling of Ingredients* 5-204.11 Location and Placement* g Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 .Reduced oxygen packaging,criteria* - 0-301.11 Handwashin Cleanser,.Availabilit 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Dr Provision Denotes critical item in.the fwlerd 1999 Foaxl Conic or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:" V .e Date: Page: Of Nem Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date NO. Reference R-Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comj ly with all mandates of the Mass/Federal Food Code. 1 understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your,food permit. , / V 0 Voluntary Disposal ❑ Other: 3-501,14(C) PHFs Received at Temperatcres Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Hems'1-22) (Cont) 41'Ft45°F Within 4Hours. PROTECTiOP9 FROM CHEMICALS 3-501.15 CoolingMethods fix'PRFs 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 3-302.14 Protection from Una roved.additives* 590.004(F) 41 145°F* 15 Poisonous or Toxic Substances 3-50L16(A) Hot PRFs Maintained at or above 140`F. * 7-101.11 identifying Information-Original 3-501.16(Al Roasts Held at or above 1300F. Containers* 7-102.11. Common Name-WorkingContainers* 20 Time as a Public Health Control of 7-201.11 Separation-Storage* 590.0 4( Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* 590.004{H) V ariance Requirement 7-202,12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP 'r 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-80 1.1)(A) Unpastemizect Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* ,Beverages with Wanting Labels* 3-801,11(B) Use of Pastemrzed$ °s* 7-245.11 Incidental Food Contact,Lubricants* 3-$01..11(0) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served, 7-206.12 Rodent Bait Statitms* 3-801.11(C) Unopened Food Package Not Re-served. '= 7-206.13 Tracking Powders, Pest Control and y Monitoring' CONSUMER ADVISORY r TIMEMEMPERATURE CONTROLS 22 3603.11 ConsAnimal F ods'Advsoryat Pasted , ConsumptionUndercooked or 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or Not Otherwise Processed to Eliminate PHFs u 3-401.]IA(1)(2) Eggs- i55'F 15 Sec. E gs-Immediate.Service 145°Fd5sec* 3-302.13 Pasteuri2.ed Egggsgs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game E * Animals-155°F 15 sec.* 3.401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in ` see.* catering,mobile food,temporary and i 3-401.1](A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be ,f Stuffing Containing Fish,bleat. debited under the appropriate sections Poultry or Ratites-]65'F 15 sec, * above if related to foodborne illness E 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. fluter 1 145°F* 590.009 violations relating to goad retail i 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 1657* Special Requirements. 3.40'1:11(A)(1)(b) All Other PIFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELAM D TO GOOD RETAIL PRACTICES 34(13.={1(A)&(D) PHFs 165T 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 Tobe* i foodborne illness interventions and tisk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the fallaxving sectionsofthe flood Code and 105 CMR 140°F* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef )tern I Good Retail Praetices FC 590.000 Roasts" ( E3.-- 1 Me agement and Personnel !-FC-2 .003 18 Paper Coating of PHFs i 24. i good and Food Protection FC-3 .004 125. i Equipment and utensils FC-4 .005 1 3-501.14(A) Cooling Cooked PRFs from 140`F to I _ Water.Plumbing and Waste FC-5 A06 4 70°F Within 2 Hours and From 70°F 27. t Physical Faciflty FC-6 007 to 41`F/45'F Within 4 Hours.* 28_�Poisonous br Trrtic Materials ! FC-7 .048 �l 3-501.14(B) Cooling PHFs Made From Ambient 29. �Shia!Hnquiremems i ,009 Temperature ingredientsto4l°F/45`F 30 Other L �_ Within 4 Hours* I Denotes uiticat i�ni in the federal 1999 Food Cale or 105 CMR 590.000, E / A +� .Commonwealth WN1assachusetts d •^ ° e Vy City ofSalemF Board of Health - Klmberlt?y DfISCAiI ` ;120 Washington Street,4th Floor,, + Mayor " ' SALEM,MA >01970 s AW, tz Food/Retail Establishment'Pertnit " =; DATE PRINTED: 12/19/2012.4," r� a 41,c- ESTABLISHMENT NAME: "Filipino"Variety"Store a ' qp =< File Number BHF-2009-000031 `r,;, .,430 Essex Street#5_ ,- y SALEM MA 01970 �. . LOCATEDAT• ,y = , SALEM, MA 01970 Permit Type Permit No. Permit Issued e,Permit Expires x — -Fee Restrictions/Notes RETAIL FOOD BHP-2013-0 257 Jan z1,2013 Dec 31,2013 7, -$7000 g e "_ . Total Fees: -$71100 Jt -g " _ . Mt 11 115'7 IW ^x. '. PERMIT EXPIRES December 31, 2013 Boa'r'd of Health o •S This Permit is not transferable and must be reissded upon change of ownership or tocatlon.The permit must be posted nu a prominent location in the Establishment. I In accordance with the State Sanitary Code,beofre any:revonation's,improvements,or equipment changes are made, . : . all plans for such must be submitted to and approved by the Salem Board of Health a� Pagetot- = _; e . � P r CITY OF SALEM, MASSACHUSETTS Publicxeatth Bonar or H1!AI:r1-i 120 WASHINGTON S'rmlt:T,41,'FLOOR KIMBERLEY DRISCOLL Tm-(978)741-1800 E,�S(978)745-0343 LARRY RAMDIN,RS/RBIiS,CHO,CP-17S MAYOR IramduaRsalenox HEN.,I'I t AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 0-t P1�J 0 VA-gk� Sr12E 2) Establishment Address: 436 PS El' MAt 011)TD 3) Establishment Mailing Address(if different): S fh i 1 t A-S t`)ovvrve 4) Establishment Telephone No: q,tg— T}0 —40 80 5) Applicant Name&Title: Lo li ef)t -Ly l� �. VA 1,S O-ft� 0 W V1 E 6) Applicant Address: ffi-y'AIA Q/} Uf A v� Sj� tkyV l t m r 01 0);-0 7) Applicant Telephone No: 91%-11+1,0018 24 Hour Emergency No:°I� $-3'�� I°l,-WEmail of Wu;(�j1 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 corporation An individual Kut)u-?,k ,K 1 VALSOTts — 0 W" f6'I,t-m1✓ o 00 0 A partnership✓ Other legal entity 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: LOWZ-Oe-I,ytJ VA�,SOrC — Dw ✓I" Address: —S 1} vl q S I}VbDA I Telephone No: Fax: Email: Emergency Telephone No: 9 Y P 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: / Fax: Email: Check#: W' Date: ��d'�� Amount: I Food Establishment Information 14) Water Source: 15) Sewage Disposal: .. DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: d)v s 10/M1— (D PVY) 17) No. of Food Employees: i 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) stablishment Type(check all that apply) (check one) ISMetail( Sq. Ft) ❑ Caterer Permanent Structure ✓ ❑ Food Service-( 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: ----1-1-11--.............................................................Breakfast Esta_blishm_ _e_nts_ -----_-_____.- ......... (check one) RETAIL STORE RESTAURANT Annual ✓ EKess 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 C More than 99 seats $420 Temporary/Dates/Time: ------------------------------------ ---------------------------------------- --------------------------------------------------- ❑ Bed&Breakfast/Childcare Services/Nursing Home $100 ------------------------------------_-- ----------------------------- -------------------------- 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(timeRemperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperature controls required) check alt 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 ;app+ 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 Oniy 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: 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: 12�5u3O9G 26) Signature of Individual or Corporate Name: v 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: 01/03/2011 ESTABLISHMENT NAME: Filipino Variety Store File Number:BHF-2009-000031 430 Essex Street#5 SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0018 Jan 1,2011 Dec 31,2011 $70.00 Total Fees: $70.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS IF$ BOARD OF HEALTH 120 WASHINGTON STREET,4""FLOOR TEL. (97 8) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUM@SAlxnl.COM DAVID GREENBAum,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT LI NAME OF ESTABLISHMENT r Iw N 0 VAgig'n S7E TEL# 9;m- 17 -W10 ADDRESS OF ESTABLISHMENT f3Q Mel\ q'• 4-5 S 6vit l4h 01110 FAX# MAILING ADDRESS(if different) 11'' EMAIL- Business': - -ItQtroyw� tjy5tur2. P r60• C10'v1 Website: OWNER'S NAME LOUKDElyl.J VA LSO-I'lF TEL# q;fT I-0018 ADDRESS qC R1(vtF[*Q A* - SRIkYII MA- 01 CR0 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) _ CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) Amo EMERGENCY RESPONSE PERSON W-t Y'l Vt M W HOME TEL# I'lo' 1-ft- 4-6 LE_ '6DAYS'OF OPERATION Monday ,. ;i . ,Tuesda Wednesday, .' "-,,Thursday r; Friday' :Saturday '':;'; Sunday-'.. HOURS OF OPERATION Please write in time of day. I�„1- (o ,,.� (Dam- (, a„ IDam- (o mj IOam- », ; loam-6 rh IDam -bpm I m -6 s•0 For example l lam-11 / 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 JtO) less than 25 seats =$140 (Outdnor Stationary Food Cad$2101 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES $100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. Signature — Va,(,�,�. Date 6 I p Social Security or Federal Identification Number }.��0 _____ g` Revised I0h1l I 0 AP201 Ladm Check#&Date } [0 $ 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 Address: FOOD ESTABLISHME T INSPECTION REPORT Tel. Name ( ( �, Dat Type ofOperation(s) Type inspection ❑ _Fpbd Service outine Address Ris etail ❑Re-inspection TelephoneLevel ElResidential Kitchen Previous Inspection 1 070) o ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Cha a(PI Tim _ ❑ Bed&Bre st ❑ General Complaint Inspector In: )� ermitNo ❑ HACCP Out: ❑.Other Each violation a require an explanation on the narrative age(s)and a citation 6f specific provision(s)violated. Noncompliance 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) El FOOD;PROTECTION MANAGEMENT_ __ _. _ _ _. a ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties _ - _,. ❑ 13. Handwash Facilities EMPLOYEE HEALTH . _ _ _ ,PROTECTION FROWCHEMICALS A ❑ 2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives - ❑ 3. Personnel with Infections Restricted/Excluded _ El 15.Toxic Chemicals FOODFROM APPROVED SOURCE TIMERFJJIPERATURE:C,ONTROLS ._� . -- a ❑ 4. Food and Water from Approved Source (Potentially Hazardous Footle) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION _ . ,_ y ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20. Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 'REQUIREMENTS FO' ' RHIGHLYSUSCEPTIBLE-POPULATIONS;(HSP)`. } ❑ 10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP ,.._._,__.. -- ---�_ _ -- ��.,.--_. - ❑ 11. Good Hygienic Practices CONSUMER ADVISORY [122. Posting of Consumer Advisories Violations Related to Good Retail Practices-(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 23. Management and Personnel (Fc-2X550.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils cited in this report may result in suspension or revocation of (FC-4X590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FCSX590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other / ]p�� ' I DATE OF RE-INSPECTION:�14. (62 0i, �A Inspector's Signature: Print: ' (r , PICS Signature: d.�.^-"� Print: I Page1o1A 1,rTA f Pages n A Violations Related to Foodbome Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 ross-contamination FOOD PROTECTION MANAGEMENT C 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foals Separated from Conked and RTE Foods* 590.003(6) Demonstration of Knowledge" Contamination from Raw Ingredients 2-103.11 Person in charge-duties 3-302.11(A)(2) Raw Animal Foals Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 59{).003(0) Responsibility of the person in charge to 3-302.1 I(A) Food Protection* - require reporting by food employees and 3-30215 Washing Fruits:and Vegetables applicants* - 3-304.11. FoodContactwith Equipment and 590.003(F) Responsibility Of A Fad Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Char. * 3-306.14(011) Returned Food and Reservice of Food* 590.003(G) Reporting b Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Ford* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* LL 4-507..1.1 I. Manual Warewashing-Hot Water 3-201.12 Foal in a Hermetically Sealed Container* Sanitization Temperatures* _ 3.201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* - Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurizzd* 4-501.114 Chemical.Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water* concentration and hardness. 5-i0LI I Drinking Water from an Approved System* 4-601,11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinlcma Water* Utensils Clean* R-602.11 Cleaning Frequency of Equipment Food 590.006(13) Watet bleats Standards is 3]0 CMR 22.0" Contact Surfaces and Utensils* Shortish and Fish From an Approved Source - 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and RecreaLionally CaaQht Molluscan Fad Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Simitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Regulatory Authority Game and Wild Authority Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* ' 3-202.15 Shellstock Identification.Present` 2-301..12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game-Animals* Il Good Hygienic Practices - - 5 Receiving/Condition 2-401..71 Eating,Drinking or Using Tobacco* 3-202.11 PRFs Received at Proper Temperatures* 2401.1.2 Discharges.From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.1 i _Food Safe and Unadulterated * 3-301.12 Preventing Contamination When Tasting* 6 Tat sfRerords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained'*. I Employees* Tags/Records:Fish Products 13 Handwash Facilities 302.11 Parasite Destruction* Conveniently Located and Accessible 3-40212 Records Creation and Retention` 5-203.11 Numbers and Capacities* 590.004(f) 1 Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance Supplied with Soap Drying 1HACCP Plans P and Hand ry 9 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,-criteria* 0-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures' 6-301.12 Hand Drying-Provision 'Denotes critical item inthe federal 1999 Pail Code or 105 CMR 590.000, Nwr MASSACHUSETTS Puulcxeatrh BOAR OF HE UrH m a 120 WASHINGTON S7REET,4n'FLOOR - [I1�IBERLEY DRISCOLL TEL.(978)741-1800 FAx(978)745-0343 LARRY RAMDIN,ILS/RE1-1S,Cf IO,CP-179 / MAYOR lrnmdin&alcm.com HEAI:I7I AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: « t?l�j D VA'xkl 17 s'f -s 2) Establishment Address: 43� SSS e X Z-ASSA"ET'I'1 M A i 01°I T 3) Establishment Mailing Address(if different): 3*y t Via ftovvc 4) Establishment Telephone No: T40 iW 90 5) Applicant Name&Title: (,p LAKj)v-"W 8. V4S0-1'F 6) Applicant Address: 4 r l 'Y l ft o F} w rr(j SA W01 I ✓T'1 ii 01 -)TO 7) Applicant Telephone No: r g--NJ-0019 24 Hour Emergency No:��$ 33�-101 gOEmail: f i li irlo Voa r dor aIWU r(a 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 individual 1- VALSOTTs – OvJvnv,'y<, 4fl,'✓�eMOA W S lv1 oiq 0 011 An individual R01��KtUc � � � A partnership✓ Other legal entity 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: LmAoxa-itJ own" Address: — S A vl r �✓0�/� Telephone No: Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: "2 W' Date: ",o`er('- Amount- 4 4 Massachusetts De0artment 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 f^ ' Address: FOOD ESTABLISHIl T I ECTION REPORT Tel. NameDat Type of Operation(s) typ�a€Inspection 1 i yr 2 ❑❑� Foobd Service routine Address Pit k (_&}'Retail ❑Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection P ❑ Mobile Date: OwnerHACCP YIN ❑ Temporary ❑Pre-operation 41 V1 ❑ Caterer ❑Suspect Illness Persort4n-C a (P Ti _ ❑ Bed&Br at 11[I Complaint Inj [IHACCP Inspector Off. ermit No ❑.Other Each violation a require an explanation on the narrative age s)and a cltation&specific provision(s)violated. Noa-complianaewith. _. Violations Related to Foodborne illness Interventions and Risk Factors_(Red Anti-chore 590M9Items Tobacco 590.009(F) ❑. Violations marked may pose an imminent health hazard and require immediate A9argen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. FOon.PROTECTK)N MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El 13, Handwash Facilities EMPLOYEE HEALTH' PROTECTtONRtOMGHEMiCAL .r F12. Reporting of Diseases by Food Employee and PIC [114.Approved Food or Color Additives El3. Personnel with infections Restricted/Excluded FOOD kOMAPPROVEDSOURCE" El 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME(TEMPEMTURE'CONTROLS#iotentlaltyHmrd6ueFaadsIt ❑ 5. ReceivingiCondition ❑16. Cooking Temperatures ❑ 6. Tags7Records/Accuracy of ingredient Statements ❑ 1 i,Reheating ❑ 7. Conformance with Approved Procedures/HACGP Plans ❑ 18.Cooling 19.Hot and Cold Holding PROTECTION FROM CONTAMINATION F19 ❑ 8. Se{)arationiSegregationiProtection ❑20. Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FORHIGHLY-$USCEPTIBLE4POPULAY(ONS WP). ❑2'1. Food and Food Preparation for HSP ❑ 16. Proper Adequate Handwashing ❑ 11.Good Hygienic PracticesCON8 Posting RY El 22. P osting 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)5 of Health. Non-critical(N)violations must be corrected OfEcial 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. 590.000ffederal Food Code.This report,when signed below C 3by a Board of Health member or its agent constitutes an 23. Management and Personnel (590 0 order of the Board of Health. Failure to correct violations 24:Food and Food Protection (FFC-3XC-3X590.4044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste {FC-5X59o.ca&) 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•7X590.006) and submitted to the Board of Health at the above address a�9.� Special Requirements (590.009) within 10 days of receipt of this order. Other � DATEOFRE4NSPECTIOM. A- ama FEE!signature: PICsSignatnre: Print Pagel of Pages a Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs _ 120 Washington Street,4"'Floor 9 Salem,MA 01970-3523 Tel. (978)741-1800 Fax(978)745.0343 City/Town of Address: FOOD EST LISH T 1NSP CTION REPORT Tel. " Name c I n Date Type of Operdtion(s) T e of spectton ❑ Food Service outine 11 Address Risk (�Ret'all El Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: OwnerHACCP YIN ❑ Temporary 11Pre-operation ❑ Caterer ❑Suspect Illness Person-in-.Cha a(PIC) v Time ❑ Bed 8 Breakfast ❑❑HGeenneCP Complaint jfjV In: o. ❑. Permit NOther Inspector Out: .. -Each viola 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) AntiCholdng 590.009(E) ❑ Tobacco 590.009 IF) ❑. Violations marked may pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. FOOOPROTECTION MANAGEMENT ':' ❑12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties 2'13 Handwash Facilities - ;*PLOYEEHEALTH - - ;PROTECTION FROM CHF:ANCALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14 Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded -17115.Toxic Chemicals FOODFROM APPROVED SOURCE 171 4. Food and Water from Approved Source IIWE-ITEMPEPA-NWCIONTRO LS(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 ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FORHIi3HLY40$CEPTIBLE-POPULAT(ONS:(HS13)` ❑21.Food and Food Preparation for HSP ❑10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices El 22. Posting of Cons _ or ❑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): IT of Health. Non-cnbcal(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- Ni 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)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 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-7X590.008) and submitted to the Board of Health at the above address 29. Special ReqLjfrments (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Print: Print: U,Rr7Is1, h � Page�oPICS Signature: fges CITY OF SALEM �--� BOARD OF HEALTH Establishment Name: Date: �w Pager of nem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Item Vedffed PL*SF PRINT CLEA LV 4 Ca 5 ,Y e to F Discussion With Person in Charge: Corrective Action Required: ❑ No es I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ 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 tw ;nty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ( ,�-"'� 0 Voluntary Disposal ❑ Other: Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4m Floor Division of Food end Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTAWLISHIAWT.INSPECTION REPORT Tel. Name 0 Date Type of Operation(s) T pe of spection ❑ Food Service outine 7Tddressl Risk Lkl-R all ❑Re-inspection Telephone Level El Residential Kitchen Previous Inspection ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time ElBed&Breakfast ❑General Complaint In: ❑ HACCP Inspector Out: Permit No. ❑.Other Each vmolatiefi checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti-Choking 590.009(E) ❑ IViolations marked may pose an imminent health hazard and require Allergen Awareness 590.009(G) ❑ immediate Tobacco 590.009(F) ❑. corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT._ _ __ - __ _ ❑12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH 13. Handwash Facilities i PROTECTION FROM'CNEMICACS_ ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded SOURCE El 15. Toxic Chemicals FOOO'FROMAPPROVED _ _ __ - _ _ _ -_ ,. ... _...- - ❑ 4. Food and Water from Approved Source ,TIMFJTEMPERATURE.CONTROLS(PoteMlallyHazardous_Food;1) __� ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling - - - - r.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:SUSCEPTBLE�OPULATIQNS'(H8P)�. ❑ El 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices C0iStJME-RADV SORY_ ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2x660.003) 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 (FCsx590.006) 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 Lj,128. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. Special Req 'r ments (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S IIFrc Inspector's Signature: Print: H PICS Signature: �a� Print: �Ou2nL-L n J � Page-[of ges i Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENTS Cross-contamination 1 590,003(A) Asiwent of Responsibility* - "1-302.11(A)(1) Raw Animal Foods Separated from aCooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in charge-duties 3-302.1l(A)(2) Raw Animal Foods Separated from.Each 1 EMPLOYEE HEALTH Other* 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 Ve etables applicants* 3-304.11 Food-Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Repor±'ro The Person In Contamination from the Consumer Chat * 590,003(G) Reporting by Person in Chane* 3-306.14(A)(B) Returned Food and Reservi,ce of Food* 3590.003(D) Ezclusioms and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-701.1 l Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* _ 4 Food and Water From Regulated Sources 9 Foot)Contact Surfaces 590.004(A-B) Compliance with Food Law* A-501..111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eons* - Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.1 W Chemical:Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water* concentration and hardness. * 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Druikin Water* Utensils Clean* 4-602.1.1 Cleaning Frequency of.EquipmentFood-' 590.006(B) Water Meets Standards in 31.0 CMR 22.0* Contact Surfaces and Utensils* Shetlfish and Fish From an Approved Source - 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Motluecaa - Fneii Contact Surfaces of Equipment* _ Shellfish* 4-703.11 Methods of Sanitization-Hot Water and " 3-201.15 Molluscan Shellfish from;h15SF I,iated Sources* Chemical* 10 Proper,Adequate Handwashing Regulatory Authority Game and Wildushrooms.4pproved by 2-301,11 Clean Condition-Hands and Arms* 3-202.18 S'hellstock Identification Present` 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 1 When to Wash* 3-201.17 Game Animals* - 11 - Good Hygienic Practices " 5 ReceivingrCondition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.1.1 PHFs Received at Proper Tem ramres* 2-401.12. Discharges;From the Eyes,Nose and 3-202.1.5 Package bite .;r* Mouth* 3-101.11 _ Faod Safe and Unadulterated* 3-30L 12 Preventing Contamination When Tasting* 6 Tags/Records;Shelistock 12 Prevention of Contamination from Hands 3-202.18 -Sbellstock Identification* " 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Employees* Tags/Records:-Fish Products 13 Handwash Facilities 3'40"2.11 Parasite Dnstntetiore* Conveniently Located and Accessible 3-402.12 Records, Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(!) Labeling of Ingredients' 5-204.11 Location and Placement* � Conformance with Approved Procedures 5-205.11 Accessibilit ,Operation and Maintenance JHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* - 6-301.11. Handwashing Cl eanser,.Availabilit 8-103.12 Confoimance with A roved Procedures* 6-301.12 Hand Drying"Provision *Denotes critical iu;oi in the Weral 1999 Frnxt Code or 105 CMR 590.000, t CITY OF SALEM �—� BOARD OF HEALTH --zk /I r/ Establishment Name: Date: 1�� Page: of_�L Item Code C-Critical Item I DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLBASP PRINT CLEA LV f h� , r la Discussion With Person in Charge: Corrective Action Required: ❑ No Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion 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 tw my-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 1 ❑ Voluntary Disposal ❑ Other. 3-501.14(C) PBFa Received at TemPeraturas Violations Related to Faodborno Illness interventions and Risk According to law Cooled to Factors fltemsY-22) (Cant.) 41'F145'F Within 4 Hoam PROTECTION FROM CHEMICALS 3-501.15 Coolin Methods for PBFs 14 �ootl or Color Additives 3q Pt+F Not and Cotd Holding 3-20_2.12 _ i Additives* 3-501 .16(B) Cold Pp3Fs*Maintained at or below 3-302.14 Protection from Ln a 3-50L 4(17) 41 (45 F ? ovedAdd'atives" 3-SOLIfi(A) Hot P1lFsMaintained arorabove 15 Poisonous or Toxic Substances 140`R * 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F, " Containers* 20 Time as a Public Health Control 7-102.11. Constrain Name-Working Containers* om e* 3-501:14 Time as a Public Health Control* 7-201.11 Se "on-St 7-202.11 .Restriction-Presence and-Ilse' 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Cattamer -Prohibitions* POPULATIONS HSP 7-204.11 Santrizers.Criteria-Chemicals° . 21 3-$41.11(A) Ust Pre-packaged Iaice s and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages wih Warning Labels* 7-204.14 Drying.Agents.Criteria* 3-80111H) Use of Pasteurized Eggs 7-205:i 1 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprains Not Served.; 7-206.12 Rodent'Bait Stations* 3-801.11(C) Un ned Food Packs Not Re-served. 7-206.13 Tmekiag Powders,Pest Control and Monitnrin CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or F6 Proper Cooking Temperatures for Not Otherwise-Processed to Eliminate PHFS Patho*ens.*�xocnw,nace!i 3401.1IA(t)(2) Eggs- 155F 15 Sec. Eggs-Immediate Senicc 145°F15see* 3-302.13. E r.Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fisb.Meats&Game Animals-155'F 15 sec. 3-401.11(13)(1)(2) Port:and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.110)(2) Ratites,Injected Meats-'155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in see * catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFS, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Paul or Ratites-165'17 t5 sec. * above if related to foodborne illness 3.401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail 3401.12 Raw Animal Foots Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3401.11(A)(1)(b) All Other PHFS- 145'F 15 sec. 19 Rehooting for Hot Holding WOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403A I(A)&(D) ' PHFs 165"1715 sec.* (Items 23-30) 3-40111(B) Microwave 165`F 2 Minute Standing Critical.and non-critical violations,which do not relate to the Tire* i foodborne illness interventions and risk,factors listed above, can be 3403.11(0 Commercially Processed RTE Food- found in the fellowing sections.of the Food Code and 105 CMR 140°F* 590.0010. 3403.11(E) Remaining Unsiiced Partionts of Beef item Goad Aetatl Practices FC 590.000 Roasts* j 23. i Management and Personnel _ FC-2 .003 1g Proper Cooling of PHFS 124. i Food and Food Protection FC-3 .004 25. Equipment and Utensils i FC-4 .005 ! 3-501.14(A) Cooling Cooked PHFS from 140`F to 26, Water.Plumbino and Waste I FC-5 o06 70`F Within 2 Hours and From 70`F 27. ( PhysicW FacilityFG-6 007 to 41`FI45'1`Within 4 Hours. * i 28_ Poisonous or Toxic Materials ' FC-7 .008 3-501.14(6) Cooling PRFs Made From Ambient ~29. Special Requirements .009 7 Temperature Ingredients to 41°Ff45°F 30 i Other �---- t Within 4 Flours* 'D-rvnz&critical here in the federan t 999 FwrJ Cade ur IW C-441:590.090. Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor KiMberley Driscoll Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/0412012 ESTABLISHMENT NAME: Filipino Variety Stare File Number.BHF2009-OD0031 '430 E^'ssex Street#5 SAUM MA 01970 LOCATED AT: SALEM, MA 01970 I Permit Type Permit No Permit Issued Permit;Expires Fee Restrictions/Notes RETAIL FOOD BHP-2012-0299 dam 1,2012 Dec 31,2012 $70.00 Total Feec $70.00 PERMIT EXPIRES Oecember 31, 2012 --Y Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 v ! » CITY OF SALEM, N ASSACHUSE'I`I'S BOARD OF HE.-�L:m f . 126 WASHINGTON STAFF.T,4'" F1.tx Ilt TFL. (978)741-1844 KINTBERI.EY DRISCOLL F_14(978)745-0343 NL\YOR hanxdjnLc?salem.com LAIM'RAMIAN,RS/RE.I IS,(J10,CP-ISS 1=II;-1VIII A(7i'.N'I' I 2412 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1}1.}NID VA91VN Si"i K' TEL# 13$- q4D- t{d e0 ADDRESS OF ESTABLISHMENTg3O ESWA W45'45• 'Atk7 irAR. 019TD FAX# MAILING ADDRESS(if different) — EMAIL- Business':_t p� IVIDa 0.f4lut '�Xt4 4a{+ffD� - orm Website: OWNER'S NAME LAuw-,in VAL1, m TEL# � ►-ODlK ADDRESS 4 Hvn"ON }m ft O j IV STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON 39ELLE`f Vif111 Q.0 - HOME TEL# IDAYS0FOPERATION Monday Tuesd� Wednesda ' Thursda favJa Saturday Sunk HOt1RS OF OPERATION Please wdieintime:ofday, ICWSte. 10am-rr m for,_& (For example llam-Itpm) TYPE OF ESTABLISHMENT FEE (check only} RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - ---------------...... ....... --............ - ----------------- -----------------•--------- �' RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Foo„Cart$210) 25-99 seats =$280 more than 99 seats =$420 - ------------- --.._..--••------------------------------------- BEDlBREAKFAST! O $100 YES CNILOGARE SERVjfES/NURSING 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 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 pians for such must be submitted to and approved by the Salm 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. - VAAL 1423 0 9 G _ Signature�--- Date Social Security or Federal Identification..Number _ Updated 523111 FOODAP201 I.adm Check#&Date -S S ' 430 Essex Street #5 Filipino Variety Store City of Salem RETAIL FOOD - Food Establishment Inspection HIACCP: ❑ Item Status Violation Critical Urgency `Telephone: PROTECTION FROM CONTAMINATION 1 (978) 740-4080 Handwash Facilities FAIL Critical ❑. RED Owner: Comment:There are no paper towels in the restroom. Provide disposable paper towels at all times. Roderick and LOurdelyn Val Violations Related to Good Retail Practices (Blue Items) j PIC: Food and Food Protection FAIL Critical BLUE I Lourdelyn Valsode Comment:There are price labels over sell by dates.Do not cover sell by dates with price labels. Inspector: 8 Knorr Beef bouillon cubes removed with an expiration date of 6/212011. Closely monitor all expiration dates. David Greenbaum Equipment and Utensils FAIL Non-Critical BLUE Date Inspected:Correct By: Comment:The Kenmore box freezer needs a thorough defrosting. 110/11/201 1 Risk Level: I Permit Number: BHP-2011-0018 Status: SIGNED OFF #of Critical Violations: 2 ,Time IN: Time OUT: i 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®2011 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 13,2011 ) 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®2011 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 13,2011 ) Page 2 oft Massachusetts Department of Public Health Salenff Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978) 745-0343 Name �^ 1 IL Vk I Tvoa of ODeration(s) Type of Insnection M, I K tQr. ❑ Food Service ` LRoutine Address If E-Retail ❑ Re-inspection SSP Level , ❑ Residential Kitchen Previous Inspection Telephone n 4�0 _ j ❑ Mobile Date: Owner / 1Il 1JJ HACCP YM, ❑ Temporary El Pre-operation a\ L�- f 017a Q Ik 1. El caterer El Suspect Illness Person in Chafgel(PIC) Time ❑ Bed&Breakfast ❑General Complaint ❑ HACCP Inspector "Wj ' C✓ C Out: Permit No. „ ❑Other Each violation check d requires an explanation on the nary"itiWpage(s) and a citation of specific provision(s)violated. I i Mon-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors anfi-'6noking f 'Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 5e0.009'(F) p action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT -,___ _�„ -.� [112. Prevention of Contamination from Hands E31. PIC Assigned/Knowledgeable/Duties El____ 13. Handwash Facilities ❑EMPLOYEE HEALTH - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC El3. 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/rEMPERATURE CONTROLS(Potentially Hazardous Fo_oda_) ❑ 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 EME661RIEMENTIS FOR HIGHLY SUSCEPTIBLE POPULATIONS.(HSP)' [1 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP [Ill.Good Hygienic Practices CONSUMER ADVISORY 0 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below C x 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) 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: 5:59JIrupMForrr514.Erc � Inspector's Signature: Print: N PIC'sSignature: I � �(h, PrinLt-tnlllx"1-//,/ V4Iurt Page�of_2Pages YL Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION S Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)('l) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of lit owledge* Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other- EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) I Food Protection* require reporting by focal employees and 3-302.15 Washing Fruits and Vc*etables applicants* 3-3(A.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservi,ce of Food* 590.003(G) Re orting b Person in Charge* Disposition of Adulterated or Contaminated 31 590.003(D) Exclusions and Restrictions* Food 590.003(F,) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources °) Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.1.11. Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water . 3-202.13 Shell EMs* Sanitization Temperatures* . 3-202.1.4 Eggs and Milk Products.Pasteurized" 4-50 LI 14 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101.11 DrinkingWater from an Approved System, 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11. Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and . 3-201.14 Fish and Recreationally Caught Molluscan 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* Game and Wild Mushrooms Approved by10 Proper,Adequate Handwashing Regulatory Authority 2-301.11 - Clean Condition-Hands and Arms* 3-202.18 Shellstock.Identification.Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* II Good Hygienic Practices 5 Receiving/Condition 2401..11 Eating,Drinking or Using Tobacco* 3-202.11 PRFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and 3-202.1.5 Package tete it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* TagstRecords:.S'helistock 12 Prevention of Contamination from Hands 3-202.18 Sheilstock Identification* 590.0(W(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to gees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.1.2 Records.Creation and Retention* 5-203.11 . Numbers and Capacities* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* � Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. S ecialized ProcessingMetbods* Devices 3-502.12 Reduced oge x npackaging,criteria' 6-301.11. Handwashin Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301..12 Hand Drying Provision "Denotes critical item in the federal 1999 Foal Code or 10 CINR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: I 2 ' Date: Page:-Z of Rem Code C-Critical Item I DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R—Red Item Verified PLEASE PRINT CLEARLY ,� � Ian 1( t r, � o rn 4—A23.11 _ f rP M• Discussion With Person in Charge: Corrective Action Required: ❑ No L�Xes 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 dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal 0 Other. 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold bolding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 410/45'F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic substances 140°F. * 7-101.11 Identifying Information-Original 3-501.16(A) Roast Held at or above 130°F. Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage"' 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-Presence andUse* 590.004(11) Variance Requareincut 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTSPOPUONS(HSP)LATI 7-204.11 sanitize".Criteria-Chemicals* 21 3-801A I(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* 7-204.14 Drying Agents.Criteria* Beverages with Warning-Labels* 3-801.11(B) Use of Pasteurized E * 7-205.11 Incidental Food Pestact,ticides, 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* 7-206..13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food PackageNot Re-sensed. Monitorin * CONSUMER ADVISORY TiMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 - Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-40i.11A(1)(2) Eggs- 155F 15 Sec. Pathogens.*Err."" Eggs-htmtediate Service 145°F15sec* 3-30113 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E=* Animals-155°F 15 sec. 3401.11(B)(1)(2) Pork and Beef Roast-130'F 121 nun* SPECIAL REQUIREMENTS 3.401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-40Lll(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F i= 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. 340111(A)(1)(b) All Other PHFs- 145°F 15 sec. * 11 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(1)) PHFs 165°F 15 sec.* (items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical.and non-critical violations,which do trot relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 C.MR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item I Good Retail Practices I FC 690.000 Roasts* 23. Manattement and Personnel FC-2 .003_ .I 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 '0041 3-.501.14 A Coolie Cooked PHFs from 140°F to 25. f Equipment ent and Utensils i FC-4 .006 ( ) g 26. Water.Plumbing and Waste FC-5 .006 I 70*F Within 2 Hours and From 70°F 27. Physical Facility FC-0 007 to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-50L14(B) Cooling PHFs Made From Ambient 29. Special R uirements .003 Temperature Ingredients to 41°F/45°F 30. 1 Other _ ` Within 4 Hours* .s:stetnex<xc� *0.notes critical item in the federal 1999 Food Cafe a 105 CMR 590.000. V+ 5'^- +.- s'r.r..r-w.r.. . -11.�..5•}'tl��s'' ,..�e.d..-i..«1..�... .w,IF - +�.1'��:' ��f^_7:iw.. To-}-Er:. ,.i.�."n r,a•: an.�Ar+1r,`.>,i'� r Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'" Floor' 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name ( t/ / D t Tvoe of ion(s) Type of Insoection ( I )111 V ,0e 1 J ❑ Food Service [Routine Address Ri Retail '❑ Re-inspection Level Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner f ) HACCP YM El Temporary E] Pre-operation I<J or'c r VW%3 V(%3 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) r Time ❑ Bed&Breakfast ❑ General Complaint In: la(J ❑ HACCP Inspector JJ Out: I� Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. I 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 W''" �(PROTECTION FROM CHEMICALS e5s r F El2.Reporting of Diseases by Food Employee and PIC t=<< ' ; "+ ""i,`Y + • •l" a ° . �s� a r.�; ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded mom, � s�p .� ❑ 15 Toxic Chemicals FOOD FROM APPROVED SOURCE „„'° �� .,., _,„,. ,m ;„ � +MI ;,„„� "TIME/TEMPERATURECQNTROLS 114. Food and Water from Approved Source (Potentlaliy Haxardoua Foods) -s �i' -ry»..."» -.,-.".,,.aa aces~ w.:��-.� E,fua.m®; [�w�A,k+`Yc•..».«.,u....€ ❑ 5. Receiving/Condition El 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling f -��__ ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION" ,�y��`"' ,H,, 9 ... ❑ 8 Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing (iREOUIREit1 NTSFOR Aid H_ SUSCEPTIBLE PDPULATION I (HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices jCONSU,MERADVISORY. „"--',�..�s', El22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(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)7rdir, 30. Other DATE OF RE-INSPECTION�� S.SNMi ,dFmm-14.d. yt„7 vv Inspector's Signature: Print: PIC'sSignature: () _/. Print: W4k0r-,;,,j P- V, tom Page4_of Pages V Violations Related to Foodborne Illness ' Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge*- Cooked and RTE Foods* 2-103.11 Person in charge-duties �� Contamination from Raw ingredients 3-302.1.1(.A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590-003(,0) Responsibility of.the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection- 3-302.11 rotection*3-302.15 WashingFruits and Veeetables 590.003(F) Responsibility Of A Foci Employee Or An 3-3(M.11, Food Contact with Equipment and Applicant To Report To The Person In UECnsits* Char e* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Resetvice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Cc.antiliance with Food Law* 4-501.111. Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.11.2 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Hatable DrinkingWater* concentration and hardness. * 5=1.01.1.1 Drinking Water from an Approved System* 4-601.1[(A) F-dui,pment Food Contact Surfaces and 590.006(A) 'Bottled Drinking Water* Utensils Clean` 590.006(13) Water Meets Standards in 310 CMR 227 4-60211 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* E2-301.14 Methods of Sanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Clean Condition-Hands and Arens* Re ulato Authorit 3-202.18 Shellstock Identification Present* CleaningProcedure* 590.004(C) Wild Mushrooms* When to Wash* 3-201.17 Game Animals* 11Good Hygienic Practices Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges.From the Eyes, Nose and 3-202.15 Package hue i[ * Mouth* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tastin * 6 TagsfRecords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F) Preventing Contamination from 3-203,12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3.402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.1.1 Location and Placement* q Conformance with Approved Procedures 5-205.11 Accessibility,Operation and_Maintenance tHACCP Plans Supplied with Soap and Nand Drying _ 3-502.11 S ecialized Processhn Methods* Devices 3-502.12 Reduced oxygen packaging'criteria` 6-301.11 Hindwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301,t2 Hand Drvin*Provision ''Denotes critical item in the fedend 1999 foci Cale or 105 CMR 590.000. CITY OF SALEM / j ��I ✓1J \ lUfie+,ry $�n BOARD OF HEALTH Establishment Name:: I Date: [ ([ Page: of Item Code C-Critical nemDESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, No. Reference R—Red Item '(�1 VBrIT10QjA PLEAS PRINT-CLEARLY f L _ ryli� r;TYv ti S r f 4 - } i 1 a Discussion With Person in Charge:_ Corrective Action Required: LiNo CI Yes k 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 Ll Emergency Closure yourfoadpermit. T�A , - U"'l 0 Voluntary Disposal ❑ Other: 3-501,14W) PHFs Received at'remperatures Violations Related to Foodborne Illness Interventions and Risk According to La"•Cooled to Factors(Items 1-22) (Cont.) _ 41 W45`F Within 4 Hous. * _ PROTECTION FF;OM CHEMICALS 3-501.15 Cooling Methods for PHFs � 19 PHF Hot and Cold Holding 14 Food iv Color AOditi` ves 3-501.16(B) Cold PHFs Maintained at(it below 3-202.12 Adchtiacti"� 3-3021 f Additives' — 590.00r(F) 41`145°F' Poisonous or Toxic Substances 3_50lrA) Hot PFIFs M aintained at or above 15 `I 7-101.11 -j,-klentif mglnfotmarion-Qri.soai --{ 140"F. * _ Coat tnyte[Y` Rsbssts Held at or above 130"'F y t 102.1 1 a {�ommott S int 'X g k -.C o ti r ra" � -�- Time as a Public Health Control -- '-"--j °)+01 I lig as a Public Health Control' 7 20Li I I5'pa a¢an si;nak _ (- — --i )t).9pggH} l mange Ac uuemelit 't 202.11 Iyen.t.on-Pi.�,r u Fuld Faa" _.._.y.»._ 7-202.12 C.'_1tdnion<ofUSv- ---�-_� 7 'rostc f ontaincr P ohilviom' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE -204.11 Sunnesti criteria lhchuc is POPULATIONS HSP 7,204.12 Chunsc d5 h i )h t hu L cul�cc C me d_n�' 2 F i<Ol 1 9(A) t;npa teuriutid Pn. par d n cd Juices enc! Bcieta e.with u Nann 1ab..ls i 7-204.14 Tar}viF At eats.L n[et - - L"- ----II 205 11 htud t ntal t x>d ont xt dninti Ix � a t Sol 1'(B3 Ls of Pa tcunr<d k c s- 4i 7-206. 1 $o7 I i(i)) Ka .or Puiit m Fa� and ,c Pe nodes7 206A -- R Sc d prrnn tS^rut s 206.1 socl S- u«n, — a, k•'1 r ontr! to? s hCO1NSUME{2; rE l.xxi Pas .tom.. <si 3 cued. SORY YiME10EMPERATi HE CONTROLS a2 j 3{1 I i (.onsui er 1tt:isort PtKied f,srt nn .nnption of .-- — --1 imunai I ads Mar Firc its r Can uu hrd t; I t l6 Proper Cooking 7emparatures tar j '— _ PHFs 'Not r}the c isc t'r«c sv a g>s'u a xe :MITI 1 3Q2 t, � [mat h nt .isx�rrr i i 5 h + uiA,: k.+a sh,11�3 L i tnat rt 1» 7 . +ea. � ' .. ------ )tAS7-PECIAL,.�REQUIREMENTS lR.E4—EN_ S t�.i! a t r >cc rca a �"0"!: i) rav ' 1= Vi(lairv). of Se .t jt._'4�( Cg )(A .'H-_)_'nFvhltR'linc I 11` 1 .. i icrxna gni Cn1e icxs< willpiiial, t d t 3-40i_tI(A01'i 1 ' sur h11d C in Spiffed 1113F-s, of nalioi 4 Awilld i d,-+'m,,d u.idL'r the 3e{)rispuate s it, -is if Il L'.i] 1 )1 )(KflvFn F i F '-, i .r..�;.cr,vvs,s 3+i.1 .Fyk i<titP s. { t Rahrstsr for H }bsdirg { VIOLA TONS RELATED TO GCSb fiZ 4R i. F°f'ACTIC;E'S r,,i.'lltU` +Ili 1414 (P 't cc 1fe-nis23-30) 4G3.1 KBj ua seaw-]t r 2 Nitaw,Stndinr C,t zd 11"17 r _ta rt< U t c. ufch s!o uov e a ,Ar 1 r i s . nr Ili r r F v vcret r s wid n I rat tors I Fud s)OW,r_ c'(,n,irr i > 1f13.1J{£:j e .mun�s::ai!) E uc"[c'u P11 1' n:Ftm� ns,.,; s'u . a=..'.nc? turlC>de Fid sO, C;i3.%C i1v1 - )-9Ys0o 3-40x.11(j R m n ifl"L +tnc,yl Porr.w)s of 13ce1` Chem Good Rets iPracnoes FC 590.00h1 �2a c E�nan+anG_Uten i�ar FU I W4 i -` � 4 fr+ad d E o-xi f crier foo� fi } ppG �1g Proper Caoiing of PNFs E ?-501.14(A) ( t rndtn Cas7, dFHis frim 1 it t to n r}n+- - i >a s ddtcr p{t n G.. tf G'N ilfo i FC-5 �h) t s f 4;lhni 2 tour: azul From'01' 1 1s a fiat htF .__ FC r, , W7 ; Y R d m t N sat _ �28 r nos s�a is of zxi h^ for t; _ 1 rt_ 7 01. 3..501.1?(B) C ca!iu PH Al 1 Fro t An f ient i_ 't Spa, si - n ml r tune.h redur r IoLIIIAS'F "rthrr.uPkrnn. . 't Commonwealth of Massachusetts City of Salem erl e n Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 08/10/2009 ESTABLISHMENT NAME: Filipino Variety Store File Number:BHF-2009-000031 430 Essex Street#5 SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0540 Aug 10,2009 Dec 31,2009 $70.00 Total Fees: $70.00 PERMIT EXPIRES December 31, 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 r^ CITY OF SALEM, MASSACHUSET"T"S r � BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIM BERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENnAUM([7�3AI-EM.CONI DAVID GREENBAUM, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT f',AU IND V*IZIGT-1 W Kf TEL# �O'yD0'b ADDRESS OF ESTABLISHMENT 47yC F`stsrX SiU sm-"fl11, MA `0j Cl IV FAX# MAI LING ADDRESS(if different) 49 � wmp 1rq- %La1 "k offlb EMAIL- Business': Website: OWNER'S NAME K4T_V .IGK and, j0011060d VA"LSsf)j-C- TEL# `lis N"-00/9 ADDRESS 49 OKW AllE- �twi ,UA al`sy STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) gyp Y EMERGENCY RESPONSE PERSON G i� M CAJ I&?A L, HOME TEL#_""lO �S 11&0 ?DAYSOFOPERATION , .i :,Honda ,.' r,N'T,uesday; ,Wednesday w I , ;Thursday sc ,.,Fnday+ Saturd t i Sund/ay HOURS OF OPERATION q a_ t Please write in time of day. G_ /-. �Gm_ Ian 6 rP�-�—�v G 6 cAm 6 For example Ilam-11pm Lw Prim Al TYPE OF ESTABLISHMENT FEE check only) RETAIL STORE YES NO <f9s than 1000sq.ft. =$70 sq. . =$280 more than 1 0,000sq.ft. =$420 ----------------------------------------------------------------------------------------------------------------------------------------------------------------- RESTAURANT YES 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 CHILDCARE SERVICES/NURSING H — OME---- --------------------------------------------------------...------------------------. ADDITIONPERMITS MAKE (notjust 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. 1, - VOAI. A 8o;� - r7� ;Z}-OSU3�86 Signature Date Social Security or Federal Identification Number ---------------- ----------- -- -------------- ---------------------- Revised 424/07 FOODAP2008.adm Check#&Date U�G 7��_ $ V 4 CITY OF SALEM ��---� 1 �1 BOARD OF HEALTH Establishment Name: 't 1 1l,pwo 1��c tee#y ,��2, Date: ��10/0(::,i Page: of Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item : .Verified PLEASE PRINT CLEARLY _ faho0e ii�c� fion � nl, fwir:t ester bli�hm(;Af u )a I ' n 4�e it .11. 10;ep5 vvt u'-'t (Act-1k C,kids " Sicn t),) ri3nwi . 4�fOU 1( Q ( t JCQ � - 4l u(1 c �`,7Q� r O Cc.61P. n c ;w ( l� IC(�>✓ rJ t i 7 Yn J \ i A UXt al S 4 d zw �o i 1 I C' of 6, I,r4 (.t OL /Ih J le) bcr't" rc r) FS�GIItS tviAt 'v v, r Ct ( V c tce� e'eticl1l �o e fn liar to /� \C. U'D P \ Q-t- _ LL i�7 � `�c�/ N-./ �Y� i P S( U R_ I11 i . a reffo r - f 'X 6_()L1 rN r,. C�('4lt fll c,�t tS�IS� _ 9 n Gii 14LYA/l(w_ 1 z I� Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ k 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. h -(� u,.ic„ - (fn.'(, c ❑ Voluntary Disposal ❑ Other: C ✓ }-5U 1.14((`} PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to l aw Cooled to ' Factors(1teMs 1-22) (Cont.) 41=.F/4.5"F Within 4 How's. 3-501.15 Coolin Methods for PHFs - PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding 14 _ Food or Color Additives 19 Cold PHFs Maintained at m belnw 3-202.12 Add rives* 590 004(F) 41`'!45°F" 3-302.14 Protection frons Unapproved Addrtiees � 3-501 16(A' Hot PHFc Maintained at or above 15 Poisonous or Toxic Substances 1 1(11.11 1denU,ymg info)m sion--{)n io u ; St 140 F. x �Riraets Heid at or move 130"F,e ' --- 4) 1 ime as a Public Health Control I 'd'.11 1 Common Nanw Work-i 7-20 L 11 SvP 1 zuor15tur ,. .._� i� 1 ..__.. j I'm .its a Public,Health Control° i02.11 i Rc: t rt on Pr unci, u�' L 4U"(},f}1) 1 S ar-tR, atr 1nei,[�- 0 .1 Cbz(fimon: of tisk 7-20111 Toxic font rwlu -p ob bili ins REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 204.1'1 Sam r itis Critc i !'tenni fcPOPULATIONS(HSP) - st- 1't+1 Unplvteat tzed Pr pacligcd Ames and J4.i ('tt nuc tis fol vh ll.hl�g 1 o1lts.e C nt.-oa` - — ( Bcti•et, es Kith Warninglahcls*. t -04.14 Dr-millSt et ts.Criteria' 4 t ) 1 Pu tunind 1 r �-- - - �� 5H' 11 R ti, o _ i PS_I t Lu.tc at tl 1 >+x1 t ont7r t.L .bay a r . i6w or Pallial! C.�)KQd Animal I'tx;d and i°06.!1 2'��nul 1' tc 1'e n tGtt tde [ t- I - i-�=- -- { �Ra Sc d �1>rrnts Not Served --- n B t ti:aucros ! i g{;i i' { t („ r tsd t<<sxt Pac' NO R 1 , 106 1 I ra k r,P Vdr 11"h'.C'a)HI J and _ - ' oPno in I -- - ' CONSUMER ADVISORY _ TitAEICEMPERATURE CONTROLS r2 3 )0 11 C,onsum ( *«riso;v Pint,d lbr('cn minption of �..� vitas <l I it'd Ith lir derux>kcd tri 1 16 Proper Cooking Temperatures Fr`- or ( r �t-t QNi< xr'rcxcx tt Liss in-te j L_.�;�� _....F PHFs _._ - .—� i z 101.11 Sit r-s l I i x. 55 r 15 s c �. _...�. F c lmnx I ateSc[-(c,r l 517'i-?c�j :' t t meal dt F:Siibs t'ui_to; RauShOl 1-4 1') G m)i 1t., 'd r .h."-ie,.w r 0-is _ Anhv3i, _i ` + cis SPECIAL REQUIREMENTS '-401A B)(1,Q)� l Poll% trd H Rwx t - 110 3 l e l nun` � aJL_it 4'' 1 < E u_ort11 It o Se�tt� t IiJ.Jir) 1 - 1lj in 1 rKrm L ;<< oviet. ratrrr to nobilr tbod c .tp at ll.ld i s-dfrL111.A)':t1 i Pnuzry �1idCr,11 fite' iut'N6a: i ii Fetiiu nt titttcl3e� upcl-tin *, Itst1i113b j S i f Lig Cala ll 4,♦islt. Meal, Ili 3 ' .iPubivL lta?dCi flit 11,(tSC`;JT:Etfi .�c'.i{jS1,5' 15 i h G,laci 11r'q `aks tr;ter ._ars,ria..ra,: l:zefo s. C 1N- ' i t I", Fi heating for iiat Holdn�g - t VIOLATIONS RES,ATEV. TO GOOD RET,A& PRACPCES 11 T, it F r t - Items 23-34i 10t.11(H3 Miouru.avc. fr r Stntc Sl India, �r1 ) u t r tca2 r rtr ,i, which do rta < ar - fie tnr n ':ewd r'o;r_ "in be V)3.11(C) 1 t im nuaatly P ^i 1 1 s'a ( < a z t #,r a t,se • ;ill, Food Code ll'"I N , c l"k nl[t it 3.i 1(1) Stu t unmg 1n41r a�Pcx torn of t1 ret j tYem Good Retail Practices FC 9q---- P-ro 111 r 2+ 1-01 x' t d u->o P oict tlo� __ FG 3 CK)4 do tt S'Tictta tlP r ori^tl l r _. 1� - _ -1--P-roper Cooling of PHFs� -- 3 —R— -- i j _20 qrl,n r1 ,no Ute' �'s _ f 4 0a_ 501.141 A) Ctn.l-nt C`txt),.d PHI=s IT,n I4, Fll. 3 4'�afr '' tic' V n FC-5 "K,6 ` 4 : kucut 2 tlour� ld From m T)1' IL Y^y'/fii Fi 't11� FC-6i W( R, 4 F(4`"O N ithill How j PC 7 OOC__ 5W A4(b) ( r t t Ln_PHI;' IMv troll] 1ti3 ieui Sacs, a. F t..1r„Irpr1 OU8 j R n1 �tliiare h red:clu=slo 1 F,15 1 13301? ` '1vn 'n�cinoalu �, . is<I 1 ?ct iorxtf -_e o' 10`i t31t ;,'r!Y,. r 8 & 8 PEST CONTROL 271 Westem Avenue,'Suite 203 LYNN, MASSACHUSETTS 01904 (781) 599-4317 DATE TIME a IN OUT .WF EG. 4 1•TI E ❑ RES. COM/M. INDOOR ❑OUTDOOR Yw. J,4'C. ADDRESS .r. y� S CITY,STATE.ZIP Q `__ PHONE - SE 3 ORMED TARGET PESTS APPLI ATIONMETNOD - ❑ IN EeTION TREATMENT b"C iis C CAMOUNT E U BE " cd�¢ / q,\ ?f�' DESCRIP11PALESWAfto =30;::3 1 I `fi I I X'i�1 GPS C Ivla uc. of TO� L O- I C 5TOM R SIGNATURE �e L SERVICE REPORT 10801 a .. Commonweal"Massachusetts._ City of Sawn Board.of.Heatth.._ KMftfty DdsoDU 120'Washington Street,4th Floor )or SALEM,MA 01970 Food/Retail:Establishment,Permit DATE PRINTED: . 01{.p2{2018 ESTABLISHMENT NAME: Filipino-Variety Store' File Number.BHF-2009-000031 430 Essex Street.#5 SALEM MA 01970 LOCATED ATe' ' SALEM; MA- 81-}7{3., Permit Type Permit No. Permtrissmed"Permit Expires Fee Restrictions/Notes RETAIL FOOD BHF-2010-0318 Jan 12,2010. Dec 31,2010.. $70:00 T"Fees: ., -$70.00 PERMIT EXPIRES (December 31,2610" Board of Health This Permit is not transferable and must be reissued upon change.o£ownership-or location.The permit eaust•be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations„improvements„or equipment-changes are-made,all plans for such must be submitted to and approved by the Salem Board of Health. . page r �� • CITY OF SALEM, MASSACHUSETTS Jr BOARD OF HEALTH 120 WASHINGTON STREET,4";FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR DGREENUAUM&ALEM.COM DAN7ID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TiUPlNO Vt%70 Wfr,, TEL# 941- T"- 4090 ADDRESS OF ESTABLISHMENT. ESWX W 46 AIM, rYlh- affj0 FAX# MAILING ADDRESS(if different) M EMAIL- Business':_- �ill I_AA0J�ie�gq� (Cr�yPkn•C' Website: OWNER'S NAME LDttrdelyn VaIWr ? CAVA, R64, r K �a64 TEL# q32— V-009' ADDRESS gIfo11WO Yale- ymm Mk 0I93'D STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) �yr� EMERGENCY RESPONSE PERSON SNELL0 \f>;?11CU HOME TEL# D`A.YSOF,OPERATION'J'9j Mondays I Tuesday I Wesinasda, ;, ;, ,hursday,, �a Frtla' Satgtday x ySunday,- I'" HOURS OF OPERATION ((�� // / Please write in time of day. gam-b �t Iqa,-� �q..n-6 la"^-lo �a'^-�ryn -la'n, -6�n, a- rP For exam le Ilam-11 ! ' TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES/NURSING HOM-- ------------------------------------------------------------------------------------------------------------------------------- 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. .. —D5o ©8w Signature Date Social Security or Federal Identification Number. Revised 424/07 FO AP2008.adm Check#&Date $ CITY OF SALEM BOARD OF HEALTH Name of Establishment: Filipino Variety Store Address: 430 Essex Street Owner(s): Lourdelyn Valsote Phone: 978-741-0018 June 29, 2009 The owner of this proposed establishment presented plans for review in accordance with the State Sanitary Code. The floor plan is approved as presented. ITEMS FOR SALE All food items displayed and offered to the public must be from a source permitted as a Wholesaler from the Mass Department of Public Health. The wholesaler is Everlasting, Inc in New Jersey. The owner of this establishment must confirm that this wholesaler is licensed with the Commonwealth of Massachusetts. This establishment is a retail store only and all items for sale must be pre-packaged. There will be no food preparation, processing or packaging at this establishment. FLOOR PLAN All surfaces must be intact, impervious and easily cleanable. All refrigeration units must have accurate internal thermometers. Refrigerated food must be held at 41 degrees Fahrenheit or lower, freezers at 0 degrees Fahrenheit or lower. EXPIRATION DATES All expiration dates on products must be clearly visible. Out dated items must be promptly removed from display. TRASH Owner must present a plan for how the trash will be stored and disposed of. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. Any changes in operation, such as meat or cheese slicing, must be approved by the Board of Health. Outside area of premises must be kept clean and sanitary. Expected opening is July 22, 2009, owner must call the Board of Health one week prior to schedule an opening inspection. A`c�eckk and a Ycation have not been received. d �'G -Z David Greenbaum Date Acting Health Agent Lourdelyn alsote Date Owner F t C 0 i _ � 4 .�+. .S�iwWw..�.rwew+s. ax,.•. ..<.r,. !F.W'sl RF . "r7a I CERTIFY Tfol cowx ms V{Tb phi:. CI�tS AND RCGLi_ATl(:ri'. �' t Ti# .. RE6iSTS'RS OF 17;` -f MASSA(AknETT:'_ ....—... ... ._.-. TW 101HIN Pt e(lxr CICa' 4 x - Yt'E INMEi1.AT£... .�t. itwituG ••, •• _. wrs AND IT ?..,'P AND AMAMI,' ` ;LAvWl OF Tn a�,: � OCAr1TN QTN 1� �APPRO%tMTE + r .H 61 ix WA M+ AREALt. t.t N�0 € _HAS At'CESS ' DC '�DarE��[dN rt 1 t j fi pp �5 t1 ' Y1 i Q W wn g r � $ � i, i uWWi r ! 3 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs� Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name FT p Type of Operationis) a of Inspection i fZ Food Service Routine Address Riskt�etail ❑Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection ❑ Mobile Date: OwnerHACCP YIN El Temporary [IPre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint [-] HACCP Inspector 0 1. Permit No. ❑.Other Out: Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti-Choking 590.009(E) ❑ Items) Tobacco 590.009(F) ❑, Violations marked may pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. cJ�� rF0013 PROTECTION MANAGEMENT'' _ _ .__ .._ _ - . ❑12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities r'EMPLOYEE HEALTH ,PROTECTIO_NFROM`CH_EMICAL_S ❑ 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�F Food and ROy r from ACE. __ I TwE rEMPERATURE CONTROLS_(l?oteMlally Hazardous Foods) 1 ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 1.6. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18.Cooling _. M _. O -- 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION __ _e_� � _ , 9 ❑ 8.Separation/Segregation/Protection Y ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing .REQUIREMENTS FOR:416HLYSUSCEPTIBLE=P OPULATIONS';(HSt?)'_ El21. 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 23. Management and Personnel (FC-2X500.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3Xsso.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATEOFRE-INSPECTION: s o-re.da Inspector's Signature: Print: PICS Signature: Print: Page_of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT x ICross-contamination 7 590.003(.0) Assignment of Responsibility* 3-302.11(A)(1) I Raw Animal Foods Separated from Cooked and RTE Foods* 2-103.11, Demonstration of Knowledge* Contamination from Raw ingredients 2-1.03.11 Perron in charge--duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.0(l3(C) Responsibility of the person in charge to 3-302.11(.0) Food Protection* - require reporting by food employees and 3-302.15 WashingFruits and Ve etables applicants Responsibility - 3_,3{k4.11 Food Contact with Equipment and Applicant Responsibility Of A ra>d Employee Or An * Utensils Applicant To Report To The Person In Contamination from the Consumer Charge* 590.003 G Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Rescr ice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-701A I Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* _ 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Cem liance with.Food Law* 4-501.1.11. Manual Warewashing-Hot Water 3-201.1.2 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 EL-* - Sanitization Tem ratures*. 3-202.14 F,,=s and Milk Products,Pasteurized* 4501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Water from an Approved System* 4-60 t.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) _ Water Meets Standards in 310 CNIR 22.04` 4-602.11 Gleaning Frequency of Equipment Food Shellfish and Fish From an Approved Source Contact Surfaces and Utensils'&- 4-702.1( Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Cau�„ht Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703-11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSF Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wit!Mushrooms Approved by 2-301.11 - Clean Condition-Hands and Arms* ,Reautato. Authorff 3-202.18 Shellstock Identification Present'" 2-301.12 Cleaning Procedure* 590.004 C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1-1 - Good Hygienic Practices 5 Receiving/Condition 21101.11 Eating,Drinking or Using Tobacco* 3-202.11' PHFs Received at Proper Tem rahtres* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* - Mouth* 3-IOL11 Food Safe and Unadulterated* 3-301.'12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.t2 Shellstock Identification Maintained" Employees* - TagslRecords: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 Ca acities* 590.004(f) Labeling of IngredienW 5-204.11 1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 -Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 .Reduced ox gen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Confoimance wih A roved Procedures* 6-301.12 HandDrying Provision 'Denotes critical itear irorhe federal 1999 Faxf Cade or 105 CMR 590.000, Massachusetts Department Of„ Public Health Salem Board of Health M F 1 120 Washington Street,a 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. Namej G 1? I(u Type of Operations) Lype of Inspection 7 0 ,, c % I a Food Service fi] Routine -Address Risk ®'-Retail ❑ Re-inspection Telephone Level E] Residential Kitchen Previous Inspection ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ElPre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time E] Bed 8 Breakfast ElGeneral Complaint In 3K3Q ❑ HACCP Inspector (gyp 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) AntChoking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ S Allergen Awareness 590.009(G) ❑ corrective 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 El 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals POOP:FROM odandAPPROVED fromApE TwE/TEMPERATURE:CONTROLS(Potentially Hazerdous Foods) ❑ 4. Food and Water from Approved Source I! ❑ 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 ❑ 8.Separation/Segregation/Protection ❑ 20. Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing •REQU[REMEWTS FOR HIGHLYSUS,CEPTiBLE=POPULATION$;(N ❑ 10. Proper Adequate Handwashing I 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. 590.000/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 FFc-2xs90.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-sxsso.0o4) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4x590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FCsx590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6x590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. OtherDATE OF RE-INSPECTION: n Inspector's Signature: Print: PICS Signature: Print: - Page_of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 3-302.11(A)(1) Raw Animal Foods Separatedfrom 1 590.002(A) Assig went )no onsibilit * _ Cooked and RTEFaxis* 590.003(B) Demonstration of lit owledge"` _ Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302A 1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590003(C) Responsibility of the person in charge to Contamination from the Environment 3-302.11(A) Foul Protection require reporting by foots employees and 3-30115 Washing Fruits and Vegetables applicants* 3-301.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* To Report To The Person In Contamination from the Consumer Charge* 590003 G Reporting b Person in Charge* 3-306.14(A)(.B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-707_71 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces - 590.004(A-B) Compliance with Food Law* 4-501.11 I. Manual Warewashing-Hot Water 3-201,12 Food in a Hermetically Sealed Container* Sanitization Te ratures* 320'1.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 _t,, and Milk Ptvducts.Pastetirized* 4-501.114 - Chemical.Sanitization-temp.,pH, 3-202.1.6 lee Made From Potable Drinking Water* concentration and hardness. * 5-101.11 Drinking Water from an Approved S stem* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bathed Drinking Water* Utensils Clean* i 4-602.11 Cleaning Frequency of Equipment Food-- 590.b06(I3) Water Meets Sbineards in z„l0 CMR 22�_.0 c� P Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.1 i. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught tvlollma,a Food Contact Surfaces oi'E ai meat* She1L`ish* _ 4-703.11 Methods of Sanitization-'Hot Water and 3-201.15 Molluscan Shellfish from NSSF Listed Chemical* Sources* Game and Wild Mushrooms.4pproved by 10 Proper;Adequate Handwashing Re ulato, Aullront 2-301.11 Clean Condition-Hands and Arms* 3-202.13 Shellstock i'dentfication Present* 2-301.12 Cleaning Procedure* 590.004 C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.1.t PHFs Received at Proper Tem eranues* 2401.12 Discharges.From the Eyes,Nose and 3-202.15 Package hue,it * - Mouth* .9-707.]t Faod Safe and Unadulterated* 3-30L12 PreventingContamination When Tasting* 6 TagsiRecosds:Shelistock 12 - Prevention of Contamination from Hands 3-202.18 Shellstock Identification* I 590.0(A(E) Preventing Contamination.from 3-203.12 Sheflstock Identification Maintained" Employees* - TagslRecords:Fish Products 13 Handwash Facilities 3-402.11 - Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacifies* 590.004(7) Labeling of Ingredients' - 7. 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Praxssin Methods* Devices 3-502.12 Reduced ox gen acka'ng,criteria* 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with A roved Procedures* 6-301.1.2 Hand-Drying Provision *Denotes critical tram in the Weral 1999 Paxl Code or 105 CMR 590.000.