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GENGHIS RESTAURANT - ESTABLISHMENTS GENGHIS RESTAURANT 179 FORT AVENUE p SEASONAL 0 a3 II a II A I, i 0 w i a- EXAM FORM NO. 4736 m iervSafe CERTIFICATE NO. 9419608 ' t y m } m F :. ,'" er vSafe er i icaf c r z5 WAYNE C., 1- for successfully completing the standards set forth for the Food Protection Manager Certification Examinations which is arcrodited by the American National Standards Institute (ANSI)-Conterence for Food Protection fCFP). Iz z y CE LL 49/24/2012 DATE OF E%AfV,:NA'fI0F1 09/20/2017 DA-Z, Of -XPIRAiJON Local Uws apply.Checx vnth ynor local req,,Ial y agency for reco:ilication mquremenls. NATIONAL4 -�._. - ----- RESTAURANT ASSOCIATION� Pacl FLnanlan rl(IEExoC,atwo birUclor, Na hu nal ae4tdU.'a[t Avsociati, Solutia115 rn1l:Ng r.�d Pxmlanrnc Asx,oiau Eduva ncnal fv rdaful.A 16cks re sawed.Se PSor and IN"San Sale lu+dlr aro rog'slerai tradawtki cd The National aur:urant++sswwbon E+duce ti:n+el kurx'ef on. zW nnvd m,nm 61 irIss'RrPktb'al HUMLIar AssocsUnn Edn hs.;Lt Cr aaft'e+o:mod sohsiAa v-1 INC,l73Fon41 AuataOYer<A snCialipn. CC llu,Juulnmin cx+nm Le-tanallu:ml cm 9llvron. Lt. IJPrri+i' 'iJeJ1 - 0 3 9 ME fA ------ - - -= --- -- ------- -------- ------ --- - ---------- --- - -- - --------- CERTIFICATE -- --CERTIFICATE OF r X24, ALLERGEN AWARE N E S 5 TRAINING Name of Recipient: Wayne J. Chin z 1 l P o Date of Completion: 9/14/2012 ; Date of Expiration: 9/14/2017 c Issued By: (rte o The ahoae-named perjon is hereby issued this cert�ficate fir completing an allergen awareness training firogram _- -� Aja recognized 6y the Massachusetts Department of Public Health ' ser"hire in accordance with 105 C.1 �,„�,RR 590.009(G)(3)(a). lalilfei AHEC m Arca Health Education Center N Zhis certificate will be valid for fee(_5}years fronr elate of completion. Pdttstield,Jiassachusetts nnaror:matouda(IergtKrainiag.org �rrw N ya City of Salem, Massachusetts r g Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 �A =9 Tel. 978 741-1800 Fax. 978) 745-0343 PL Id, u ) Iramdin@salem.com Present. Promote. Protect. Kimberley Driscoll Larry Ramdin RS/RENS, CHO, CP-FS Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM-15-37 Permit Type: Food Establishment< 25 seats Goods& Services: Food Service: 0-24 seats Name of License Holder: Genghis-Wayne J. Chin Name of Food Establishment Genghis Address of Food Establishment 210 Nahanton Street Unit 302 Newton MA 02459 Restrictions: This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: $140.00 Issued: 1/1/2015 ` CITY OF SALEM, MASSACHUSETTSIeubtf�xeatrh BOARD ot,Hu'..ALt it •....,...a..,...�,..,. 120 WASI'IING'.ION S'TRF.E'r,4111 FLOOR KIMBERLEY DRISCOLL Tial..(978)741-1800.FAx(978)745-0343 LARRY RAN-(DIN,RS/RFA IS,CHO,CP-ISS MAYOR Iramdin(@salem.com salem.com H1;A1:I'H A66NT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: lJL!a /S 2) Establishment Address: / � 0/1170 - s 3) Establishment Mailing Address(if different): -- 0 /1//�#1,7 IJ7-0A) S7 Lwt 3°a-'� A)Cu'A0,0)n4 4) Establishment Telephone No: �3',,--1 5) Applicant Name&Title: /\)L � /V 0W//t% `)-n 471/111-6&t- 6) Applicant Address: /v A S 3 0t2/ A161410 7) Applicant Telephone No: Hour Emergency Email: (�SC/fin// 8) Owner Name&Title(if different from applicant): -S-'/O,m 6e i 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address A corporation I/ GFti A) � e� O A/NiAAR l .V �— An individual �it) Apartnership NC. ��fy�J c(le� Other legal entity � n ryL_ �A4-qC, 12 Person Directl Res onsible For Daily Operations(Owner, Person in Charge,Supervisor,Manager,etc.) Name&Title: �� NLS �/ �� 12 � / � �r,�� Address: J't) Telephone No: 6 /9- 0-PLq/d-z)— Fax: Emall:I&CHIV 160 6)" -ccx" Emergency Telephone No: 7 96 99�a 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: //3 � Date: /O /I —i. r Amount: 140t 6D " Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: 1A '60 Pohl 17) No.of Food Employees: S 18) Name of Person in Charge Certified in Food Protection Management: R Required as of 101112001 in accordance with 105 CMR 590.003(A) L� 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) O�etail( Sq. Ft) ❑Caterer Permanent Structure✓ [d Food Service-( /8 Seats) ❑ Frozen Dessert Manufacturer Mobile dFood Service-Takeout ❑ Residential Kitchen for Retail Sale 0 Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: -Breakfast Establishments .................................... ......-----•---------------.... (ch ck one) RETAIL STORE RESTAURANT Annual r/ ❑ Less than 1000sq.ft. $70esC3 ss than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑More than 10,000sq.ft. $420 17 25.99 seats $280 ❑More than 99 seats $420 Temporary/DatesMme: ......................................... ........................................................... - .................... 13 Bed& Breakfast/Childcare Services(Nursing Home $100 ADDITIONAL PERMITS ........................................ ................... ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare&private club 23) Food Operations: Definitions: PHF-potentially hazardous food(timeltemperature controls required) Non-PRFs—non-potentially hazardous food(no timdtemperature controls required) (Check all that apply): - RTE—read -to-eat foods Exsandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Nan-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other a plicable law. I have n instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec.49A,I certify u der the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: s-,7 - /� #-:2 6E V-// ' 26) Signature of Individual or Corporate Name: (�C� �141 S -S/-(.0-M �• z , tag j . ` 4 _ _ '1­ -1 yl�yil, 1� li,� -107 ��5 ���,-uoihmotiweaitiiot.massaciiusetts * _C5 �A city of Salem M, 'A tp'A Zz, p", 4k pv Q 410a BoirdofHealth_�` �Vilk Irl Mc 6y'44, SCOII �`IAU Washington iyork iz ,tv N4 1 'q SALEM,A Foott/Retail Establishment A Al Permit DATE PRINTED... A pg -BLIS A 'Ge- It' -­Q ng is* Me V A June 4 ­ 40J Lime File Number:BHF 20W000144 vlo, �2c.7l "On J, �v WNY, We _3j­ 41, %­l2 W A LOCATED AT: M wn,qx- nk Vy- _97W�� ALEK,�Mk `01 A* V AltFlV4" ? *tT indifIsime-d 'Tiimi'lt E -'�­FeeR0*,ttictiom;/,Nkei runt NQi Pe a Permit e Pe 5-1 'e; p 11 2": BHP-2014-023 WIN SERVICE n 1�2014,g­,Dic.3l,-2014,;,-' $140 00iAjTri1-OcC/,WATEk SOURCE PM4'17 'q s;-iC-IT.Y,,WATEkSEWFRD-I,S,P *,, tqT U ��ESTABLISIBIE 44" t-A �v V a_p�b UTYMATEK 4 d , 71 p *-00 ofid Foes: 04o' 'M �A _fA A, �k- ZiAk� Q W _4 0, f! - Y - Mill _T o� -4rl R "k, A 'A" ? p .....17 X, ilw 'A 0: -K� ffihi k a �r 24�, w 4P N*� 'M ... wl I - �0 PERMIT EXI flbiiiinl�e_ 31 2014 W -W, 0 kL 1Z. N"M -,;3 .-Q , w V M, i�� Y"A A� uard of HMithUr CA. v A 17 L -ONO W. W_�h Ifil �This Permitisnot t change 9fo-w-neris-hi mit musfb transferable mp46i,r6hsd4'4mlcfi p,,or 166tign.The per W� F1 g"', -,Fi , _,*rAk�. 1--' 0111 t�ki .4-­"r F in'a prominent Ioiition'in the Eiiabllsllim'eut'M�e�� U 4 --In accordance with the State Sanitary.'Code,­b6fre any re;vountioiis,--improvement,,,dreqiiionieiit-changes, all-plans for such must be submitted to and approved by the Salem Board ofHe'althSk v V­ Pagel _�p 4- CITY OF SALEM, MASSACHUSETTS >axesitn Boman or WAL II 120 WAsf IINrroN S'1Ri-.[er,4rii FJ,OOR KIMBERLEY DRISCOLL, Tc;I..(978)741-1800 FAX(978)745-0343 _ L kIZRY RAMDIN,RS/lUTIS,CHO,CP-FS • MAYOR lramdint salem.com HuAI;rHA(;ENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 6b-A)61+1S 2) Establishment Address: vx- Vi / v�11 3) Establishment Mailing Address(if different): a/D 11 p N / 4) Establishment Telephone No: 5) Applicant Name&Title: RIAJOW-A169f— .,,, 6) Applicant Address: /d�0 Nla� ST eu�•% 3aa �� 2na 0 7) Applicant Telephone Ro�7�969 o 'yZ 24 Hour Emergency No: /'-9lSn7"a EFnail: /t17G f/n/ 6�® G4 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address A corporation✓ OJI/I�V ' CHI AJ yjj SI 3a An individual "/ 109-64 A partnership AI&90 ti hrt O Other legal entity r Ir U,ILL`IZ r. .12 Person Directly Res onsible For dd Daily Operations(Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: /T /z /� � 1L1T 06LrN/6-9 -7 Address: ��� /v / /O Al �< Telephone No: bt 9 -"76/ - rte. Fax: Email: Nv T68-14) /A��®6 C04^ Emergency Telephone No: 6 /-2 -96 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: br�-Ll Date: �� I(o /— Amount: _ Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) S/1-YY1 SIDosAl_� 16) Days and Hours of Operation: InON,-M "0- 11 �l�ov`ra.. 17) No. of Food Employees: l 78) Nam a of Person in Charge Certified in Food Protection Management, / NGS G/ /�� Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) 0 Retail( Sq. Ft) 0 Caterer Permanent Structure✓ GrFood Service-( /? Seats) 0 Frozen Dessert Manufacturer Mobile ErFood Service-Takeout 0 Residential Kitchen for Retail Sale O Food Service-Institution 0 Residential Kitchen for Bed and ( Meals/Day) Breakfast Home 0 Food Delivery 0 Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments- ------------------- (check one) RETAIL STORE RESTAURANT Annual ✓ 0 Less than 1000sq.ft. $70Les�5 seats $140 Seasonal/Dates: 01000-10,000sq.ft. $280 0 Residential Kitchens $140 0 More than 10,OOOsq.ft. $420 0 25-99 seats $280 0 More than 99 seats $420 Temporary/DatesMme: ❑ Bed&Breakfast. hildcare Services(Nursing Home $100 --------------------------------------------------------- -------------.-----------------------------.................. ----------------- ADDITIONAL PERMITS O MAKE ICE CREAM,YOGURT/SOFT SERVE $25 0 PASTURIZATION $25 0 ALL NON-PROFIT" $25 *Including, church kitchens, state funded childcare&private club 23) Food Operations: Definitions: PHF-potentially hazardous food(fimeltemperature controls required) Non-PHFs—non-potentially hazardous food(no timeltemperature controls required) (check all that apply): RTE—read to-eat foods Ex.sandwiches,salads,mu/fins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs ✓ ✓ for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And ✓ PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum PackaginglCook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other pplicable law. I have been in rutted by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A, I certify under We penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: s 26) Signature of Individual or Corporate Name: �(16�f4S my Y A '.. yt �• .. £ 161 t Commonwealth'Of Massachusetts; Y. AK City of Salem Board of Health x Kimberley Dnscoll 4 _ z . 120 Washington Street,4th Floor P May m yOf A r v SALEM,MA -01970 } Y ; nk j Food%Retail Establishment Permit; 4-6 .: DATE PRINTED: 12/13/2012 k 4 :.,� .,. � ... x. : 8._ uz . � � sr� 3: • a0. �- `.sc.y ,€ ESTABLISHMENT NAME: x e >. Genghis ,i .- �� - `: , a. a aN; .s ,g _ File Number.BHF2004-000144 40 June.Lane "a„s Y .5' b ui Newton. s :' s =• MA 02459; _ '. LOCATED AT- 4 - T }_ § SALEM MA 01970 ' n z F { y Y aPermit Type Permit No: Permit Issued Permit-Expires t Fee'Restrictioas/Notes ++ X FOOD SERVICE BHP-2013-0172 Jan ,2013 Dec 31;2013 x$'140 00'4rii-o kv WATER SOURCE ESTABLISHMENT. s .<_ ` CITY WATER SEWER DISP x `CITY WATER m W v - � Total Fees $140 00 '�` � �� � � rte` � .� t. y�. . ,p MIft z. _ m s' K 14 4 , X gr k PERMIT EXPIRES December 31;2013' a r S.r Board of Health 40 pv This Permit is not transferable and.must be reissued upon change of ownership Sr location The permit must 6e posteds, li, in a prominent location in the Establishment. 41 In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, x m all plans for such must be submitted to and approved Ify the Salem Board of Health frt '<" page 1 CITY OF SALEM, a1 MASSACHUSETTS � Public,Heait]i BOARD OF HEA1:Tl-1 40 WAS1,IINGTON SIRt"t-T,4:m FLOOR KINIBERLEY DRISCOLL `12 Ti.,,[,.(978)741-1800 FAX(978)745-0343 LARRY RAb4DIN,RS/RF1-IS,(A 10,CP-FS MAYOR �' ' Iramdin@salem.com. HEA],'n I AGENT G - BOARD OF Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: 3) Establishment Mailing Address(if different): #ti A) oAJ Sl- u&L! v.3D 4) Establishment Telephone No: , /c�-- 5) Applicant Name&Title: 6) Applicant Address: AJ S oZ— A U d�J . Od-CLC 7) Applicant Telephone No: (j/ 96 �q�et 24 Hour Emergency No 7! Email:NTCH/N /6 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address A corporation✓ t1 p , / An individual A � � C I/lt/ 0 � AM oL10 1il dN _f *32.2— A -ZA partnership Other legal entity 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: /LE S - /U Address: A 1lj /. 644 / / Telephone No: �� Fax: EmaiA-WSGW//J/b L. Emergency Telephone No: b l l - 6 - d-- 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#:jnj Date: /� Amount: nrD Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) G/T //rW t � 16) Days and Hours of Operation: S I/ n�,, 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: y 2_1/A/Required as of 101112001 in accordance with 105 CMR 590.003(A)„ (/V J% 19) Person Trained in Anti Choking Procedures(if 25 seats or more): ❑ Yes No .N114 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑ Caterer Permanent Structures/ Food Service-( /.0- Seats) ❑ Frozen Dessert Manufacturer Mobile 0?Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: Breakfast_Establishments-___-_--_-----..-__--- (check one) RETAIL STORE RESTAURANT Annual;/ ❑Less than 1000sq.ft. $70 C Cess than 25 seats $140 Seasonal/Dates: ❑ 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 ❑25-99 seats $280 ❑ More than 99 seats $420 - -- ------ ----- --- - ---- -- -- --- --- ---- -- --- - - --- Temporary/Dates/Time: -- - - ❑ Bed 8 Breakfast/Childcare Seryices/Nurs- ing Home $100 -------- _. -------------------------------------------------------------------------------------------.----. ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 O PASTURIZATION $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare 8 private clubs 23) Food Operations: Definitions: PHF-potentially hazardous food(timeRemperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperature controls required) (check ale of Commercials PHF Cooked to Order . ( H lads,muffins which need no further processing apply): RTE-read -to-eat foods Ex..sandwiches,salads,, " Commercially of PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of.PHFs For Hot And / PHF and RTE Foods Prepared For Highly ✓ Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHF Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- _ Retail Sale ,- _. Animal Origin Perishable Foods Only Preparation of Non-PHFs✓ Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale. Events or Institutional Food Service Offers RTE PHF in Bulk Quantities - To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Pay Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have bee instructed by the Board of Health on howto obtain copiesof 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: _... ._. __. Pursuant to MGL Ch.62C, sec. 49A, I rtify u er the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: S 26) Signature of Individual or Corporate Name: �� S , FAX TRANSMISSION ELATE: TIME: __ NUMBER OF PAGES: ({WCLUDI"COVER) TO: �1 COMPANY: FAX NUMBER: G t"�3 FROM: PHONE:FAX NUMBER: MESSAGE: .�f Td WdSS:60 ETOE WT '200 'ON XUA WDdd I " TRANSMISSION DATE: TIME: , _ _ NUMBER OF PAGES: (INCLUDING COVER) TO: COMPANY: -� FAX NUMBER: _ FROM: VAYNE J. QHIN PHONE: FAX NUMBER: MESSAGE: Ak ��� Zig Td WdZO:OT ZTOZ OT 'q30 'ON Xtid W06J IL a- i CERTIFICATE OF Cq tell ALLERGEN AWARENESS TRAINING I Name of Recipient: Wayne J. Chin t I Date of Completion: 9/14/2012 Date of Expiration: 9J14J2017 Cl Cl 4�) q Issurd li}': The above-named poson is hereby issued this certificate J fce rorszplefing an alle?yen awareness trainrur,prniv,rung rrcn,nized by ehe A4assadyusetts Department ofPublir health Herksf.irc inuaordazxe with IOS Ci1d12 590.009 fGJ(-)(iz). AHEC Are.Itcailh Y lucatio.,Center ltris rertifseate will be valielforfavr(5)year-sfrom date of completion. Pawflew,nmssswill ms s"�l .��-y. »..Rv.nz�Eoodallergttriittingexl; E r CY tL r� EXAM FORM NO. 4736 CL low Se rvSafe CERTIFICATE NO. 9419608 CD ti tm 0 O ! ! 3 0 Se#wSafell Certiri(ccation ' . r To WAYNE CHI !'+,f for suuc^ssfulryr Completing the st?ndaids sec torch for the Se.vSaW Food Protection Manager Cei-ificatian Examination• which is accredited by the American National Standards Institule iANSI7-Corrference for Food Protection 1C.rP). o i 09/20/2012 ©ATF OF EXAMINATION 09/20/2017 DATE. ..^..E EXPiRAT.ON Local Taws-&;..fly.GhuG4•,vich yaur ica7i re9s'Ialrry ataenc;r.'v aCsrtii'sat on�a9uirenren[s. F si• � I 1 � +; NATIONAL RESTAURANT ASSOCIATION O Pau!Hina.ran nJ555 E:?ncutive Oitectvr, Notional Pestn,rznt Asl- raetiun Solutions •• +£;Y,tO itanrns:nesranr,,u[FsmNalun Ed,,u Ucrui Fae:dnfim All:ighlsrecsr.nd.Sery°<'p xndthe smsn(e lobo yrere stere)rrademskzu(Ilm 141liona117estamaIAsmc soon G'ostlagai FIr"dadnn. 0 ern o.m::>mrllr:cuse hr HOGus;'kua:mram Ascciadon SnL:ons.LLC,a ofidly un.neJ ntei9'ary oliho paiioual Ps;eaunrnAssucis:[n. 0 i.�ip=3srnnvcvt Dann._=Ua rnun,♦firrd o,ulw:ed. FAX TRANSMISSION DATE: TIME: NUMBER OF PAGES: (INCLUDING COVER) COMPANY: FAXNUMBER: FROM: FAX NUMBER: MESSAGE: Cf-00 op Td W8Ft:8O ETOE tT 'daS 'ON xuil WOad Gmail-Pilgrim Hospitality,LLC Transaction Confirmation,7iID:4318'/Uy4 wayne chin<wjchin188(fgmaiLcom> Pilgrim Hospitality, LLC Transaction Confirmation,XID: 43187094 t message Pilgrim Hospitality,LLC Transaction Processing<piigrimone@pilgrimhospital4.com> Tue,Sep 4,2012 at 1:34 AM Reply-To:"Pilgrim Hospitality, LLC"<pilgdmone@pilgrimhospitatity.com> To:wayne chin awjchin168@gmail.coma Wayne chin, Thank you! The following transaction was processed, This email wiii serve as your receipt For questions, please contact pirgr mone@piigdmhospitality.com. TRANSACTION DETAIL Merchant Name: Pilgrim Hospitality, LLC URL: Last Four Digits: 9619 Card Type: MasterCard Date&Time: 9/3/2012 23:34:40 Transaction ID: 43187094 IP Address: Logged for security purposes. YOUR INFORMATION: Customer Name: wayne chin m Address, 614 Dedham St. City,St.ZIP: Newton,MA 02459 Country: US Telephone: (978)6259232 E-Mail Address: wjchin168Qgmall.corn Customer ID: Description Amount Quantity Subtotal 13027598110.00 1 110.00 Transaction Total:110.00 Sincerely, Pilgrim Hospitailty, LLC hensffmail.umaic.comimailP7ui=7&,ik—do)O2dbfOT&view=pt&scarch=inbux&9th—Li9BPcb3G�t 68b(I 4f14;2012 Ed WtiZ#:r7 ZtiLn7- #T •das 'ON Xd. : IJ0 Berkshire AHEC-Secure Online Registration Berkshire AHEC Area Health Education Center . xnoutus Confirmation of Re istration 30th Atmrcersary Event Oniuii3�Rt:ylstraUOn ' .. Thank you for registering online!You have completed the process successfully!You should receive a confirmation of your registration via email shortly. Please close your 9 me a e. Educahcn and,7�imn browser window at this time or return to our o Healtli,Careers , PuonctlealU kNtiaaves R istration Summa ry c m(k(enre Management Confirmation of Order Connections, to the tdews Print Confirmation Con(actu$ wayne chin 51te.Nap Food Allergen On-line Training Quantity Amwnt Finenclal Option g10.00 I orna F.ad .. - Program eabtutae $10.00 subtotal for wayne: W-00 Grand Total: $10.00 Amount Paid:($10.00 Balance Remaining: $0.00 Order Confirnnation Number: 37439818 � ;rjv M...'4,& '�'Y , ,,',' .• ^.r Aja ! /J .�. WR.I,LEGR��'t:arfHGe C8 (M B%O�rQ� (Ar/lFf/ t od (A.,n�rrta c�/�attae H�alct Copyright- -- -- eluM,lla can FJ 1012 The Active Network,Inc. �Torms of Ilse�Privacy-Pollcy�Abqut Aetiye.cam :Dn6fle Reglvrav<,n i-vint fvtanas)'"ment and Keylaenon 3ngwmi. httne//thrive 9%14/20(2 art.ivenCllVVrk,com/lt,eg4i(S(rnlcnu4mscgY SY845mrg11Aw�5))/Norm.�epx'rc��keY-R�YOYP.x t3:17.. £d Wy£V:80 %NIDE VT -aa5 'ON XdJ 110dd rood Allergy Training for Restauranrs and Food Smiees Food Allergy Training for Restaurants and Food Services Your request for certificate has been submitted. i H. Network MassAHEC ire AHECMl�as& AneaHealth,EducationCenter. x`"°'• Berkshire AHEC is supported in part by HRSA,the Commonwealth of Massachusetts, and the University of Massachusetts Medical School as part of the Mass AHEC Network. inrn "Zr,:80 Ehiu"dlecnrt:/IlGtiPpnitillS/hnln�q>ap '`pFluins,�totvl uiONI, hui+enit t'4p�.rvk.IrhG 9ISI"a'D:PZ td tJHtb:8t3 ZL�+v �i 'dag Ot l xUj WOJU i- i Commonwealth of Massachusetts aCity of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/28/2011 ESTABLISHMENT NAME: Genghis File Number:BHF-2004-000144 40 June Lane Newton MA 02459 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2012-0123 Jan 1,2012 Dec 31,2012 $140.00 April-Oct./ WATER SOURCE: ESTABLISHMENT CITY WATER SEWER DISP: CITY WATER Total Fees: $140.00 PERMIT EXPIRES IDecember.31, 2012 Board of Health This Permit.is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for:such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM MASSACHUSETTS BOARD OF HEM;rH _ 120 WASHINGTON STREET,4„,FLOOR TEL. (978) 741-1800 KINfBERL.EY DRISCOLL FAx(978) 745-0343 MAYOR lramdin@salem.com LARRY RANI[DIN,RS/IWI IS,010,CP-FS H I Al xl I AG IiN'1, 201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT q NAME OF ESTABLISHMENT E. EA) 6A/f—), TEL# ��— ADDRESS OF ESTABLISHMENT / :29 FW J / :11&�54&k FAX# MAILING ADDRESS(if different) �� U N z4wr , 4/fr w/ dot/ , Mly o.�L���°J EMAIL- Business': / Website: OWNER'S NAME /tJ�yE- //L/ TEL# (2/7 -969 d-9 .4--,ADDRESS 4 -O .,_/L(AUG _/IjyJ d�� �/6Y� �/✓��S� �J� STREET ,• , a CITY/ STATE n ZIP CERTIFIED FOOD MANAGER'S NAME(S) W/T'�/�G' //(J CERTIFICATE#(S) - 5 ® �otS� (Required in an establishment where potentially hazardous food is prepared) Q EMERGENCY RESPONSE PERSON HOME TEL# pAYSOFOPERATION ' Monday­. l ' Tuesday ' ,_Wednesd - *,Thursd , ", `;,Fdd Saturday Sunda HOURS OF OPERATION ��� Please verde in lime of day. �/PM // PIY` // M ! /! For example 11 am-11 pm !7M TYPE OF ESTABLISHMENT FEE (check only) _ RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 --------------- ------- - ---------------------------seat-------------------------- P.ESTAUP.ANT YES NO ' Ips?han 25 seats =$140 +� , (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ------------------------------------------------------------ BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOM---- --------------------------------- ----------------------------------------------------------------------- ------------- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Wctjon 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns a paid all slate taxes uired under the law. /01 -01 Signature Date Social Security or Federal Identification.Number Updated 5/23/11 FOODAP201 Ladm Check#&Date •60 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHME SECTION REPORT Tel. Name Dat Type peratlonfs) Type of Inspection ood Service ❑ Routine AddressIEylq Risk ❑ Retail f/l�spection Telephone Level ❑ Residential Kitchen Previous Inspection _ ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Ch e( ) Time ❑ Bed&Breakfast ❑ General Complaint l n In: El HACCP Inspector E�WOut: Permit No. ❑.Other Each violation checked requ es 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 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ Allergen Awareness 580.009(G) ❑ corrective action as determined by the Board of Health. FOOD.PROTECTION MANAGEMENT_ _J_� ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties I[EMPLOYEEHEALTH - --�" El13. Handwash Facilities j PROTEC_T_ION FRO_M_'C_HEMICACS_ � ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives .� ❑ 3. Personnel with Infections Restricted/Excluded __..- __ _ _.�. -.,,..-._ _._ _ - _ , El 15. Toxic Chemicals -,F..000'FROMAPPROVED SOURCE - _-:, F.�, ❑ 4. Food and Water from Approved Source )TIMEfrEMPERATURE.CONTROLS_ .(P_oterltlalljlHa¢ardousods) ❑ 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 .REONTS FOR..HIGHLYSUSCEPTIBLE=POPULATONSt(HSP).D ❑ 10. Proper Adequate Handwashing ❑21.Food and Food Preparation for HSP ❑ 11.Good Hygienic Practices ICONSUMERADYISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order forCorrection: 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-2x590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-axsso.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-5x590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6x590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. Special Re (590.009) within 10 days of receipt this order. 30. Other DATE OFRE-INSP TI - S: 6�4doc / / J Inspector's SignatureK c / PICS Signature: Print: - Page of Pages Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from I 590.003(A) Assig m- ent of Responsibility* Cwked and RTE Foods*. 590.003(13) Demonstration ofKnowled,e* Contamination tram Raw Ingredients 2-103.11 Person in clime-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 i»charge to 3-302.11-(A) Food Protection* require reporting by food employees and 3-30Z,15 Washing Fruits and Vegetables a 1scants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To ReportTn The Person In Contam patron from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting b Person in CharLe* Disposition of Adufteraied or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590,003(-) Removal of Exclusions and Reatrictians 3.701.I I Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 4 Fnod and Water From Regulated Soarces 9 Food Contact Surfaces 59 WOIiA-B) C'om Bance withFo d Law* 4-SC>1.1i i. Manual washing-Hot Water - & xx 201.12 Food n a Henne(ica#I Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Prcducts* 4-501.1 IZ Mechanical TernWarhiresng-Ha Water . Sanitization Tem res* " 3-202.#3 ShellEags* 4-501.114 Chemical Sanitization-to H, 3-202.14 b,.s and Milk Products.Paste16741* �"P concentration and hardness.' 3-2132.16 Ice Made From Potable Nmkinq Waver* 4-601.11(A) Equipment Faod 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 51)4)O0}6(B) Water Meets Standards in 31.4 CMR 22.01 Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caug.,ht hfolluscaa Focal Contact Surfaces of E ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hix Water and 3-201.15 Molluscan Shellfish from NSSF Listed Chemical* Sources* to Proper;Adequate Handwashing Game and Wild A,4"hrooms Approved by 2-301..11 Clean Condition-Hands and Arms* Redularary AuthorN 3-202.18 ShellstockidenfificatiWhenn tto Wash* onPresent" 2-301.12 Cleaning Procedure* 590,004(C) Wild Mushrooms* �^ 2-301.14 he 3-201.17 Ganes Animals*.. it Good Hygienic Practices g ReceivingfCond@ion 2-401.11 Eating,Drinking or UsingTobacco* 3-202.11' PHFs Received at Pro er Tempetatnres* 2-x'01.12. Discharges Fromdhe Eyes,Nose and 3-202.1.5 Package litre it'* Y^ Mouth* 3-!02.1 i Frx�d Safe and Unadulterated* 3-301.12 PreventingContamination When Tasting* 6 Tags/Records:and Unadulterated 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.0{41(-) Preventing Contamination from 3-203.1.2 Shellstock Identification Maimained' --1 Employees* Tags/Records;Fish Products 13 Cndwasfi facilities onvenrenty 4ocated and Accessible 3-402.11 Parasite Destruc don* 3-402.12 Reu ids.Creation and Retention* 5-203.11 Numbers and Capacities* 3-4A012 Labeling of eation and R S-214.1.1 Location and Placement* Conformance with Approved Procedures 5-205.11 "Accessibility,Operation and Maintenance Supplied with Soap and Hand Drying i Conformance Pians 3-502.11 S Devices ecdalized Processing Methods* 3-542.12 Reduced a*t gen ck ng,critera* 6-301JI, Handwashing Cleanser,.Availabilit 8-103.!2 Conformance with Approved Procedures* 6-301.12 Hand"Dxn Provision 4 Denotes critical item iathe federal 1999 Paid Code or 105 CMR 590.(M. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page:__2Z!,tof _ Item Code C-CriticalItem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT C LEARLY VY 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 described, and to Exclusion p Emergency Suspension comply with all mandates of the Mass/Federal Food Code. s a ❑ Re-inspection Scheduled ❑understand that noncompliance may result in daily fines of twe -five d rs or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: 3-501,14(C) PHFs Received at Temperatures Violations Re)ated to Foodborne[lines&interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cant.) 41'F/454 Within 4 Homs&. PROTECTION FROM CHEMICALS 3-501.,15 CoolitiMethods for PHFs 14 Food or Color Additives 19 i#iF Not and Cold Heeding 3,202.12 I Additives* 3-50116(11) Cold Pl Fi Maintained at or below 590.004(F) 4101450 F* 3-302.14 Protection from Una roved Additives* 3-501.16(A) Hot PRFs Maintained at or above t 15 Poisonous or Toxic Subetences - 1400F * 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. " Containers* 20 7-102.11, Common Name-WorkingContainers* Time as a Public Health Control ' * 3-501.19 Variance Re Time as a Public Health Control* 7-201.11 Separation-Stora 7-202.11 .Restriction-presence and Use* 590.004( uiremem 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and l 7-204.14 DryiM ACria* .Bevm es with Waring labels* 3-801.11M Use of Pasteurized Eggs* 7-205.1 I Incidental Food Contact,Lubricants* 3-801-II(D) Raw or Partially Cooked Animal Fowl and { 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of T►MEREMPERATURE CONTROLS Animal Funds That are Raw.Undercooked or ib Proper Cooking Temperatures for PHFs Not Otherwise-Processed to Eliminate Patbo gens.* 3.401.11A(i)(2) Eggs- 155'F 15 See. EM--s-immediate Service 145°F15sec* 3-302.13. Pasteurized Eggs Substitute for Raw SlieIl 3-401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155'F 15 sec. 3-401.118)(1)(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3 401.11tA)(2) Ratites,injected Meats-155°F IS 590.009(A)-(D) Violations of Section .590.009(A)-(I3)in sec.* catering,,mobile food,temporary,and j 3-40111(A)(3) Poultry,Wild Game,Stuffed PRFs, residential kitchen operations should be i Stuffing Containing Fish,Meat. debited under the appropriate sections Poul or Ratites-165°F 15 sec, * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3401.11(A)(1)(b) All Other PRFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(x)&(D) PfiFs 165'F 15 sec. * (Items 23-30) 3-403.11(B) Microwave I6Y F 2 Minute Standing Critical..and non-critical violations,which do not relate to the Tile* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and JOS CMR 140'F* 590.000. 3403.11(E) Remaining Unsticed Portions of Beef mIteGood Retail Practices FC 39�oxvo Roasts* ` 2I 3. i Management and Personnel FG-2 .003 i 18 Proper Cooling of PHFs 24.- Fax!and Food Protection FC--3 .004 i 25. Equipment and Utensils i FC-4 1075 i 3-501.14(A) Cooling Cooked PHFsfrom 140`FtO -I Water.Plumbino and Waste FC-5 .006 70'F Within 2 Hous and From 70'F 27. - ! Physical Facility i FC-6 007 to 41'F145'F Within 4 Hours. ' 26. Pasanous w Toxic Materials FG-7 .008 r 3-501.14(B) Cooling PHFs Made From Ambient 29. S eciai R uiremems .000 1 Temperature 1agrerlients to 41'F/456F • 30. i Other Within 4 Hours* s5sa:,ma�ru.:.c *Dtm mq crincat item in the federal 1999 Food Core ur 105 CMtt 590MOM t i Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax (978) 745-0343 Name D / T BOO rations e f Ins ectfon (( Mood Service Ina Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owneri n HACCP Y/N ❑❑ Caterer E3Pre-operation ❑ Suspect Illness Person in Charge( IC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector ) Out: Permit No. ❑Other Each violation Wcked requires an p ati n on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. P ention of Contamination from Hands El 1 PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH . Handwash Facilities - - - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.9pproved Food or Color Additives El3. Personnel with Infections Restricted/Excluded L_�5.Toxic Chemicals / FOOD FROM APPROVED SOURCE -. El 4 Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements (:117. 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.HIGHLYSUSCEPTIBLE POPULATIONS_(HSP). El21. Food and Food Preparation for HSP [I 10. Proper Adequate Handwashing _ ❑ 11. Good Hygienic Practices [122. Posos ting of Consumer Advisories .4 Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below c. x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(5590.090.0 044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-5)(590.006) the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-S)(5so.00s) establishment operations. If aggrieved by this order, you 7. 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)(590.0011) and submitted to the Board of Health at the above address 29. Special Req uir (990.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:59JlnspeclFom514.Ex Inspector's Signature: Print: 1 PIC'sSignature: Print: �� �G� C Pageto�Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination i ' S90.003(A) -Asia t ment_ofResponsibility*� 3-302.II(A)(0 Raw Animal.Foods Separated from Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* _ Contamination from Raw Ingredients _ 2-103.11 Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables alicants* 3304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In - Contamination from the Consumer Charge* 590.003 etin b Person in Charge* 3-306.14(A)(B) ,Returned Food and Reservice of Food* G R Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of.Exclusions and Restrictions - 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE rte* 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces - 590.004(A-B) Compliance with Food Law* 4-501.111. Manual Warewasbing-Hot Water - 3-201.12 Food in a Hermetically Seated Container* . Sanitization Temperatures* . 3-201.13 Fluid Milk and Milk Products* - 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem ersttures*- 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 ChemicalSanitization-temp.;.pH; 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5=101.11 ` Drinking Water from an Approved S tem* ` 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 EquipmentFoiod--' ShetBish and Fish From an Approved Source Contact Surfaces and Utensils* 4-70.2.11 Frequency of Sanitization of Utensils and - 3-201.1.4 Fish and Recreationally Caught Molluscan Shellfish - Foal Contac[Surfaces of Equipment* 4-703.11 ,- v 3-201.15 Molluscan Shellfish from NSSP Iasted Methods of Sanitization-H.ot,Water and Sources* Chemical* m 10 Proper,Adequate Handwashing Ae ulafo Authority - Game and AutWilMushrooms Approved by 2-301.11 - � Clean Condition--Hands and Arms* 3-202.18 Sbellstoek 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 - 5 Receiving/Condition 2401.11. Eatin ,Drinking 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 Contamination When Tasting* 6. TagstRecords: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 10 ees* Tags/Records:'Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients* 5-204.11 Location and Placement* q Conformance with Approved Procedures 5-2(15.11 ..Accessibility,Operation and Maintenance tHACCP Plans - Supplied with Soap and Hand Drying 3-502.11. Specialized Processing:Methods* Devices 3-502.1.2 Reduced os ance wigen packaging,criteria* 6-301.1E Handwashin Cleanser,Availability 8-103.12 Co. Approved Procedures* 6-30L12 Hand Drying Provision '-Denotes critical item in the federal 1999 Food Code or 105 CMR 590000. a. V �� :'117.1. ��i'�Ti!. i ►.. .� _.�.1�'!�_lr 0IvagG�T.NIF"I IJAI=1 V44 -W jb &S r4MATOM 217117 VIWATA� Eli Ma =w!F#iMJI1 !,ISI.�a1i'.MPIUMN1�41►.►�!�7�1�}7�=11 your food permit. . . . 3-501,14(C) PHR Received at Temperatures Violations Related to Foodborne Illness bnterventlons and Risk According to law Cowled to 'I Factors(fietns 1-22) (Cant.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolin Methods for PRFs 14 Food Or('Alar Additives 19 PHF Etat and Cold Holding 3-501.16(B) Cold PFs Mantained at or below 3-202.12 Additives o 590.0040 4101450 3-302.14 Protection from Unapproved Additives" F* i 3-501.16(A) - Hot PHFs Maintained afar above 55 Poisonous or Toxic Substances 140`P. 7-101.11 Identifying Information-Original 3.501.16(A) Roasts Heid at or above 130'17. ° Containers* 20 Time as a Public Health Control7-102.11. Common Name-Workin Containers* 7-201.11 Separation-Stara * 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* 590.004(H) VarianC'e Requirement l 7-02.32 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitize".Criteria-Chemicals* 7-204.1.2 Chemicals for Was Produce,Criteria* ZI 3-801.1](A) Unpasteurized 1?.re-packaged Iuiees and t .Beveraees with Warmna Labels* j 7-204.24 n eats.Criteria" 3-$01.11(8) Use of Pasteurized Eggs* 7-205.11 Incidental Food Co ntam Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and t 7-206.11 Restricted Use Pesticides;Criteria*' s Raw Seed Sproms Not Served 7-206.12 Rodent Bait Stations* 3-801AI(C) Unopened Food Package Not Re=served. 7-20fi.13 Tracking Powders,Pest Control and Monitoring! CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted fir Consumption of 16 Proper Coaidng Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Odterwisa Processed to Eliminate 3-401.21A(f)(2) Eggs- 155F 15 Sec. Patbo ns.* Eggs-Immediate Service 145°F15sec:* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec.* SPECIAL REQUIREMENTS + 340111(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590-009(A)-(D) Violations of Section 590.1109(A)-(D)in. 3-401,11(A)(2) Ratites,Injected Meats-155`F 15 sec.* catering,mobile food,temporary and 3-401.1I(A)(3) Poultry-,Wild Game,Stuffed PHFs, residential kitchen operations should be t Stuffing Containing Fish,Meat,. debited under the appropriate sections c Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness ,r 3-403.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-441 A IW(1)(b) All Other Pt s-145°F 15 sec.° 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3403A I(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Timc* foodborne illness interventions and risk factors listed above,can be 3403.11(C) Conimeroially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 1400 590.000. .i 3-403.1l(E) Remaining Utuliced Portions of Beef lann 1 Good Retail Preadcas 1-FC 640.000 i Roasts* j 21 1_ sn amen and Personnel { FC-2 .003 18 Proper Cooling of PHFs i 214.. 1 Food and Food Protection I FC-3 .004 1 25. 1 Equipment and Utensils FC-4 .005 1 3-501.14(A) Cooling Cooked PHFs from 140`17 to ! 26, I Water.Plumbing and Waste i FC-5-7666-1! 70°F Within 2 Hours and From 70°17 27. l Phys cal Faci 4ty '-' FC-6 .007 to 4FF/450F Within 4 Hours.* ; 28. 1 Poisonous or Toxic Materials ' FC 7 .008 3-501.14( 8) Cooling PHFs Made From Ambient 29 Special Requirements .003 Temperature Ingredients to 4PF/456F - 30 l other �. f Within 4 Hours* 'Denotes Critical win in the federal 1999 poral Cale w 105 CAIR 90.Ot)0. 'r f F 24 At =10 _ LIM ...A..� M ' , ' MUM 0 ra VI 911 NOR M,MAMOM Jam' l 3-501.14(C) PHFs Received at Temperatures - Violations Related to Foodborne Illness.Interventions and Risk According to law Cooled to Factors(Items 1-22) (Cont.) 41'F1457 Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Conlin Methods for PRFs t _ 14 -)Food or Gator Additives lg Pt1F riot and Cold Holding 37202.12 Additives* 3-501.16(B) Cold P13Fs Maintained at or below r 3-302.14 Protection from Unapproved Additives* 590.004(F) 4101450 F* 15 Poisonous or Toxic Substances 3-501.16(A) _ Hot PHFs Maintained at or above { I40'F. 7-101,11 IdeneifyingInformation-Original 3,501.1 (A) Roasts Held at or above 1.30'F. Containers* t 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control t 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-presence and Use° 590.004(11) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPT18t E 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS HSP 21 3-&01.17(A) Unpasteurized Pre-packaged Juices and �' 7-204.t2 Chemicals for Washing Prcxhux,Criteria* Sevenaes with Warning Labels" 7-204.14 Drying Agents.Criteria* 3 801.11fB Use of Pasteurized Eggs* ;1 7-205.11 Reidentel Food Contact, ,Criteria*s* 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 Bair Smtinns* 3-801.11(C) Unopened Food Parka N 4 Re-served. 7-206.13 Tracking Powders, Pest Control and Monitor in * CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3 401.11A{t}(2) Eggs- 155'F 15 Sec. Pathogens.'�`"'t i3-302.13. Pasteurized Eggs Substitute for Raw Shell , E -Immediate.Service 145'F15see- Eggs' . 3-401.7I(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec. " 3-401.11(B)(1)(2) Pori:and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.]1(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-{L)) Violations of Section 590.009(A)-(D)in sec. * catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHF's, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-765'F 15 sec. * above if related to foodborne illness 3-40I.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and Tisk factors. Other 145OF* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under k29- Microwave 165'F* Special Requirements. 3-401a(A)(1)(b) All Other PHFs- 145`F 15 sec. ' 17 Reheating for Hot Holding WOLA710h1S RELATED TO GOOD RETAIL PRACTICES 3-403:11(A)&(D) PHFs 165-F 15 sec. * (Items 23-30) 3-403.11(B) Microwave 165'F 2 Minute Standing Critical,and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed abate, can be 3-403.i i(C) Commercially Processed RTE Fowl- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3-403.i1(E) Remaining Unslic:edPortions ofBeef j Inert ! Good Retail Practices ; .FC I 590.0W i Roasts" X23. 1 Management and Personnel ! FC-2 1 .003 - 1 lg Proper Cooling of PRFs 1 24. ! Food and Foal Protection FC-3 004 -i 25. Equipment and Utensils 3-501.14(A) Cooling Cooked PHFs from 140'F to 1 26, Water.Plumbin2 and Waste FC-5 .006 70`F Within 2 Hours and From 70'F 27. Pt cal Foci' FC-6 007 to 4 VF/45°F Within 4 Hours. * i 28. Poiscmous or Toxic Materials FC 7 .008 i 3-501.74(B) Cooling PHR Made From Ambient 29. S ecial R uiremams ,003 l Temperature Ingrediem&.to 41'Ft45'F 30 I Other ! __ Within 4 Hours* s� ±s,.+�:�.•.m: �4 'Dem)tu critical icvrn in the L-decal 1999 Foal Cmie or 105 CMR 590.000. ,r