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GENERAL NUTRITION CENTER - ESTABLISHMENTS (en<f4( rufW;u Cn)er 3io btu AVMVO ttt�j � i Lniversal one. www.myuniversalop.com phone: 1-800-756-4676 UNV16162 MADE w Ass 1 I i Commonwealth of Massachusetts x ` 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: General Nutrition Center#5310 FileNumba:BHF-2004-000143 300 6th Avenue,Retail OP Pittsburgh PA 15222 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0062 Jan 1, 2011 Dec 31,2011 $280.00 Total Fees: $280.00 PERMIT EXPIRES December 31, 2011 Board of Health I� � (Ally This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 . CITY OF SALEM, MASSACHUSETTS + BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGRcf:..1v1;AUN12SAI.FM COM DAVID GREENBAUM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT IT,yO,�OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT G�i✓W-V 41W;1'/Tl0/� �N S3/d TEL# q7g ��' 2444 ADDRESS OF ESTABLISHMENT '?AeW-ZWS_C-- RbF.54Lf_—A,/r1AD(97oFAx# `f1a-33& ' 8878 Hach MAILING ADDRESS(if different) 3,0�6SIKr-BxfoE ��C 4- EMAIL- EMAIL- Business': Website: -WWW• �a rJC Cc�M OWNER'S NAME 6C-&6P4Z_ AJtA7-yj�TLoA) �R-i� —TEL# 4Q —4(c(o e- ADDRESS 3c-0 SC�t( tR7rsott Cy N, lSadd STREET ° CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) (6`63)'493 -9169 -/-,� y ,y EMERGENCY RESPONSE PERSON �/�e0N P/A49,6 HOMETEL# 16`63)'` 93-9169 DAY.S;OF OPERATION ION€ ''Monday r :e Tuesda�r: 'hWednesdayr. .Thursday Fnday �'Saturda _ ;' '_. ;:'Sundaay r ;v HOURS OF OPERATION j Please write in time of day. For example 11 am-11 m j ]w[M_ I'•• �I/H I]0-/�Tk1� pM l b/YM— irl 16RYr1 rf{�M 16/Vn /YI ]o2IJtC1n1— M TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. =$280 more than 10,000sq.ft. ---------------------------------------------- ------------------------------------------------------------------------------- -5----------------------------- ----- RESTAURANT YES �� less than 25 seats =$740 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------------------------------------------------- -------------------------------------------------------------------------------------------- BED/BREAKFAST/ YES $100 CHILDCARE SERVICES/NURSING HOM--------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE YES 4tig> $25 TOBACCO VENDOR YES CNel,�, $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 n d paid all taxes rgeuircd under the law. -�- �r�C//te� 1a-a-10 a5-t /a45174- Signature Date Social Security or Federal Identification Number -------------------- Revised 10n1I1 FOODAP201 I.adm Check#&Dat 3 90 t5 q $ � /�z-� ,-/lb y w♦•- ° .. `!A^,c'i -+-`s+1 a r R tbr'..{w,.i•�t.re4ri..w �}n ... . .Y z'�+'tirz'r:Jy:•y!n.;4;vr.Kn.rd"4dYM.,y`R.ti't',r(`�� i'�' A_ 'y^f's^ = _ . 5 Massachusetts Department of Public Health salem Board of Health Division of Food and Drugs 120 Washington Street,4th Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name /� I Dae T of 0 eration(s) Type of Inspection ( Ynr r v� r n fC� - 4 ❑ Food Service W Routine Addressro �� Rik Retail El Re-inspection Level Residential Kitchen Previous Inspection Telephone ' ❑ Mobile Date: Owner HACCP YM El Temporary [3 Pre-operation C ? ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In; ��. E] HACCP Inspector �r Out: ' ` Permit No. El% Other Each violation checked fecluires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 59o.00g(F) ❑ action as determined by the Board of Health. E FOOD PROTECTIQN MANAGEMENTS" ,w ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities LEMPLOYEEHEA.. m ®." .,�. .,.a.: ., ,-u" r `+"PRQTECTIONFROMCHEMICALS�€F ' ❑ 2. Reporting of Diseases by Food Employee and PIC mss»- •� -� M� �� sreh T�ea e El 14.Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals y F004 FRO,M'APPROVED SQUiiCE t" 4«� „ E] 4. Food and Water from Approved Source 77ME7TEMPERATUREOONTROLS(Potentlatly H3zardqus Fdcds) "a T 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION =;"" ""'�_ '°? ❑ 19. Hot and Cold Holding .I- 5"`_ 'R r r, z ❑ 8 Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing R QUIREMENTSFOR HIGHLY S0 dlI_T1 fi,P(PULAT(QNS(NSP) ... ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices 0C641§UMERADVIS6RYTa') 'm.,were',°° ❑ 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 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-a)(sso.00a) 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)(591.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s:ssoiospo o m 14,m Inspector's Signature: I Print: PIC's Signature: /� Print: 4 4e E Z� �C Paged ofZ Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A I Assignment of Responsibility* 3-3011I(A)(1) Raw Animal Foods Separated from 590.003(13) Demonstration of Knowledge* Cooked and RTE Fonds* 2-103.11. Person in charge-duties Contamination from Raw Ingredients 3302.11(A)(2) Raw Animal Foals Separated from Each EMPLOYEE HEALTH Other'r 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by foot employees tmd 3-302.11(A) Food Protection` a rlicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-30,11.11 Food Contain with Equipment and - Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charee* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food - 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590A04(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Foal in a Hermetieall Sealed Container* Sanitization Tem eratures* 3-20113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shelf EW* Sanitization Tem eratures's 3-202.1.4 E as and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.11 Drinking Water from an Approved System* 4-601_17(Aj 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- ShelNlsh and Fish From as Approved Source Contact Surfaces and Utensils 4-702.11 Frequency of Sanitization of Utensils and 3-20114 Fish and Recreational'ly0aught Molluscan Food Contact Surfaces of u went* Shellfish* 4-703.11 Methods of Satritization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.1an.1. Clem Condition-Hands and Anus" Regulatory Ipato Authority 3-202.18 Shellstock Identification Prescm* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* r 2-301.14 When to Wash* 3-201.17 Game Animals* t1 Good Hygienic Practices g Receiving/Condition 2401.11 Eatin ,Drinkin or Using Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contatrination When Tastin * Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-40111 Parasite Destruction* Conveniently Located and Accessibie 3-402.12 Records.Creation and Retention* 5-203.11 1 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility. Operation and-Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3--510032..11 S k Methods* Devices 3-5021122 Reduced Oxygen 2aca"nom,criteria* 6-301.11 Handwashing Cleanser,Availability Conformance with A roved Procedures* 6-301.12 Hand D Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590000. I CITY OF SALEM - BOARD OF HEALTH I Establishment Name: Gn��uy (y� l��, . �� Date: sl ia� �u 4 Page: of ) i DESCRIPTION OF,VIOLATION/PLAN OF CORRECTION _ Date ` Item $ Code C-Critical Item �. .; 'No.' ` 'Reference' iR 'Red Rem `' Verified" y v w PLEASE PRINT CLEARLY 1 c 5_A43/A S14 city J e v .v - I ! U i 1 hf`a.R )_�>,lYeSJF C� : � ��U•5d-01-,c Cf�y57 r�AQs ckJl 156 v ('vtJc � .Su(i 119, . pr* _ O� j r - �/ C `f)7>GVCj,4 SIAUA K _Z vI i e � � Or _r} . i F f E ? l / Cor Discussion With Person in Charge: Corrective Action Required: ❑ No ;❑ Yes � 1 have read this report, have had the opportunity to ask questions and agree to correct all rpn�Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: fakif's Reunved at Temperaturesto Violations Related to Foodborne fitness Interventions and Risk Amerdin.,to Lio% Cooled to Factors(Items 1-22) (Cont.) 4 1'F/45F Within 4 Hole s. PROTECTION FROM CHEMICALS PHF Hot and Cold"ding L!4 Food or Color Additives 3-501J6WE) i-20212 Addnnc,° 590,0()Aff; 4 1�/45r Fx 3-302,14 Poltection firomnIll La nlved Addhlvcs'-- 17 ------- Poisonous or Toxic Substances 3-501.16(A) I tot PHI shunforned at or above 7 141.11I T Identifying Infonnation -Ori.mal Hc1d 41, 1�1111 1 Time as a Public Health Control ComralojOw.nae-- A orki��mt�iularl- 02,11 T;hfic Health Conaroll 3-501 19 Timc,as a 7-201.11 T� Variap qEanrli':aaa-,��R ireoletu .202,IT R(��tnction -Prestnco aud tl�e* ---7 7-202,I2 Cleldiflom if Use' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7203-I1 Toxic ConlaftaoPOPULA IONS(HSP 7-204.11 salliti7erN,Criteria-Chemicals* d hoc"'aI� 21 3-80 1A I(A) 1:npasieurized Pre-pack-8g, 7-204.E Chemicals for cta� 7-204,14 Be.veeaats with Waram, ;ASCUI I(fl, ljw at Pa,,tlalrized Emll- 7 205.1 i IncidevAl FX)d C'OraaM 1,0111 Wanti' Raw or Food aild [2-206 ReMrieted U'&U ("Thelia, Raw Sred k7-206.12 Rellew Beit Stahit)TW -L'a-fin—di -s 72061_ 1 Tracking Powdem faPi Control and CONSUMER ADVISORY 2 3 0 1 ciswdfor Cullsmulptionof TIMEITEMPERATURE CONTROLS Anitiall FlNl& Thai I are Raw, Undenxx)ked ill 16 Proper Cooking Temperatures fo�-- PRFs Not Otticl-wise Processed o Elbill"ale 3-.101.1 I A(1)(2 T, 1 S,5'F 15 SlAbslituw 1�,i P,,lw Shell 152 --T401 INA)(2) Comminuted Fish,xfcat�&Game Annuals L„"F le stc. SPECIAL REQUIREMENTS J 461 1 ITB)(I)(2) T(,,T and I4 of Roast 130"1-' 12F minx 590J)09(A (D)T T401.I I(AR?) Rattles,bilievicki Melds - 1 5 F 15 1 ! Su catteringmohikfilod, ternportuy and r� 4(ll 11(A)(3} Ponhr.,Y,Wild Game, Solfed remdent'al kitchen operations should he Soilluic Conwnina,Fish,Moat, dehiled under tile appropriate seetiolls Perdtn or 'U", ,,, I ,,SM above if rehhed to foodhortic illnoss 3-401JI(C)(3) Nvilde-tolecle.Intact Itce'l"Steakii nitcfvehtiows a-,)d rkk fariorli. {)flier 145'T 1 590.009 violluiooti relatin.0 to mood retail I Alronal 17�li�,%Cooked ill a 401 12 practices hoold lie debited under 1129 - Miciowave 165 F spccla[ Requirclnonts. � 7AII Othei 1451715 scc- L17 He- aling for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES I-i5T1i-(,A)-&(1T)-- (Items 23-30) 3-403.11(B) Microm avc- 165'F 2 Mini Te Standing Criw-al avd cion,riot:af lioialhoni, whil:h do noT relate:)th, foodborne illness i irervelmora and rokfa,riors fisted abm;e, tins be 3-403.1- filund in drefc4lowing sec!toro(,,;f the Fol,d Code and 105 C,111? 140'P,` --- Willaillin. unsileed Portions of ficef ttom Good Retest PracAets QFC 5300b0 Ruasis CXoasls* -23, Managrimcril and Peronnel FC -2 I .603 tg 24 Foodind Food Protection FC--' 311 -,004-1- I . -� Proper Cooling of PHF& --7-1—fp---n-—d- � 'A_ae� 4 '005 501,14(A) Cutling Cooked PHI-'s fr(;n J,t)-F of 25------,'Ec _j�oL FC 26 i Vkhater.,piumbal 'T I aste i FIC-5 W6 7WT7 Within 2 Hours laid From 70`F 27 Flhpwd Facility to 41'F/45"F 1kqthm 4 Rours. I 122 , Fniisonous or Tooc Matevals _LFC -7 00& 4(B) (falling PHR Made From Ambient009 Tctirpur erate Ingredients to 41 OF/45,I" --------- Within 4 IRAMI,� Denotes uilh:at a0m in the faLl-'Tal 1999 Foix?Codecs RIS CIMR 5T)000, i - Commonwealth of Massachusetts s s City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 i Food/Retail Establishment Permit DATE PRINTED: 01/11/2010 ESTABLISHMENT NAME: General Nutrition Center#5310 File Number:BHF-2004.000143 300 6th Avenue,Retail OP Pittsburgh PA 15222 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes RETAIL FOOD BHP-2010-0174 Jan 4,2010 Dee 31,2010 $280.00 Total Fees: $280.00 I PERMIT EXPIRES December 31, 2010 Board of Health Ir/ �r � l This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS e BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DFZCOLL FAX(978) 745-0343 MAYOR DGREENBAUMQSALEM.CONI DAVID GREENTBAum, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT /TO OPERATE A FOOD ESTABLISHMENT l��M � NAME OF ESTABLISHMENT 60 Q0N 06VZZ453/0 TEL# q 78- 7-41- x444 ADDRESS OF ESTABLISHMENT q 1�fj'/r 4 A:-,y`,515ZDFAX# 4I� ,3 3&-Eg 7g Y �Q MAILING ADDRESS(if different) �o ,5l,T744f�- &TXhIL 1)yP.5, f1Ti36L1a4, PA 16��a EMAIL- Business':gnQ• �I�Website: ) llyyy , 6AIC, GDM OWNER'S NAME "AfAL AIU7- I7707J 0DA10 TEL# a 4f --299-4 ADDRESS 300 <51Y7-H A1/� , ET736ttxG//. Prol Saaa STREET „�� CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) /i //� CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON A201-4 V)/SVA 2—b HOME TEL# 4Q-7Z(r - 1 t_1—> / DAYS�QF OP,E-RATIQN mea",'ctiMontlay�, Tuestla t""��+c„Wed�tlay '� `� hursday '`� Fr)"tla "Satuldayt �' Sunday`��' HOURS OF OPERATION ; lDAyvl D A-M `f b Please write in time of day. 'For example Ilam-11 pm I (x/17 I (pT TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 � / 1000-10,000sq.ft. =$28011 more than 1 0,000sq.ft. =$420 - ---------------------------------------------------------------------------------------ie-s-s---------------------- ---- ----- RESTAURANT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------Y-------ES------id $---10-------- BED/BREAKFAST/ NO 0 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of Perjury that I,to my best knowledge and belief,have filed all state tax returrys,and paid all state taxes required under the law. c�75 Signature Date Social Security or Federal Identification Number. Revised 424/07 FOODAP2008.adm Check#&Date `-(�� R T Commonwealth of Massachusetts s a City of Salem Board of Health lGmberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: General Nutrition Center#5310 File Number:BHF-2004-000143 300 6th Avenue,Retail OP Pittsburgh PA 15222 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0180 Dec 23,2008 Dec 31,2009 $280.00 Total Fees: $280.00 PERMIT EXPIRES IDecember3l, 2009 Board of Health /-Alp This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 ti. • CITY OF SALEM, MASSACHUSETTS ' BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR )DIONNE&S,ALEN1.COM JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT f� NAME OF ESTABLISHMENT l6AMaL 1VU('IZIT7W 0647befS310 TEL# ADDRESS OF ESTABLISHMENT 9 PA2AT>i S6 TD FAX# MAILING ADDRESS(if ,,diifffer�ent) ✓?00SlKrff�iil?�"IL [�i`�fL9'T(On)Si ��g(t(LC61 ¢} lsaaa EMAIL- Business': ROjE�/Jnt�'t INR@�h1^' C website: WW►NI .1504C NA1y1 OWNER'SNAME 6ti "AL NI {TRIT740n1 Cp2P TEL# ADDRESS 300 9111_ - A"VE IPG 4 r 19 ISaa a� STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) 4A- CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) ,( EMERGENCY RESPONSE PERSON A•A'2otJ P1 Nit z-b HOME TEL# 4(Z'`730-1 (51 DAYS OF OPERATION. , `IMond -' Tuesday: , Wednesday . Thursday Frida Saturday Sunda HOURS OF OPERATION /g rV\� Please write in time d day. (Forexample llam-llpml 47OMPF j S pM TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO . less than 1000sq.ft. =$ 70 1000-10,000sq.ft. 280 more than 10,000sq.ft. =$A20 4ES?P.URANT YES less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 2-99 seats =$280 more than 99 seats =$420 -------------------- $- ---------------------------------------- ------------------------------------ BED/BREAKFAST/ YES NO 100 CHILDCARE SERVICES ---------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns nd paid all state taxes required under the law. ir- t�-o Fl as - I (a457-e Signature Date Social Security or Federal Identification Number ---------------------------q-moi - ----------------'---------------------------- Revised 424/07 FOODAP2008.adm Check#&Date POW y /5wz $ Mayo Clinic Proceedings Page 1 of 7 MAYO CLINIC Isearch the Journal 4 search W Advanced Search> ayo C inzc IF'roceedings Home Current Issue Past Issues Reprints Submissions Subscriptions I F Permissions About Us Download to Citation Manager In PDF version of this article >Create account Ii MAYO CLIN PROC.2005;80:541-5450 2005 MAYO FOUNDATION FOR MEDICAL EDUCATION AND RESEARCH >Log in CASE REPORT NEW.Journal CME Ischemic Stroke Associated With Use of an y Ephedra-Free Dietary Supplement Containing E-mail Alert S l, tll �— lYJMedia request /i NICOLE C.BOUCHARD,MD;MARY ANN HOW LAND,PHARMD;HOWARD A.GRELLER,MD;ROBERT 5.HOFFMAN MD; LEWIS S.NELSON,MD \Fmm the NYC Poison Control Center, New York,NY(N.C.B.,M.A.H., R.S.H.,L.S.N.);Department of Emergency Click here to submit your Medicine,New York University School of Medicine, New York,NY(N.C.B., H.A.G.,R.S.H.,L.S.N.);St John's manuscript online 17r University College of Pharmacy,New York,NY(M.A.H);and Bellevue Hospital Emergency Department New L - p�_` York, NY(M.A.H) _--- ! MEDopportumhez.com,i Presented in part as an abstract of the European Association of Poison Centers and Clinical Toxicologists J (EAPCCT)XXIV International Congress, Strasbourg,France,June 1-4, 2004. FREE CONTENT {{,� Individual reprints of this article are not available.Address correspondence to Nicole C.Bouchard,MD,NYC Articles older than 6 months ,tk�l Poison Control Center,455 First Ave,Room 123,New York, NY 10016(e-mail:nbouch3@hotmail.com). are available without '(1��ii ''aq registration to all Web site 'A� ��a Abstract visitors % In response to concerns regarding the safety of ephedra-containing dietary supplements,manufacturers Learn more 5 n have marketed"ephedrafree"products.Many of these contain synephrine,a sympathomimetic amine Pas[Issues �A6 .)1 from the plant Citrus aurantium.Synephrine is structurally similar to ephedrine and has vasoconstrictor properties.We describe a 38-year-old patient with ischemic stroke associated with an ephedra-free Supplements dietary supplement containing synephrine and caffeine.The patient presented with memory loss and unsteady gait after taking 1 or 2 capsules per day of a dietary supplement(Stacker 2 Ephedra-Free)for 1 Editorial(s) Week.He had no notable medical history or major atherosclerotic risk factors and took no other Letters to the Editor medications.Physical examination showed a mildly ataxic gait and substantial impairment of both concentration and memory.Computed tomography and magnetic resonance imaging of the brain Residents'Clinic Ike showed subacute infarctions in the left thalamus and left cerebellum in the distribution of the Medical Images arr�1 vertebrobasilar circulation.Other causes of ischemic stroke were evaluated,and findings were unremarkable;a vasospastic origin Was considered most likely.The patient Was discharged with nearly Art at Mayo Clinic L+ complete resolution of symptoms.Synephrine,a sympathomimetic amine related to ephedrine,may be Historical Profiles of Mayo associated with ischemic stroke.Consumers and clinicians need to be informed about the potential risks of ephedra-free products. C--1 Clinic /� ' Commencement Address Mayo Clin Proc.2005;80(4):541-545 cejv Stamp Vignette CNS=central nervous system;ED=emergency department;FDA=Food and Drug Administration Book Reviews �- 1 v Of the$37.1 billion spent by Americans for weight loss products and services in 2001,$17.7 billion was spent for Courses and Meetings dietary supplements.Spending for weight loss is estimated to increase at an annual rate of 6%to 7%.1 During Order Forms PA the past decade,there have been hundreds of reports of severe neurologic and cardiovascular complications Advertising Information associated with use of ephedra alkaloidcontaming supplements. Nearly 1000 suspected cases of ephedrine Professional http://www.mayoclinicproceedings.com/inside.asp?AID=881&UID= 7/14/2008 Mayo Clinic Proceedings Page 2 of 7 toxicity from me huang(Ephedra sinica),reported to the US Food and Drug Administration(FDA)between 1995 I Opportunities and 1997,were reviewed extensively.'In 2000,Haller and Benowitz3 published a similar review of 140 ephedraassociated adverse events that were reported to the FDA.Both reviews identified serious neurologic and cardiovascular sequelae associated with ephedra use,including stroke,myocardial infarction,seizure,and M Article Feeds sudden death?'3 In December 2003,the FDA announced that ephedracontaining products were considered loo unsafe for unregulated sale.4 A ban on their sale was announced in February 2004 and was enacted on April 12,2004.5 It Neoplastic Hematology: is likely that a combination of the FDA ban on ephedracontaining products in the United States and the"bad Diagnosis and Treatment press"regarding safety concerns about ephedra led manufacturers worldwide to develop"ephedra-free"products _ as alternatives.6 The ephedra ban does not preclude the use of other structurally related sympathomimetic ;ror_�r amines in products for weight loss and energy enhancement.Despite little supporting evidence,ephedra-free products are portrayed almost uniformly as a safer alternative to ephedra.Synephnne(also referred to as p- synephrine and oxednne),7 is a sympathomimetic amine derived from the plant Citrus aurantium.8.9C aurentium (previously called Fmctus euranth)is known commonly as bitter orange,Seville orange,green orange,sour orange,or zhi shi.In traditional Chinese medicine,synephnne is used frequently to stimulate overall gastrointestinal function and as a general tonic.Synephrine has become the most frequently used ephedra replacement in dietary supplements and is listed often as"extract of C aurentium"or"extract of bitter orange." ,_. .,....„ As an indirect-acting sympathomimetic amine,synephrine has structural and pharmacological similarity to This 192-page,soft-bound ephedrine and phenylpropanolamine,both of which have been banned from sale in the United States because of collection reprinted from their association with adverse cardiovascular events(Figure 1).A recent case report described an association Mayo Clinic Proceedings between acute myocardial infarction and consumption of a synephrine-containing supplement.1I Another recent provides state-of-the-art case report described exercise-induced syncope associated with QT prolongation in a young,otherwise healthy diagnostic and treatment woman who was taking a synephrine-containing product(Xenadrine EFX).11 We describe a patient with ischemic guidelines for practicing stroke associated with short-term daily use of an ephedra-free product that contained synephrine,which,to our oncologists and hematolo- knowledge,is the first reported occurrence gists and should be useful as an adjunct to national board review courses. To order your copy today 91i OH Click Here Ali cor CHI t i ig Chi, Liphcdrim phcnylpntpgnntun:inc Oil .A Id N119 �_J V. G1F1 IIC1 symphrinc A.mphculniinc FIGURE 1.Chemical structures of synephrine,phenylpropanolamine, amphetamine,and ephedrine. REPORT OF A CASE A 38-year-old man presented to the emergency department(ED)with recent onset of dizziness,difficulty in concentrating,memory loss,and unsteady gait.He had no notable medical history,no major risk factors for atherosclerotic disease,and no family history of atherosclerotic disease;he had been taking no long-term medications.The patient had a remote history of light cigarette smoking(approximately 5 cigarettes per day)and used no alcohol or illicit drugs. For 1 week before presentation,the patient look 1 or 2 capsules per day of the weight loss dietary supplement Stacker 2 Ephedra Free for mild obesity(he was 5-7 kg overweight).This dosage was less than the 3 capsules daily suggested by the manufacturer.According to the container label,each capsule contained 6 mg of synephrine and 200 mg of caffeine alkaloids(kola nut extract).The patient denied taking other medications or herbal preparations that week or in the recent past.During the 4 days before presentation,he experienced several episodes of"dizziness"and had trouble"thinking."Three days before presentation(a Friday),he http://www.mayoclinicproceedings.com/inside.asp?AID=881&UID= 7/14/2008 Mayo Clinic Proceedings Page 3 of 7 increased his dosage from 1 to 2 capsules daily.Later that day,the patient experienced a severe"ditty"episode associated with brief loss of consciousness.This event was not associated with postural change,diaphoresis, chest pain,or palpitations.On Monday morning,the patient noted a transient episode of diplopia,which resolved after 30 minutes.He described"not feeling right"that morning and had difficulty ambulating and locating his keys.While at work as a city bus driver,the patient was unable to recall the details of the bus route that he drove daily.He came to the ED directly from work.He continued to take 2 capsules per day of the dietary supplement until presentation to the ED. The patient's initial vital signs were as follows:blood pressure,120n2 mm Hg;heart rate,56 beats/min; respiratory rate, 16/min;and temperature,36.0°C.His blood glucose level at triage was 95 mg/d L,and electrocardiography showed a normal sinus rhythm at 50 beats/min with a corrected OT interval of 430 ms.On physical examination,the patient appeared alert and was grossly oriented to person and place.He showed mild ataxia with a slightly wide-based gait and had difficulty performing tandem gait.He was right-hand dominant. Although joint position sense and temperature sensation were intact,the patient experienced postural instability when standing with outstretched arms.Fine finger motion exercises were better on the right hand than the left, and results of rapid-alternating-motion and finger-to-nose exercises were normal.There was no dysfunction in the territory of the cranial nerves,and strength and reflexes,including Babinski sign,were normal and symmetrical throughout.The patient could not recall his own or his wife's birthday,the current year,or the names of famous public figures.He also described difficulty concentrating and was unable to perform the serial 7s test. He was able to read and comprehend.Computed tomography of the brain performed within 1 hour of presentation showed acute to subacute infarctions in the left thalamus and multiple infarctions in the left cerebellum(Figure 2).These infarotions were in the distribution of the vertebrobasilar circulation.Magnetic resonance imaging performed shortly afterward confirmed findings of recent thalamic and cerebellar infarctions (on diffusion-weighted images)and showed an additional infarction of indeterminate age in the temporal lobe (Figure 3). y� FIGURE 2. Non—contrast-enhanced computed tomograms of the head show - multiple subacute infarctions(white arrows)in the left cerebellum(left,middle)and left thalamus(right). r Findings from routine admission laboratory analyses,including a urine toxicology screen for commonly abused drugs,were unremarkable.The erythrocyte sedimentation rate,hemoglobin A1c level,serum lipid profile,serum homocysteine level,coagulation studies(including thrombin time and fibrinogen),and thrombophilia panel (including antithrombin,protein C and protein S,factor II and factor VIII,factor V Leiden/activated protein C resistance lupus anticoagulant/Dilute Russell Viper Venom Time)were all normal.Results from an extensive evaluation for ischemic stroke,which included transthoracic and transesophageal echocardiography and carotid artery Doppler ultrasonography showed no abnormalities.Furthermore,magnetic resonance angiography of the intracranial and extracranial cervical(neck)arteries showed both normal course and caliber of all vessels, including vertebral,basilar,and posterior cerebral arteries. The patient made a nearly complete clinical recovery with only residual,mild,subjective impairment of concentration and was discharged after approximately 1 week with aspirin and immediate-release dipyridamole. His discharge diagnosis was ischemic stroke,presumably of vasospastic origin,probably secondary to synephrine.The patient was advised to discontinue use of that supplement and to avoid other dietary supplements for weight loss or energy enhancement.Although a follow-up appointment was arranged,the patient did not return and could not be reached after hospital discharge.This case was reported to the FDA Med Watch program.12 The case also was reported to the manufacturer,who indicated that no similar adverse effects had been submitted to them regarding synephrine-containing products(D.Caldwell,oral communication, January 2005). http://www.mayoclinicproceedings.com/inside.asp?AID=88I&UID= 7/14/2008 Mayo Clinic Proceedings Page 4 of 7 P � 1' r� ( JJ FIGURE 3. Magnetic resonance images of the brain show multiple subacute infarctions(white arrows)in the left cerebellum(left,middle),left thalamus(right, a),and left temporal lobe(right,b). DISCUSSION The multivessel distribution,stuttering clinical course,and nonnal magnetic resonance angiography in our patient could be consistent with a diagnosis of stroke of vasospastic origin.Onset of the patient's symptoms of dizziness,gait instability,memory loss,and cerebral infarctions coincided temporally with his ingestion of a synephrine and caffeinetontaining weight-loss supplement.On presentation,electrocardiography showed no notable OT prolongation,but a dysrhythmic event leading to hypotension,dizziness,and syncope could not be excluded.However,it is highly doubtful that such an event could produce the pattern of infarction seen in this patient.No other etiology for his stroke was identified despite a comprehensive evaluation;moreover,the dietary supplement was the only vasoactive medication in the patient's recent medical history. 4 - NI-1, a 4 FIGURE 4.Generic sympathomimetic phenylethylamine structure with activity alteration. See Table 1 for details. Dietary supplement manufacturers suggest that synephrine has fewer undesirable central nervous system(CNS) effects(eg,less nervousness,jitteriness,anxiety,tremor,and insomnia)than ephedra.Internet resources for the general public describe C aurantium as an herbal supplement that directly stimulates fat metabolism,suppresses appetite,and increases metabolic rate and caloric expenditure without negative cardiovascular adverse effects.1316 Other direct-acting and indirect-acting sympathomimetic phenylethylamines are well known to cause peripheral, coronary,and cerebral ischemia from vasospasm.In the largest review of me huang(ephedrine)—associated adverse cardiovascular effects, 16 strokes were identified,of which 75%were ischemic and 25%were hemorrhagic.2 Vasospasm can occur in large cranial arteries or in small arteries in the microvasculature and can be evenly and/or unevenly distributed.The deleterious effects of vasospasm can be exacerbated further by sympathomimetic-induced platelet aggregation. TABLE t.SUMMARY OF A AND B CARBON,AMINE AND AROMATIC RING SUBSTITUTIONS IN SYMPATHOMIMETIC PHENYLETHYLAMINES,AND THEIR ASSOCIATED PHARMACOLOGICAL AND CLINICAL EFFECTS' Substitution Pharmacological effect Clinical effect a carbon Resists oxidation by monoamine oxidase Increased duration of action for Indirect acting noncatecholamines http://www.mayoclinicproceedings.com/inside.asp?AID=881&UID= 7/14/2008 Mayo Clinic Proceedings Page 5 of 7 0 carbon Decreases CNS penetration Fewer CNS symptoms Hydroxyl(—OH):mandatory for adrenergic activity Increased HR and BP Amino group No substitution:a>(3 effects Increased BP Methyl(—CH.)group:maximum a and R effects Increased HR and BP Larger group:P>a effects Increased HR,inotropy,and t-butyl group:02 selective bronchodilation Bronchodilation 3-,4-of Hydroxylation at 3-and 4-(yield catechol nucleus): Increased HR and SP;no CNS aromatic ring increased a and 0 effects effects Absence of hydroxylation(at one or both positions) prevents degradation by catechol-0- Increased oral bioavailability and methyltransferase prolonged duration of effect 'BP=blood pressure;CNS=central nervous system;HR=heart rate. Synephrine shares structural similarity with other sympathomimetic phenylethylamine drugs such as ephedrine, amphetamine,and phenylpropanolamine(Figure 1).All phenylelhylamine compounds comprise an aromatic ring with a substituted elhylamine side chain(Figure 4).Substitutions on the aromatic ring and at the 0 or a carbons or the amine positions of the side chain determine pharmacological activity(Table 1). In synephrine,substitutions at position 4 of the aromatic ring,the p carbon,and the amine group of the carbon side chain suggest that synephrine may be a potent a-and Radrenergic agonist.Moreover,substitution of a hydroxyl group both at the(3 carbon and at position 4 of the aromatic ring likely reduces the ability of the drugs to penetrate the CNS;hence,the drug should have fewer CNS adverse effects.Furthermore,single(rather than double as in catecholamines)hydroxylation of the benzene ring suggests that synephrine is not degraded by catechol-0-methyltransferase,thereby enhancing oral efficacy and prolonging its duration of action.Although synephrine may stimulate lipolysis by binding at P3-adrenergic receptors in adipose tissue,its clinical effect on weight loss is uncertain. At least 2 animal studies suggest that synephrine is a vasoconstrictor with dose-dependent effects on arterial blood pressure."-"Interestingly,C aurantium extract was found to induce L-type calcium channel opening in guinea pig ventricular myocytes.19 The L-type calcium channel is the target of calcium channel antagonists, which are used commonly to treat hypertension and tachycardia.A review of several poorly controlled human studies showed a trend toward increased blood pressure after both treatment with parenteral synephrine and ingestion of synephrine from natural products.20 Another recent review failed to show a weight loss benefit 21 Of note,synephrine(oxedrine),sold as Sympalol,Ocuton,Sympathomim,Sympalept and Fraxipos,has been used clinically as a nasal and ocular decongestant as well as an agent for treating hypotensive states;most of these drugs are no longer commercially available.7,22 In many ephedra-free, C aurenfium—derived products,p-synephrine is the main active ingredient;other active components include hesperidine,N-methyltyramine,hordenine,octopamine,and tyramine."90ctopamine, sometimes listed in supplement ingredients,is structurally similar totyramine and appears to stimulate primarily the 03-adrenergic receptor.20 It is possible that these amines,in combination,have synergistic cardiovascular effects.The product in our case,as with many other similar products,also contained a high dose of caffeine. Caffeine is believed to potentiate the cardiovascular effects of other sympathomimetic agents.23-25 Two established clinical tools were used to assess the probability that an adverse drug reaction occurred in our patient26,27 If our patient's adverse event of cerebral ischemia is considered the first reported with use of synephrine,this adverse event was possibly associated with use of Stacker 2 Ephedra Free.If our patient's adverse event is considered a sympathomimetic class effect,the infarctions were probably associated with exposure to this drug.For obvious reasons,the patient was not rechallenged. CONCLUSION In an otherwise healthy young man with no defined risk factors,an ischemic stroke was associated with recent use of Stacker 2 Ephedra Free,a supplement that contains the vasoactive sympathomimetic amine synephrine and caffeine.Two similar agents,ephedra(ephedrine)and phenylpropanolamine,have been banned by the FDA secondary to serious neurologic and cardiovascular adverse effects.The medical community needs to be aware of the potential risks of ephedra-free products,to continue to report adverse events to the FDA Med Watch program(1-800-FDA-1088 or online at www.fda.govlmedwatch),and to continue to advocate for better regulation of dietary supplements.12 http://www.mayoclinicproceedings.com/inside.asp?AID=881&UID= 7/14/2008 jr /7 ✓vu v . zhrrn� L 15a C-41 IM V5 *71Y Mayo Clinic Proceedings Page 6 of 7 We thank Dr Saran Jonas and Gene Schultz for their assistance with the preparation of the submitted manuscript REFERENCES 1. Beales JH III. Issues relating to ephedra-containing dietary supplements[Federal Trade Commission for the Consumer Web site].July 24,2003.Available at:www.ftc.gov/os/2003/07/ephedratesl.htm#N_3_ Accessibility verified February 1,2005. 2. Samenuk D,Link MS, Homoud MK,at al.Adverse cardiovascular events temporally associated with me huang,an herbal source of ephedrine.Mayo Clinic Proc.2002;77:12-16. 3. Haller CA,Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids.N Engl J Med.2000;43:1833-1838. 4. Food and Drug Administration FDA announces plans to prohibit sales of dietary supplements containing ephedra:consumers advised to stop using ephedra immediately.December 30,2003.Available at www.fda.gov/oGinitiatives/ephedra/december2003/.Accessibility verified February 1,2005. 5. Food and Drug Administration Sales of supplements containing ephedrine alkaloids(ephedra) prohibited.Available at:www.fda.gov/oGinitiatives/ephedra/february2004/.Accessibility verified February 1,2005. 6. Marcus DM,Grollman AP. Ephedra-free is not danger-free(letter].Science.2003;301:1669-1671. 7. Sweetman SC ed Martindale:The Complete Drug Reference.34th ed.London,England:Pharmaceutical Press;2005. 8. Pellati F,Benvenuti S,Melegari M,Firenzuoli F. Determination of adrenergic agonists from extracts and herbal products of Citrus aurantium, L.var.amara by LC.J Pharm Biomed Anal.2002;29:1113-1119. 9. Pellati F,Benvenutt S,Melegari M. High-performance liquid chromatography methods for the analysis of adrenergic amines and flavanones in Citrus aurantium L.var.amara.Phytochem Anal.2004;15:220-225. 10. Nykamp DL,Fackih MN,Compton AL. Possible association of acute lateral-wall myocardial infarction and bitter orange supplement.Ann Pharmacother.2004;38:812-816. 11. Nasir JM,Durning SJ, Ferguson M,Barold HS, Haigney MC. Exerciseinduced syncope associated with QT prolongation and ephedra-free Xenadrine.Mayo Clin Proc.2004;79:1059-1062. 12. Food and Drug Administration Med Watch.Available at:wwwJda.gov/medwatch.Accessibility verified February 1,2005. 13. Citrus aurantium[Supplement Watch Web site).Available at: www.supplementwatch.com/supatoz/supplement.asp?supplementld=87.Accessibility verified February 1,2005. 14. Xenadrine ephedra free[Bodybuildingforyou.com Web site].Available at: www.bodybuiIdingforyou.com/xenadrine/xenadrine-ephedrine-free.htm.Accessibility verified February 1, 2005. 15. Aceto C. 11 Ephedra-free fat-burners to melt away the pounds.Muscle and Fitness Online.Available at: www.muscle-fitness.com/nutrition/20.Accessibility verified February 1,2005. 16. Preuss HG,DiFerdinando D, Bagchi M,Bagchi D. Citrus aurantium as a thermogenic,weight-reduction replacement for ephedra:an overview.J Med.2002;33:247-264. 17, Huang YT,Wang GF,Chen CF,Chen CC, Hong CY,Yang MO Fructus aurantii reduced portal pressure in portal hypertensive rats.Life Sci. 1995;57:2011-2020. 18. Huang YT,Lin HC,Chang YY,Yang YY,Lee SD,Hong CY. Hemodynamic effects of synephrine treatment in portal hypertensive rats.Jpn J Pharmacol 2001;85:183-188. 19, Fang F,Dong M,Zhu H. Effect of Citrus aurantium extract on L-type calcium currents in ventricular myocytes of single guinea pigs[in Chinese].Hunan Yi Ke Da Xue Xue Bao.2003;28:353-356. 20. Fugh-Berman A,Myers A. Citrus aurantium,an ingredient of dietary supplements marketed for weight loss:current status of clinical and basic research.Exp Biol Med(Maywood).2004;229:698-704. 21. Bent S, Padula A,Neuhaus J. Safety and efficacy of Citrus aurantium for weight loss.Am J Cardiol.2004;94:1359-1361. 22. Wlso CO,Gisvold O,Doerge RF,eds Textbook of Organic,Medicinal,and Pharmaceutical Chemistry.6th ed.Philadelphia,Pa:JB Lippincott Co; 1971478. 23. Benowitz NL. Clinical pharmacology of caffeine.Annu Rev Med. 1990;41:277-288. 24. Robertson D, Frolich JC,Carr RK,at al.Effects of caffeine on plasma renin activity,catecholamines and http://www.mayoclinicproceedings.com/inside.asp?AID=881&UID= 7/14/2008 Mayo Clinic Proceedings Page 7 of 7 blood pressure.N Engl J Med. 1978;298:181-186. 25. Brown NJ,Ryder D,Branch RA. A pharmacodynamic interaction between caffeine and phenylpropanolamine.Clin Pharmacol Ther. 1991;50:363-371. 26, Naranjo CA,Busto U,Sellers EM,et at A method for estimating the probability of adverse drug reactions.Clin Pharmacol Ther. 1981;30:239-245. 27. Blanc S,Leuenberger P, Berger JP,Brooke EM,Schelling JL. Judgments of trained observers on adverse drug reactions.Clin Pharmacol Ther.1979;25(5,pt 1):493-498. Privacy I Contact Us Terms of use applicable to this site. Use of this site signifies your agreement to the Terms of Use Copyright©2001-2008 Mayo Foundation for Medical Education and Research.All Rights Reserved. http://www.mayoclinieproceedings.com/inside.asp?AID=881&UID= 7/14/2008 04/08/08 12:08 FAX 412 338 8878 GNC CONSTRUCTION . 0001 (food 1 � Lime T T Ell: Retail Operations&Construction 300 6th Avenue Pittsburgh,PA 15222 (412)288-2057 Fax:(412)338-8878 April 8,2008 To: Mr. Joseph Reale Massachusetts Dep't of Public Health Fax# 978-745-0343 Mr.Reale, This letter is to inform you that GNC has contracted with Professional Retail Services,Rocky Point,NY,to have the floors at the Vinnin Square GNC Store in Salem repaired.The repair consists of,removal and disposal of VCT in the sales area,stockroom and restroom,to patch and reAaj)the s�lbfiool as ngeded and to install approximately 1700 sf of new VCT.Materials have been ordered and installation will be scheduled as soon as the materials are received. If you need any additional information,please contact me. Yours truly, A AOL- Ray Pegher Manager of Facilities ray-oeeller(a¢nc-hq.com i Commonwealth of Massachusetts City of Salem • • Board of Health lGmberiey Driscoll 120 Washington Street,4W Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: General Nutrition Center#5310 File Number:BHF-2004-000143 300 6th Avenue,Retail OP Pittsburgh PA 15222 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0008 Jan 3,2008 Dec 31,2008 $280.00 Total Fees: $280.00 PERMIT EXPIRES December 31,2008 Board of Health l 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 20 of 28 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 4 120 WASHINGTON STREET,4r"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR ISCOTTOSALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT N�IQ&L NUTitZIT10A7 � -531 EL# �g ' t��"�444- ADDRESS OF ESTABLISHMENT ]PAQI+1AT1j�ISERDISA/ty:�lvl, rylA 01970 FAX# 41Z'339-9g7e MAILING ADDRESS (if different) 1W.9A644 t 104 1523L2 3L2 EMAIL-Business': fOANN -Fl;&r4A&e1NC-If151.CQM Website: OWNER'S NAME46AIUAL. A&M? 17-7 04 0-17ZQ TEL# ADDRESS 300 SIXTH A✓E P172�(3Lt(Z44r P-14 l6aaa STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) hd& CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON CO"Z'2AT15 Loss HOME TEL# 973-940-016 DAYS OF OPERATION Monday Tuesda Wednesda Thursday Friday Saturda Sunda HOURS OF OPERATION j(A7K — Please write in time of day. "I For example 11am-11 m 7 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than I000sq.ft. =$70 1000-10'Nosgft. =$280 more man 1 0,00sq. . -Mtr- -------------------------------------------------------------------------------------------..... . -- ........ ................ RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------'-- --------------- ------------------ '-------. BEDIBREAKFAST/ YES NO $100 CHILDCARE SERVICES.. ------------------------------------------------- - --------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have fled all state tax retur s and paid all st to axes required under the law. Lau �z �s-l�a4574 Signature Date Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008.adm Check#&Date °1kw a=!r s ATC) . s 300 6th Avenue, Retail OP General Nutrition Center #5310 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-2444 Food and Food Protection FAIL Critical BLUE Owner: Comment:There are supplements and vitamins stored dirrctly on the floor of the back room. Store all supplements and vitamins at General Nutrition Center I least 6-8 inches off the floor. PIC: 1 jar of calcuim250/magnesium155 foind outdated. Closely monitor all expiration dates. Alex Kaplan Physical Facility FAIL Non-Critical BLUE Inspector: I David Greenbaum Comment:There are many missing floor tils in the back room. Replace all missing floor tiles. Date Inspected:Correct By: The bathroom fixtures need a thorough cleaning. 12/27/2006 GENERAL COMMENTS: Risk Level: 1078: Permit Number: BHP-2007-0016 Status: SIGNED OFF #of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 04,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) v Cityof Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 04,2007 ) Page 2 oft 1 CITY OF SALEM, MASSACHUSETTS _ BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL 978.741-1800 FAx 978-745-0343 Kimberley Driscoll wWW.SALEM.COM Mayor JOANNE SCOTT, MPH, FIS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT676h/�jQ�L. N147?e177Qr4 ai�nIW-4° 53lo TEL# L778 4l;�4� ADDRESS OF ESTABLISHMENT f tllrieADI MAILING ADDRESS (if different)300 IIOFI G 1 a}r DTPA T77oxJS�pj77�$U PPlP1� Saaa EIAAIL--Business': Owner's: OWNER'S NAME 6105 ty"Ae. &U` eJ-r7© 4 Cole 0AA-rt 1J TEL# 41.)62"--46 ba- ADDRESS 300 Y41-1.59"/6 }r- 26917 1 Sated STREET ! CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) AIM- CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) 024 EMERGENCY RESPONSE PERSONC6deAaeaT254x5S HOME TEL# 977-010`/?/q BAYS OfOPERAMON Monday Tuesday Wednesday Thursday^ Friday 'SaturdaySunday HOURS OFRPLUTIOR /grycry� Please wine In time of day' ci sa» (for examplellarn-llnml T �r TYPE OF ORE YES' FEE {check only) RETAIL STORE YES NO less than 1000sq.ft. _$ 50 1000-10,000sq.ft. =$100 Ls More than 10,000sq.ft. =$250 - -------------YE- _ 5 NO--- --- ----------... - ..-- --- less- -th - ..a.-n-.25. ---seatss ...-a-t . .-- - RESTAURANT =$100 25-99 seats =$150 more than 99 seats =$200 _.-... _.... .... - VIES NO_. ......__ -- ----- -----------._.........._...$10_ -.... . ... . -- .... ..... ............ 8ED/BREAKFAST 0 - ...- .._.... --- ------ - ... _.. .... ----- ..... __------ -------------- ----------....... i ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health, Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have ti! d all state tax returns artil paid all state taxes required under the law �r . -exQ� a /.?-9-0& -26- !/ a -9�o7� _ Signature Date Social Security or Federal Identification Number -----------I---------------------------- ------ -- ----------- ---- --------- - Revised 11/13/06 FOODAP2007.adm Chec"E�v apB55$—_I 6 $ __ 100.6)e) rc rl*f . uP , GENERAL' NUTRITION INC"' ' 000'0208558.CNI-001866155 — -� , INVOICE PURCHASE INVOICE GROSS - NET,• NO. ORDER DATE AMOUNT DISCOUNT AMOUNT aF07FD5310 005310 12/06/06 100.00 : .00 ••100.00 s , i; • i i r I f i ' • _ - 1 lad , I - , i , IL f it �Y,I 4 �r r 3 r , - t • _ , i; i T O T A L S 100.00 .00 ,100.00 + Tear along this perforation before cashing+ .1' 1. 1 1` • • • ! • •' � • � �` �i�� ♦ �;^'tY a«`=, 'i .�', to , V t • i•.♦ ) is ♦ 1 • it _v v i ti \ 1 ) y�l�'�\lyt, tl Im. \i♦1 t$ R i \i♦1 ST \i♦i': )Vl e I ♦ ' .fix i ,'r`7 � .` 1♦ + 'c n r ,.,. ♦ x A ♦ •,Y�§Ij 11 ��, i`�11 Y y 1 It • i I;�wl { ;;Yea ^>•�� sy'�i n ♦t`'t� + n� �� i vz's�;i; � , t +• - 'tvti" � . +res. � �, to Y � � ''1 �1♦v �2. Ila ` ♦ +.f.mi I )♦ {:�' gg1 \ ate 3.•�i��' tY�i# 1♦ •1 \i♦ n l�`. 1 j1�. :Y� il^ RY1,_,-j1 '"EY 1 •1 \. ♦,Yly ��+v i1V w";y�il y1: \"'YYY�'1 y1V�/6 ( A, F .wYa� x � kM ^.. ,.$ r �`"� .+rts•r Mrdrk•' z r " + C°mmonwealth of Massachusetts �+"�'^�Y�M� ar ��'�w'• e .:.-�xi::.• s i.��-�'""��s�TMCityoytSalem ��e,'t��"*�` � ,;s,F'° � t .� �� S's'. Board of Health IGmbertey Dnsooll 120 Washington Street 4th Floor ,` f y5 a4 ` MByOf SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: General Nutrition Center#5310 File Number:BHF-2004-000143 300 6th Avenue,Retail OP Pittsburgh PA 15222 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0016 Dec 19,2006 Dec 31,2007 $100.00 Total Fees: $100.00 PERMIT EXPIRES ;December 31, 2007 Board of Health y 0 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 11 of 29 Y 300 6th Avenue, Retail OP General Nutrition Center #5310 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 741-2444 Handwash Facilities FAIL Critical ❑d RED Owner: Comment: Provide disposable paper towels in the restroom at all times. General Nutrition Center PIC: Provide a sign in the restroom stating"Employees Must Wash Hands Before Returning To Work" Alex Kaplan - Violations Related to Good Retail Practices (Blue Items) Inspector: _ Physical Facility FAIL Non-Critical BLUE David Greenbaum - Comment: The bathroom fixtures need a thorough cleaning. Date Inspected: Correct By: #' _ There many missing/damaged floor tiles.Repair or replace all missing/damaged floor tiles throughout establishment. zi1d/2oos Risk Level: _ Replace all ceiling tiles in the back room. GENERAL COMMENTS: Permit Number: 483: BHP-2006-0250 Status: SIGNED OFF #of Critical Violations: 1 .Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 15,2006 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) v V�v�l City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 15,2006 ) Page 2 oft i Commonwealth of Massachusetts City of Salem Board of Health _ ? . 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: General Nutrition Center#5310 File Number:BHF-2004-0143 300 6th Avenue,Retail OP Pittsburgh PA 15222 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0250 Jan 3,2006 Dec 31,2006 $100.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 5 of 10 CITY OF SALEM, MASSACHUSETTS BOARD OFHEALTH C 19RTC IIS�. ( � 120 WASHINGTON STREET, 4TH FLOOR yV&y Ill SALEM, MA 01970 q TEL. 978-741-1800 DEC 2 7 2005 STANLEY J. USOVICZ, JR. FAx 978-745-0343 MAYOR WWW.SALEM.COM CITY OF SALEM JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT at0 oN TEL# q 78 /� n ADDRESS OF ESTABLISHMENT / T 1-Ri4 25 — IQ MAILING ADDRESS (if different) Ii`�f1TlQ� /S YP/TISf311Q�i{� Y�lti I ;a OWNER'S NAME604,q L tifsiRrr(ot�I ®QF�/QFmCJYV _TEL# ADDRESS 300 J/JCS CITY �'aTs6tl A6:3N STATE_ ZIP_ CERTIFIED FOOD MANAGER'S NAME(S) Al If] CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON {ASK HOME TEL# HOURS OF OPERATION: Mon. Tue. Wed. Thu. Fria Sat.- Sun._ mo,v- 5c�r I o.4�n �n -la s�i>'J TYPE OF ESTABLISH d FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. $ �J�V 0 . 00 morethan 10,000sq.ft 250 RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 --------vES -----N---O------------------------------------------------------------------------------------$- -10----------------- BED/BREAKFAST Y0 -------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (nol just serve) ICE CREAM, YCGURT, SOFT SERV: YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best know) dgeand belief, havve�filedd�all state tax returns and paid all state taxes required under the law. Vpr e r .n 2 � - Signature ' _ : Date Social Security or Federal Identification Number ----------------------------------------------------------------------------------------- - -------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Dale � 9 ��/js � x/00 p' '.. ^h" v, :' "' y ,•. }� tr••j''�a A` �� .p a � r r- ' ,. •.t a Yy� �.,%` ., ..._ w,,.. .. .."fr tom.... •r-q„_. ti +..,y.,,.�Li7r,+- ."t-... '...--,...F .:-., -_.T.......-.-�.w-.—,r..: i .+... Fr 'c,.,,.._ ++pp, CITY OF SALEMV' MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: General Nutrition Center#5310 Address of Establishment: 9 Paradise Road Owner's Name: General Nutrition Center Restrictions: Application Date: 12/3/2004 Permit for Food Establishment 149-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. 3 HEALTH AGENT CITY OF SALEM, MASSACHUSETT CEUIV4 BOARD OF HEALTH u 0 ® y 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 NOV 3 0 2004 TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALEM STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT gf,53/0 NAME OF ESTABLISHMENT C��i/�� U A1014770d R TEL# q (g'*-&;c t44 ADDRESS OF ESTABLISHMENT / )ORletq N5 1ZD� 5&r=-MJ 0* 01,170 MAILING ADDRESS (if different) VOA6 RrIZCAW, ?014- 4�2aa OWNER'S NAME C,1C2g ?LrIL /10W9770d C0X)P0.2A770At TEL# 4/a.29&--4(v 6a ADDRESS 300 1421E CITY j7it/S/�//Ql�ff zip lSoZo?c�� CERTIFIED FOOD MANAGER'S NAMES) N - CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSO N6o/LPoeA-M LASS ekL6 1-10ME TEL# -.5 3-(P.80 A Nb2E,.o 6Auvs 1, /ZEG M 5 oFs-e24/-9a5/ HOURS OF OPERATION: Mon. Tue. Wed. Thu. Fri. Sat Sump-& TYPE OF ESTABLISHM FEE check only RETAIL STORE YES NO less than 1000sq.ft. 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO dJ less than 25 seats =$100 I JJJ 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 „LL h'ON-PROF!T(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 bKsttowlledge and belief-,/have filed all s ate tf x returns and paid all state taxes required under the law. Signature Dat4 Social Security or Federal Identification Number ----------------------------------------------------- - -- --C ------- ------ -- Revised 11/03/03 FOODAP2.adm Check#&Date /a d Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4°i Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name r Date Tyae of ODeration(s) Tvoe of Inspection G I P ,� t A_0< ❑ Food Service �] Routine Addressr ) I Risk' Retail Re-inspection Telephone �]--',_ Level / � El Kitchen Previous Inspection d ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation ricn,gr' ❑ Caterer ❑ Suspect Illness Person in Charge(PICTime ❑ Bed& Breakfast ❑ General Complaint Jl/ In: ❑ HACCP Inspector / Iby)UQ Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) [1590.009(F) ❑ action as determined by the Board.rof Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties - - -- - ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION.FROM CHEMICALS -- ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14 Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE - ❑ 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous.Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling „PROTECTION FROM CONTAMINATION - ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR o.C Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils cited in this report may result in suspension or revocation of (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S.5Mns OFOrm 14,dm In �ec . 's Si n Lure: Print: _ SPI 's rgnature: // Print: ( • Page ) otPages o na T s vvi�,� Violations Related to Foodborne Illness . Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F S Cross-contamination I 590,003(A) Assignment of Responsibility" 3-302.11(A)f 1} Raw Animal Faxis Separated lon" t90003(B)_ DernonstrttionofKnowledge* Conked and RTE Foods* L 2-103,.1 t Person to charge-duties Contamination from Raw Ingredients 3-30111(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(() Responsibility of the person in charge to Contamination from the Environment require reporting by Raid employees and 3-302,.1(8} Food Protection* applicants- 3-302.15 Washin¢Fruits and Vegetables 590.003(F) Responsibility Of A Food,Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person]n Utensils* Chsa"& Contamination from the Consumer 590.003((3) Re onin by Pelson rn Char e* 3-306.14(A)(B) Retained Food and Reservice of Fends' 31 590"003(1)} EsclusionsandRestrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal ofF..xclasionsandRes fictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Fa"rd Law* 4-501.111. Manual Warewashing-Hot Water 3-20 12 Food in a Hermetically Seated Container* Sanitization lc. L rae�atures* 3-201.1.3 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing Idot Water 3-202.13 Shell E .s* Sanitization Tent era� 3-202.14 Eves and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. s; 3-202.16 Ice Madefrom Potable,Drinking Water" 4-601.11(A) Equipment Food Contact Surfaces and 5-101,11 Lltensits Clean* 590.006(8) BottledBetWater"` 4-602.11 CleaningFrequencyofEquipmentFood- Contact Surfaces and Utensils* 590.006(B) Water Meets s Standards in 310 CMR 22.0* Shellfish and Fish From an Approved Souree 4-702 11 Frequency of Saritization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Li ui intent* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chernical* Sources* 10 Proper,Adequate Handwashing Game and wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms"' Reaulatow Authorit 3 202.18 Shellstock Identification Present" 2-301.12 C;leauing Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* ll Good Hygienic Practices g Receiving/Condition 2-401.11 Eating,Drinking ar[Icing Tobacco* 3-202.11 PI Fs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,lose and 3-202.13 Package httcgrtty' _ Mouth* 3-701.11 Food Safe and Unadulterated* 3-301.12 Preventinv Contamination When Tastin r" 6 TagsiRecords:Sheiistock 12 Prevention of Contamination from Hands ' S90.004(E) Preventing Contamination from 3-202.18 Shellstock Identification 3-203.12 Shellstock Identification Maintained* Em h>vees* TagstRecords:Fish Products 13 Conveniently Facilities 3-4021't Parasite Destruction* Numbe;s an LCapadand Accessible. 3-402.12 Records.Creation and Retention"` 5-203.11 Numbers and Capacities* 590.004(,) Labeling of ingredients" 5-204.11 Location and Placemenf* ry Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Nand Drying 3-50211 iahzed Processing Methods* Devices 3-502.12 Reduced oxygen >acka tie,criteria 6-301_tI Handwashin Cleanser.Availability 8-103.12 Conformance with Approved Procedures"' 6301.12 Hand llrvin Provision Denotes eriocal Sem in the federal 1999 Food Code or 105 CMR 390.000. l CITY OF SALEM f BOARD OF HEALTH �J Establishment Name: 1 # JO-Date: / aos' Page: 02 of - Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verifies= -, PLEASE PRINT CLEARLY n 17 rI e )/ G S IW ' r r< -'� is 141 /; bra y -A, ho /7 n� S - 'i I t T 3 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ 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 oft elnty-five dooll%arshor suspension/revocation of Ll Embargo Ll Emergency Closure your food permit. / jQn ❑ Voluntary Disposal ❑ Other: n - V 3-501.14(C)� PHFs Received at Temperatures Violations Related to Foodborne fitness 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 CoolinnMethods for PHFs 14 v Food or Calor Additives ig PHF Hot and Cold Holding 3-202.12 Add elves* 3-501.16(6) Cold PHFs Maintained at or below 590.004(F) 41°145° F` 3-302.14 Protection from I7nar roved Additives* 3-501,16(A) lot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. 7-101.11 Identifying Information-Original Containers" 3-501.1.6(A) Roasts Held at or above 130°F. 7-102.11 Common Name-Working Containers* 11 2t3(50(1)� Time as a Public Health Control 7-201.11 Separation-Stora*e* 19 Time as a Public Health Control* 7-202.11 Restriction-Presence-and User 0. 04tH) Variance Requirement 7-202.12 Conditions of Use"` 7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemi< ils* POPULATIONS{HSP} i 7-204.12 C'henucals for Washing Produce.Criteria* 21 3-80t L I(A) Unpasiem�ited Pre-packaged Juices and 7-204.14 Davina: ents,Cnteria* Beverages with Warning Labels* 7-20.5.11 Incidental Food Contact, Lubricants* 3-801.11(B) Use of Pasteurized Ess* 7-206.11 Restricted Use Pesticides.Criteria* 3-801.1.1.(D) Raw or Partially Cooked Animal Food and ERaw Seed S xroats Not Served. * !:::12 ,Rodent Bait Stations" 3-801.11(C) Unopened Food Package Not Re-served, Tracking Fowders,Pest Control and Monitoring* CONSUMER ADVISORY T_ IMEITEMPERATURE CONTROLS22 3603.71 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods,rhat are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate `1-101.1 IA(l)(2) Foks- 155 t 15 Sec. Pathogens.*Err coo +.agar 1': s-hnmedtatr.Service 145°F15see, 3-,02.13 Pasteurized Eggs Substitute for Raw Shell 3- 001.11.(A)(2) Comminuted Fish,Meals&Game Eggs* Animals- 155°F 15 sec. '* 3-40L11(11)(1)(2) pork.and Beef Roast-130".F 121 nrin* SPECIAL REQUIREMENTS 3-�101.11(A)(2) Ratites,injected Mears-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 PRFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F I5 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F" 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-- ls icwwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F15sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(.A)&(I) PHFs 1WF 75 sec."' (.Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time' foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590 000. 3-403.11(E) Renarnong Unsliced Portions of Reef Item Good Retail Practices FC 546,065 Roasts"` 23. Management and Personn_e_I_ __ _FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25 _Equipment and Utensils FC _4 .005 3-501.1.4(A,) Cooling Cooked PHFs from 140'E to 26 _ Water, Plumbin and Waste FC 5 .006 70°F Within 2 Hours and From 70°F 27. Physical Facti 07 _ FC-6 .0 to 41`F,45°F Within 4 Hours. * 28. Poisonous or Toxic Materials F0--7 .008 3-501.14(3) Cooling PHFs Made Front Ambient 29. S talar R ulrements _ _ .009 Temperature Ingredients to 41°Fl45°F 30. Other __----- - Within 4Hours* s r n.re.zao< Denoleg critical item in the tedera l 1999 Food Code or 105 UNIM 5901)00. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: General Nutrition Center#5310 Address of Establishment: 9 Paradise Road Owner's Name: General Nutrition Center Restrictions: Application Date: 11/26/2003 Permit for Food Establishment 35-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved b the Salem Board of Health. PP Y HEALTH AGENT e c ' CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH I'll • w 120 WASHINGTON STREET, 4TH FLOOR (I()N ,9 SALEM, MA 01970 NOV 2 4 2003 ,pB. TEL. 978-741-1800 Qppp� FAX 978-745-0343 GI FY OF SALEM STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO 80ARL) OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT 6YZf 41L NOTAIT10,,1 NAME OF ESTABLISHMENT Cir e jilL 5S 1 O TEL ADDRESS OF ESTABLISHMENTq Pi jH l7l S E �Z` D�p5 NIA- G(GI rJ O MAILING ADDRESS (ifdifferent) c�IJG7 Fes- /L (/ t79N& I i f 5.6U12� OWNER'S NAME /V0-1)Q17-101f Cd KP TEL#4/27,2 o2 ADDRESS S60 sl ,_ r�9"tom �'�GRTrm..JS CITY ParSOLL R-&fL STATE pp�� ZIP &S�fa F rte— EDF D MANAGER'S NAME'S �.cRTIFICATE#�s CERTIFIED 00 NAME(S)_ N/.�c 1 ) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON AIVI>AK� &ALIN5K-1 HOME TEL# 50e-,241- 80 fOA +� 9 GM l,lAm f a�Pm HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri. Sat. Sun. TYPE OF ESTABLISHMERI FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 a� 3�0` more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my ,be�Iknowledge and Wef"e have filed all state tax returns and paid all state taxes required under the law. �Ko�catiL n.� �-[�.,�A-, //- -c)3 a 5_1 ( a Signature Date Social Security or Federal Identification Number ------------------------------------------------------------------------------ ------------------------------------------------------ Revised 11/03/03 FOODAP2.adm Check#&Date 1,50-2 7,5-7— 3'43 0% /0-0 THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date Type of Operation(s) T f In i n �Ty,, -(� f-0/f L��ood Service 1. Routine Address /� Risk Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ) ❑ Mobile Date: / J-1,5-,63 Owner HACCP Y/N ❑ Temporary ❑ Pre-operation / Ati iYl i"; Z!' eF /� ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector 7T� a �/ Out: Permit No. ❑ Other ,.J e�Pis1 Ad 1/ ��.i;lA�/f/// C Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F7 ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ El 16. Cooking Temperatures ❑ 5. Receiving/Condition El6. Tags/Records/Accuracy of Ingredient Statements El 17. Reheating El7. Conformance with Approved Procedures/ HACCP Plans [1 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing El❑ 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected - Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address L-H29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's' -igna(u"re: Print: PIC's Signature: Print:�+S Cif Page of C2,Pages FORM 734A HOBBS d WARREN - BOSTON a N D Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION -8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assi nment of Responsibility* Cooked and RTE Foods* 590.00Demonstration oKnowledge* Contamination from Raw Ingredients 2-103.113(B) Person in Char f e-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment AV 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* KOW require reporting by Food Employees and Applicants 3-302.15 Washing Fruits and Vegetables * 3.304.11 Food Contact with Equipment and n_. 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated K'--3] 590.003(D) Exclusions and Restrictions* Food 590.003(.) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces Food and Water From Regulated Sources 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water Sanitization Temperatures 3-201.12 Food in a Hermetically Sealed Container' 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products, Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating, Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* F-12- Prevention of Contamination from Hands s6= Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* °r`13% Handwash Facilities Tags/Records:Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.0040) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* j *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: /- "q g-041 Page: ;z of Item Code C-Critical nem - -- DESCRIPTIONOF VIOLATION./PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 1F D f 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 Emersion 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 LJ Embargo ❑ Emergency Closure your food permit. ,r� 'y ❑ Voluntary Disposal ❑ Other: r 3-SOI.14(C) PHFs Recti ved at Tengter2tures Violations Related to Foodborne Inness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cant.) 41'1,145'F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Coolin^Mathods for PHFs Food or Color Additives 19 PHF Hot and Cold Holding 14 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41.'/45°F 3-302.14 Protection from Unapgtnced lddttives" 3-501,16(A) Hot PHFs Maintained at or above 1y Poisonous or Toxic Substances 140°F. 7-101.11 ContiPy3n¢Information-Ur,iginal 3-50LINA) RoastsHeldatorabove130'A * Containers' 7-102.11 Common Name-Workina C:ontatnem' 20 Time as a Public Health Control 7-201.11 3-50119 Time as a Public Health Control` Se tara[ion-Stor�teer` 7-202.11 Restriction-Presence andUsa, 590.004(14) Variance Requirement 7-202.12 Conditions of Use" 7-203.11 'CoxicContainers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Saniti7cm Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce,Ct avria* 21. 3-801,11(A) Unpasteurized Pre-packaged Imces and 7-204.14 Drying Agents,Criteria* I Betel tees with blaming Labels* 7-205.11 incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-SO].I i(D) Rau or Partially Cooked Animal Food and Raw Seed Sprouts Not Served * 7-?06.12 Rodent Bait Stations* 3-307,1l(C) Unopened Food Package Not Re-seared. 7-206.13 'Tracking Powders,Pest Control and Monitoring" CONSUMER ADVISORY - TIME)TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 I Proper Cooking Temperatures for Animal Foods That are Raw, Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(t)(2) Ekti- lis°F 15 Sec. Pathogens,': F_ s-Immedi rte Service 14 54,P]jSe,' 3-302.1.3 Pasteurized Fags Substitute far Raw Shell Fang` 3-401.11(A)(2) Comminuted Fish,Meats&Game Animals-155'F 15 sec. ' 3-401.11(B)(1)(2) Poi Land Beef Roast- 130'Ft2lmin' SPECIAL REQUIREMENTS 3-401.11(A)(2,) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Seaton 590.009(A)-(D) in sec, * catering, mobile food, temporarg 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 it related to foodborne illness 3-401 11(C)(3) Whole-muscle,Intact Bcef Steaks interventions and risk factors. Other 145`F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#f29- MiGowave 155°F** Special Requirements. 3-401.11(A)(1)(b) All Other PHFs - 145'F 15 see. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-401.11(A)&(D) PHFs 165"F 15 sec, It (Items 23-30) 3403A I(B) Microwave- 165°F 2 Minute Standing Critical and non-crilical violations, which do not relate to the Time* loodhorne ittness inierrentions and risk faciotalisted above, can be 3.403.11(C) Commercially Processed RTE Food- fecund in the following sections of the Food Cade and 165 C:64R 140°F* 590.0011. _ 3-403.11(E) Remaining Unslieed Portions of Beef Item ; Good Retail Practices FC 590.001 ement and Personnel FC-2 003 Roasts' 126 PSI'Equipment d Utensils Waste FC-4 '005 18 Proper Cooling of PHFs 24, Food 3-501A4(A) Cooling Cooked PHFs irate 14WF to 70`F Within 2Hours and From7U`F 1 27. Ph sinal Facility FC-6 .007 to 41'F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials I FC-7 ,008 3-501.14(B) Cooling PHFs Made From Atnbient 29 Sp Ia Requirements ._ 009 Temperature Ingredients to 41°F/44'F l 30. 1 Other Within 4 Hours* 'Drno[cs critical itcru in die iedual 1999 Fnod Code or Ins CP-1R 590 000. ��oxwr CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET. 4TH FLOOR SALEM. MA 01970 �f ^^• TEL. 978-741-1800 gyp' FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner ' s Name : General Nutrition Center Name of Establishment : General Nutrition Center #5310 Address of Establishment : 9 Paradise Road Type of Establishment : RETAIL FOOD Application Date : 01/02/2003 Restrictions : Permit for Food Establishment 199-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Bo(arr�d- of Health. HEALTH AGENT CITY OF SALEM MASSACHUSETTS °� o 6�GONOIT�,10 III jIIIJ,$ •_., 'r`7 BOARD OF HEALTH �c 120 WASHINGTON STREET. 4TH FLOOR ` . DEC 2 6 2002 SALEM- MA 01970 �✓'�' TEL. 978-74 1-1 800 9NC�'IIN61' FAX 978-745-0343 LII '( LIN iJMLEIVIM ST- LEY USOVICI- JR. JOA=NNE SCOTT. MPH_ RS. CHO L3OARD OF HEALTH MAYOR HEALTH AGENT' 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT / /��rrR2m01J lle 53 EO# q/0-77� a49� ADDRESS OF ESTABLISHMENT q P<F��t�rSED /{SA-t-67-k1 , m Ol`17a MAILING ADDRESS (if different) fir, �imt L13iG (/ �N�T�rs3✓1RGN/ �j9 OWNER'S NAME 4eSVCZ92. IVLrfg TI&J C 8 TEL# `Sam Ora- � lna ADDRESS 300 5">C7_H CITY r i TS�v�C� ST, TE �!P oZ CERTIFIED FOOD MANAGER'S NAME(S) /U CERTIFICATE#(s) (required in an establishment wtiere potentially�1a�rdous foo��V6 prepared.) sycRe r17 ✓ yep GS//��Q? cczzh£ EMERGENCY RESPONSE PERSONOO tr/1A7L 55 197¢IOMETEL# 40 S53'(0)eD /0*9XI 'fV -3 P/n HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri Sat. Sun' /t �-k Pm TYPE OF ESTABLISHMENT FEE check only RETAIL STORE ES NO 199'd� less than 1000sq.ft. =$ 50 / 1000-10,000sq.ft. =$100 t-- more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES N $5 TOBACCO VENDOR YES N $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Furs ant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my be nowledge n ief,,have filed all state tax returns and paid all state taxes required under the law. i.-2-i'9- 0. mss- i /�4s114 gnature Date Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------ ------------------------------ Revised 11/25/02 FOODAP2.adm Check#&Date I V-/0 6/Y—/off/6 -0..'-- ;% 160 t----_.•_-• _ -^'._."'"_---•--.. .-.m-.-...--,.�..-+... ..r oar,-...�-..r.-..-..m.:...,.�.....c.*„.�„.,.,,o,,,,-r..,r,�..^-.-w v THE, COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978)745-0343 Name -y- Date Type of Operation(s) Type of Inspection hA�E L GfXi Lf irt/ R "�S 4� ❑ Food Service 0 Routine Address Jji � Risk Retail ❑ Re-inspection Li Level ❑ Residential Kitchen Previous Inspection Telephone (9 1 '711/ Qa(W L1 Mobile Date: P-/b- 6,;2- wner ( n HACCP Y/N ❑ Temporary ElPre-operationO G&1.1A71 )1Qj-,�,W 6 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ El 5. Receiving/Condition 16. Cooking Temperatures El 17. Reheating El6. Tags/Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/HACCP Plans El 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ElEl 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) - the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: y Print: PIC's Signature: . - / 1 /,�jv Print: S-- �j�'j Page-L_or Pages v FORM 734A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATIO9 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1. 590.003(A) Assi nment of Res onsibilit * Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2, 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and Applicants* 3-302.15 Washing Fruits and Vegetables 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 1w311 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE '9 Food Contact Surfaces Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 She]] Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* `10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating, Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7' Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. ,f CITY of SALEM 4 BOARD OF HEALTH iFi Establishment Name: l c lag�7 '_ /Z/u,4701 4.r/i LPA-n is Date: /-/S"- 0,:? Page: of Item- Code C—Critical Item DESCRIPTION OF VIOLATION / PLAN OF, CORRECTION: Date Nod Reference RI—Red item_ r �`� " ' •� a " Verified-- , ,v E'.: NK-EASE PRINT CLEARLY C '. A/� ro�r�i' ��e. U�/�►5�1nr�s h,Pp trr � /'a � .n. .LP ('P ,/--bs7' /7- / Awe/ /�lt)d 777n-5 T,IA('77(- 35 rine t��daPe--l_ A, A9 �S R'e2,t1 /;r .rfnr Ty 1 Discussion With Person in Charge: Corrective Action Required: ' ❑ No ❑Yes J I have read this Y report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance 1:1Employee Restriction/Exclusion violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may 1:3 Re-inspection Scheduled 1:1 Emergency Suspension result in daily fines of twenty-five dollars or suspeAsi� cation food permit. I ��//��/ �s ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other t FORM 7348 HOBBS &WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatup s Factors(Red Items 1-22) (Cont.) According to Law Cooled to' - 4l°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives =19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* S 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21.. 3_801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for WashingProduce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations 7-206.13 Tracking Powders, Pest Control and 3-801.11(C) Unopened Food Package Not Re-serve Monitoring* CONSUMER ADVISORY 22'' 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS _ Animal Foods that are Raw, Undercooked or 16" Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs - Pathogens.* Eilecft a 11112001 3-401.11A(I)(2) Eggs- 155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D) in 3-401.11(B)(1)(2) Pork and Beef Roast- 130*F 121 Min.* catering,mobile food,temporary and 3-401.1l(A)(2) Ratites,Injected Meats-155°F 15 Sec.* residential kitchen operations should be 3-401.1l(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodbome illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.1I(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23.30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, Can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 to 41*F/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45*F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Ma3sachusetts 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 DateType of Ooeration(s) Type of Inspection / j'g ❑ Food Service ,❑A Routine Address Risk F1:1'Retail ❑ Re-inspection ri.r __� Level [3 Residential Kitchen Previous Inspection Telephone I El Mobile Date: 4-( - 4a HACCP Y/N El Temporary ❑ Pre-operation Owner 1, Q Ili\ , �e� I�� ❑ Caterer ❑ Suspect Illness Person in Charge(PIC)' Time ❑ Bed&Breakfast ❑General Complaint In:V I' ) ElHACCP Inspector w" , Out: ', Permit No. ❑ Other Each violation iffiecked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. . „rivFOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities 7 EMPLOYEE {�� 3 3 f �t ry + yf �u „!. z .,&m wa ... I PRf1TECTON FROM CHEMICALS t yi n i %`%7 ❑ 2. Reporting of Diseases by Food Employee and PIC - r ��_� _�--•=dam « -- - x� a ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El. Marni m g, 15.Toxic Chemicals u.FOOD FROM APPROVED .k i�ta�,�,�,��., tTIME/rEMPERATURE CANTROLS Poteirtiall Hazardous Foods) ❑ 4. Food and Water from Approved Source 9 ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION.FROM CONTAMINATION"' 1=TfT� ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing r REQUIREMENTS FOR HIGHLY SUSCEPTIBLE P©PUL:ATIQNS(HSP);;,m ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMEfiADVISORY ,;„,,, C�„sa`',„,u ❑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 " by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-z)(s90.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s:5901nspectForm6la me (�� J� J. Inspector's Signature:,. ` �/ Print: - PIC's Signature: Print: P _!V / l / Page_f ofK pages x Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Crass-contamination 1 590.003(A) Assignment of Respcnisubility* 3-302.11(A)(1.) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE F<xxis* 2-103.11 Person in chat,,e-duties Contamination from Raw Ingredients 3-302.1l(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 W'ashin Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char e* Contamination from the Consumer 590,003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food'* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated - 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 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* 4-507..111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization'rem eratures* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-HotWater 3-202.13 Shell Ea s* Sanitization Temperatures* 3-202.14 Eu gs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinkin.-Water* concentration and hardness. * 5-1.01..1.1 Drinking Water from an Approved System* 4-601..11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authorit 2-301.11 - Clean Condition-Hands and Arens* 3-202.18 Shellstock Identification Present* 2-301.1.2 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* If.1 Good Hygienic Practices Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* - ite it * - Month* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tastin * 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstoek Identification* 590.004(E) Preventing Contamination from 3-203.12 Shelistoek Identification Maintained* Employees* Handwash Facilities Tags/Records: Fish Products 13 i h Conveniently Located and Accessible 3-402.17 Parasite rds: 5-203.11 Numbers and Capacifies* 3-402.12 Records.Creation and Retention* 590.004(J) Labeling of Ingredients' 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Nand Drying 3302.11. Specialized Processing.Methods* Devices 3-502.12 Reduced ox en ttcka 'nom.criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with AEgE2ied Procedures* 6-301.12 Hand Drying Provision •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. i i CITY OF SALEM IBOARD OF HEALTH Establishment Name: �Pif12v� n 1 r� t n�� Q"L�� Date: r'�(Aci e),J Page: a of C�?' Item CodeC Critical Rem y r DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION =f , ,� ? Date-,, Reference nce,. s.R_ Red -c..:. t'1'•rsr.L ._ r. ., , a,^:r, k Verified r PLEASEPRINT CLEARLY 1 , , , ry✓r/lca1s t VDA4- Q , e -tk, _ 9 r` 1 S , (j, r kA, C S rnr. i, it r 1, nA G _ 4 e 1 I ..�lAn n1l p�rlA rX llc ., -�;. 1. i �. 1Pu( ,. r ,_� e� ,,,-El1 L' L qq I l l /4 / t bl/A/ I / i 'C' ('On rel/ l 1./1 , i _ /� //�r l, H✓ l Ci n/l 7 h-T% V r T) A — /` .i �.Y . ) 1 v r CC(P_ P tS nl n ...�^ L/ —fl 1 1' MI .r�r � ��✓ (� I.J. _ I �-- .Ir�G nr T A IIIf r,r �( I� InnnI( h ue r O—, nn._ � n _ c_ Q c� e QMMi Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to ❑.�Re-in pection Scheduled Ll Emergency Suspension (4 comply with all mandates of the Mass/Federal Food Code. I understand that s� noncompliance may result in daily fines of twenty-five or suspension/revocation of ❑ Embargo ❑ Emergency Closure "four food permit. ❑ Voluntary Disposal ❑ Other: s . Violations Related to Foodborne fitness Interventions and Risk Accoydirig to LasvCaroled w Factors(item 1-22) (Cont.) WF/45",F Within,! flowri. SP1.I5 Coolin-,Wtho&,for PHIFs PROTECTION FROM CHEMICALS 14 Food or Color Additives LL9 PHF Not and Cold Holding 3-501.16(B) Cold PHFs Muinkinted at or beloo, 3-20212 Additive,, 590,004(1`; 41745"F� 3-302,14 Protection froulli E24mfed A<fdtiSves* 3-501710(; ) Hot PHF, or above 15 Poisonamir or Toxic Substances 140'F, ,miifying.kitinmanon ioxists 1�,Td It or abase 130-1 Time as a Public Health Control -Tol!I Common—Naaw Wm o -n-- ow—an—r0— 7201A 1 a—, a—Publc ITalh—Confl,)l - 1-202.11 ReStrictirl.n -Presence and Ue* 7-202.12 Condition,of Use' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7303111 Toxh,Conlamei,,-PicanSinon4* POPULATIONS ST) -727411 sanitizers,Crile le--chenticltis, ' 21 4-sol t J(A) lipaltenneed Pre-pacl�,agcd Juices and 220-3.12 Chemicals forWa,ht criteria" 7204,14 Revefa"'es'v'th 1-4-.0�.11(8) 1,,!,e of Pa�tculized E hicidernal NN)d Conhict,I.Atricaats' ?-901 )-lo)I II(13) Rllvl Or Ilarlieliv Cooked Anklaill Filed arld 206 V I Reairicisd Use. Peticides, RUSU'dSprouts N0tSf1'VM Criterta� t-206.12 Rodoct tllit Stations' 3-90 1 11(() Ulm riled Folel Pack ,c Not Re-smed, 7-206.13 '1 racking Powder,;,Pest COntrol and Monitarin _ .. CONSUMER ADVISORY u— TIME/TEMPERATURE CONTROLS 22 3Z)3.IF Tor—Zoll' Inpiton of Animal KxyJK Mar lire Raw Undilic(okvd oi 16 Proper Cooking Temperatures for Not Other,ise Processed to FUrinmar, PHFs 401 1 jkill -7jT-T5 —---------- F -F Sc- 155 _ heti cehate Servicr I'W'Fl 5sec, i -.q12.11 fIz.steuro,4d Fps Substicile fol Raw Shell corlinunlited Ii,h,Meat's& Gault, AnnVAS - I 5� F 15 sec, liffin 73�40 A I(R)t 1!(2) Polk and &��ef Roast - 1:fWF 12 nun* —SPECIAL REQUIRE 3-4'01.11(A)( 7 -' Rafites, Injeoed 755'6,cats - 155� IS T) of Section in catering sec'. "lliertirobilc bldrn a ,te ,{nary olid Pouter},ii�ild Galtle� residential kitchen operations should be 5"lg Containing FishNf , eal, 1 debited wider the appropriate,sections 7 i abow if teboed to foodborne ibnoss Whole muselo, Miller Beef Steaks itaciventions ruld risk faclo-'r, Offif-r 145F 1500 009 vicalatiost relating to food retail 3-401.12 Raw Amoral Food,Cwkod in a practice,,hould be debited under #29 - Microwave 165'F* Special Reqfli uireonts- 74T) I—1(A—) I)�(b) All Oiherlib[[`;-- 149'1715 sec. L17 ___ Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL ff—cir 3-10T, -P—Hbs 1'65°f 15 sec. {peons,23-30) 3-403.11(8) Microwave- 165'F 2 Minnie Standing Critical and non-crlor�al vwknwns, which do not relate,w the Time, 'foodhorro,illness interventions riA factors tiered above. am be 3-403.11(C) Comalci,ja1h,Processed RTF.Food found in the ftp serinons of the Food Code and 105("ill? 90,OW, 3-443.1I(R) Rellanda", UnFlIced Poaiems of beef I Item C Good Retail Practices t FC 1-25— and-Per soni�.ql--------7W� Proper Coaling at—PHFs 1 24 ---FM2�)d and Food Protector* FC--,3 1 .004 LL8— 2& and Utelelits FC-4 1 006 -T!ii)l,14(A) CoohiqrCookcdPRF� lorai IZ�Fto -- 11,-7 26, 'Watel.Plunitimg aste 70'F W�ithin 2 flour�and Frien 1�or"T --------- I Physical Fa FC-6 �007 28 - ------_F6-_-7--T 008 3—S01. 14(8) Cooling P14Fs Made From Ambientc4------I Pec a1EhqL ana-- 009 Tomporawre InLredicnts to 41'f,/45T Other Within Hliura a J)ejjkies critical item ie the fedend 1994 I'orld Gade,r 105 CMit 5T l WO 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 x Name / 1 \ - Date Type of Ooeration(s) Type of Inspection ❑ Food Service ❑ Routine Address Rik rO Retail ®-Re-inspection Level -❑ Residential Kitchen Previous Inspection Telephone i� r El �Mobile Date: / "Xt 1).� Owner HACCP Y/N ❑ Temporary ❑ Pre-operation 0, , k, Cf/� r ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint HACCP Inspector / In :a' I r Permit No. ElO herr 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 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 , 17,11, � ��- ,,, ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ElP 13. Handwash Facilities EMPLOYEE HEALTH s` a ' ' `� €m� _ .. � mE �a .PROTECTION FROM CHEMICALS �, ,a : `'' �'" �' •'® p - ` El i' Reporting of Diseases by Food Employee and PIC ❑ -- ` 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals •;FOOD FROM APPROVED SOURCE a. °' „z„ rsN� . ,r ®rx � =aTIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods)'� "�" ❑'4. Food and Water from Approved Source a, m„ . , 9 rdou 0� - , ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling I'PROTECTION FROM CONTAMINATION" '�;" 'P "` ❑ 19. Hot and Cold Holding ..., .d,u. .a®.,..,. ❑j 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing [REQUIREMENTS FOR HIGHLY SUSGEP,TIBLitpdOULATIONS(HSP)`„„ ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices 1."CONSUMEi AGIVISORY,'. gs„.„; . ❑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 ' by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3)(5550.090.0 044)) 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 j 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- Inspector's E-INSPECTIONInspector's Signature: Print: ) y / t rA PIC's Signature: ��e{ %� R�t p 0 \( I C C ( ( lC"k ( Page/ of C _Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F S Cross-contamination . 1 596.003(A) Assignment of Responsibility* 3-302.1.1(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge" Cooked and RTE Foods* 2-103.11 Person in charge-c_i_a_ties Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washin Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant_To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(03) Reporting by Person in Charge* 1-306.14(A)(B) Returned Food and Reservice of Food* 3 1 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tenr eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.1.3 Shell Eo- s* Sanitization Tem eratures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,- 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.1,4 Fish and Reereadonally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arens* 3-202.18 Shellstock Identification Present* 2-301-12 Cleaning Procedure* -590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g ReceivingfCondition 2401.11 Eatin .Drinking or Using Tobacco* 3-202.11. PITFs Received at Proper Tent eratures* 2-401.12 Discharges,From the Eyes, Nose and 3-202.15 Package tette it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination Wlten Tasdn 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em lovees* 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' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 S ecialized Processin Methods* Devices 3-502.12 Reduced ox en acka hg,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301.12 1 Hand Drying Provision '`Denotes critical item in the federal 1999 roml Cale er 105 CMR 590.000- - CITY OF SALEM f BOARD OF HEALTH f ;. Ak Establishment Name: 691- '0 lj ram t . 4-5- r ., Date: L+ '._)OS Page: a ofd Item .Code- u Cy critical Item k- ,' .,, a 3 DESCRIPTION OF VIOLATION/PLAN OF CORRECTION "' �„��„ ,; ."Y;: Date .,..�.. ?No:" ' Reference R=' Red Item - ,,, 'i',, " - ,�`a •"ter" aw a w, , - 7 " y. 3� Verified j f s m /A �., e5.. nA` amr .` ' . PLEASE PRINT CLEARLY - �'�� < r (moo M o re� rec,r rho d,35-. ) 16<',""e L'A. 1 AA J D_4 _- o S'. , qjv U , /1. Al V UL /t AA t✓I N.APd o ) i .1/`n. 5,✓t "h.l �l n. {-?.J �A 0 ('L c� L c1L J _� 11� rVNP f troll, r / i F 1 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 asescr , and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension ,comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �^ r rk V•,)C'xL3 Voluntary Disposal ❑ Other: U r I 14lC, PHFs Reocived at Tempateaures Vilo4tions Related to Foodborne illness interventions and Risk Accoidiag to Law Cooled to Factors(Ifents 1-22) (Cont) 1 Pr/45"F Within 4 Hems. 5011 is coolial, ethodsfor l"IfFs PROTECTION FROM CHEMICALS L!9 �---�M LL4 Food or Color Additives PHF Hot and Cold Holding I l�B )fit PHF,ldamtaircd at or bolvir, 590, F- 3-30114 Protectimi from :1 111c" 590,0041" 41�145 IS Poisonous or Toxic Substances-- 3-501,16{A) liot PHPq Maimajeam at or above --:;--- i 140'F, 101.11 tying InRalliation-011."Ined Roalits Held at oi-,Aro.c 130'F, — 26 Time as a Public Health Control 3-50i 19 Timo as a Public f klalth ConlroV 1 02 11 Common Name--Workin 'ontaincri;* Se �90.004(H) Varive 13clit 7-292.1,` R(ntriclron--Pree;vnce and 7-20112 Condilimis of tjtileREQUIREMENTS FOR HIGHLY SUSCEPTIBLE )K-w,coilf�' 7 Sanid7ers,C[ile-is -C1!eo&l&S* POPULATIONS HSP 1-204.11 — ?-2X}4.32 Chemicals for wic�h ilrridacc�Clitetia* Unnoiicurizrd Pec-pac�,agcd Amens olid flevcrrlaes euh St atiw F,a1-W 3-80 1.11(B) 1 se of Pae�ttunzcd Eq,,s* 7-2.04,I� yi� 1-205,11 Incidemal VoiIJ Comm.I Atbricants'4 3-801 IRD) 1:2-0-611 Re"llioed U're,Pe tides"Crifell�e* Raw S" 7'06.11 Rodent B itlsrauel"N — � 3-RGI j_ _ NoRe-sel 13 1 1rackngNl"dcrl �si Control<'ro L CONSUMER ADVISORY out e, 22 ko, I I C�On TIME/TEMPERATURE CONTROLS Allyis i v Posied for Cousumpt cuen of 'it erc Raw. Undervorked o 16 Proper Cooking Temperatures for Rrod,'Thl i I PHFsNot Othem isc Preecesed to Flillarfale Padlo'Iens 3 401 11 A(I i Eggs- 15VF 15 Skx, Fps diate Service 145VI 5se 3-30:1 11,,meurgzrel Eu'-substitute for,R3W she], I Comou turted Fish, Milays&Garliv animas- 155'F 1 sec, ` SPECIAL REQUIREMENTS 3 401.1 I(B)(1;0) Perriand Feet Roast-13G1 121min* --llnnS of �L-tlon-i90JX)9(A'i-(D)lni 3401.1 l(A)Q%t R;rliles' feliected Wall,--T55 TF catering. rnlrbih�.kxld.temporai y I and — --- If lr"�idcinal kitchen operations Alraild be 46TI I(Ak3) Fs, Stuffing COWMlin-FiSh,lkleill., 7 1 debiled under tire appropriate sections above if rcliuod to ftx)dborne Illness 3-40LI lfc),-3) Wholerlaeselc Imactfieef"Sicaks inlet ventlons, and risk factors, Other 590.009 violations relating to good rcWl 9-401.1" Raw Annual Foods Cookctf hi a PracticesMica dd be debited wader#29 - Micollivree 165'F __ Sprcr'll Rs c,Ft�tretncnts. 3-401,11(Agl)(to M!Other IIIJF145°F 15s", Reheating for Hot holding -V1-0LAT10!ii§REI 000 RETAIL PRACTICES I.- )3TH.4)&(17) Cl*s 165T IS w,.- (items 23-30) 3-403.11(11) Micomil 165'F 1 Mimn,:Standing Colioaland villifationI, which kerl not retare.Ill Ike I ime, fteeirehorne illnfts,r um-i-vi-noorry and riskfiic tors listed above. ,on be, 3-403 11(C) Cornmerciady Processed RTF Fraid- found at Mejolh-oweig sections o0ke Food Code and 105 CMR 140'F' 5C)0000. itemGood 590,00 3u1{)3 11(F) Remajaim, Uii6wed Portions of Beef "--- -- -- I Roast,' �-23' MtmaQPTL.,tand reerexanel FC -2 0013 -F-roper Cooling of PHFs 24� ForA and Food Prolectarri FC 3 .004 25 EguE,nment-end Ulenaes -F0-4 005 F 26 Wpter�Plumbinelarld`1+ este 5:0�1 4(A) ng Cooked PHFs 15 oner J40'F t 7 70'F Within 2 1 fours and From 70` Phy�tjr Fa�kktL FC r aL 7 to 4 1'F145'F Wifili n A Hom s. Poisonous or Torct NkiteF;ls r 008 -501 144B) Cooling I1HFc Made,From Aribiten 009 30� Other Temperature begiedieraq 14,41�F/45'F ------ Within 4 Hours "])mates critical item in cru ro;lerell 1999 Food Code or 105 COIR 5900(10 Page 1 of 1 Heather Lyons From: Roseanne Fabina[Roseanne-Fabina@gnc-hq.com[ Sent: Friday,January 06,2012 11:48 AM To: Heather Lyons Cc: Roseanne Fabina subject:GNC#5310-Invoice Payment Info for Food License Renewal Hi Heather, As discussed,below is the payment info for the food license renewal. Hopefully,the application and check will be found in your building. I will be in the office until 5:O0 p.m.today. Thank you for your assistance with this. Roseanne Fabina GNC 300 Sixth Ave—Retail Ops Pittsburgh,PA 15222 (412)2884662 Direct (412)338-8878 Fax LZn 8 f Vend Ure Mone Geste rrtamat Data Database laaD Invoice Payment Inform tion Yertdor{tame C[IY f2FSN.FM NASSAd/115FT1 VeoAor_td: 001866 Iirokos Hurabet F F12FD531O. vantlarluc rw le eIDe gate F 12/7/2011 Bald IR chedmethod aiRK 9alz11,dhte: v/tVmu check mmrbar SW — ImRlloe 526D Chert Date: 12/15/21111 � 1 lumen I\`// Date Fnteieebltn AP 12/1472011 Fvrmrud`1Ys�v65�Parthelp I dose Wd. �FOrn Why VO t �� fit °G' 1/9/2012 CITY OF SALEM, MASSACHUSETTS - BOARD OF HEAUI I 120 WASHINGTON STREET 4t"FLOOR P11blicHC8lth STREET, _ Prevent.Promote.Protect. TEL. (978) 741-1800 FAx(978) 745-0343 KIMBERLEY DRISCOLL IxamdinQsalem.com LARRY RaMDIN,RS/RFFIS,CHO,CP-FS MAYOR This Form will be collected during your next Board of Health inspection. QUESTIONAIRE -GREASE TRAPS 2012 / 1. NAME OF ESTABLISHMENT: ��lI�, G Nv-(T1T10n1 (: V'T=e, 2. ADDRESS OF ESTABLISHMENT: 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? !V 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE. GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?