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GEORGIAS PIZZA - ESTABLISHMENTS 074 r ftNIVERSAL® I UNV-12110 MADE IN USA SUSfAINAR� Mgq,pEyy(,�/T'1 �� OplD3Q1014 C~FiibotSwrcft mnt:m l I Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01106!2011 ESTABLISHMENT NAME: Georgia's Pizza FileNumber.WIF-2009.00035 28 Norman Street SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No Permit Issued Permit Expires Fee Restrictions I Notes FOOD SERVICE BHP-2011-0191 ,Ian 1,2011 Dec 31,2011 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31, 2011 y Board of Health f This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 ,r, CITY OF SALEM, MASSACHUSETTS a BOARD OF HEALTH 120 WASHINGTON STREET,4'"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 INIAYOR DGREENBAUN19SALEn1.CONI DAvID GREENBAum,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Gc QIL G[ffiS Pt Z2 TEL# M9 ' 7 �0 — 2S D ADDRESS OF ESTABL.ISH1I1ENT 2,,�N D�. MA-fNI FAX# MAILING ADDRESS(if different) Snlf__ '1 Vill- - 002 -0 EMAIL-Business': Website: r�� t� OWNER'S NAME I ) , Olt C �-e_nc9 TEL# '-//u' ADDRESS_ `JtI TUL_TON STREET CITY J STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) V �'C 5E Imo-) f CERTIFICATE#(S) pos: (Required in an establishment where potentially hazardou food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# 0A%OF�OPERATIO . .Tuesday: 'Wednesday Thursday 4' Fridayy,` , i .N;Saturda '71 HOURS OF OPERATION 1 ooavq Il;oo��4fi 11!�omi Please write in time of day. 11'-�o fNrvY1 I(',.,moo i1rw1 ((i d 0 el,vf _ Forexamplellam-11 Io.3D 'fn to,. Ez?�! -Dory)!h11. '0`o h"rl TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES d0 less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ------------------------ •�-- --------------------------------------------•---------------------------------------------- --- --- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$2 25-99 seats =$280 more than 99 seats =$420 -_------------------------ BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES/NURSING HOM-------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and ai all state taxes required under the law. J;R110 jj-a6-ro �`1 - �� y � 3o Signature/ �_--—_--Date _ Social fSecurity or Federal Identification Number Revised 10/7/11 FOODAP201 Ladm Check#&Date Ci T +' Commonwealth of Massachusetts ` • City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: Georgia's Pizza File Number:BHF-2009-000035 28 Norman Street SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0021 Jan 4,2010 Dec 31,2010 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS * BOARD OF HEALTH 120 WASHINGTON STREET,4m FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978)745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GREENBAImi, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT G C U° �j22a TEL# 97S - t!Fo - 2ga) ADDRESS OF ESTABLISHMENTNLYI'Y)m <S FAX# 9)9- 5110 - 2372 MAILING ADDRESS(if different) EMAIL-Business': �\ I Website: �7 OWNER'S NAME VIOI1 1(a EE � TEL# 999 ` tl - q20 ADDRESS 171, ILL 5 I I I I-I STREET CITY ,— STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) I�F n C^, CERTIFICATE#(S) �n,45 Lill—002,'7- (Required in an establishment where potentially hazardo6b food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# ERN T, ? Montlay � $�Tuesda"" � ,WeSlnesda �. T,hursday �FndaySatutdayt SunCay,; ( HOURS OF OPERATION 1t I pyyt _ t t Ckm e 11 CXM - Please write in time of day i —,T> ) I -T-7 I m For example 11 am-11 pm I(7 f7m T— - py1'1 lO TYPE OF ESTABLISHMENT O FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 - ------------------------ RESTAURANT YES NO less than 25 seats (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ----- ----------------------- ------------------ -- --- -- ------------------------------------------------------------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME----------------------------------------------------------------------------------------------------------------- ------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES `N0') $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. Signikire Date � Social Security or Federal Identification Number. -------------- - --------------- --- Revised 424/07 FOODAP2008.adm Check#&Date $ � CITY OF SALEM BOARD OF HEALTH Establishment Name6- 0ayin S Date: I I (U -1 Page: I of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- F No. Reference R-Red Item Verified PLEASE PRINT CLEARLY Al l'' JI [JS � _/ _-le v / //�]/ ` i D1U U . _ . _ Knd 14M p iit , f 4 roo / d S. r - o f n pie C/ r :yP i r i L / ? 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 L1 Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five'dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. C2Voluntary Disposal ❑ Other: l 3-5i!Li4(C') PHF's Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Lau•Cooled to " Factors(!left 1-22) (Cont) 41-17/45"F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cixilin-Methods for PHFs 14 Food or Color Additives � 19 PHF Hot and Gold Holding 3-501.16B) Cold PHFs Maintained at or below 3-202.12 Additives", 5WN)4(F) 41°/45°F' 3-302,14 Prutec6on front Unapproved Additives"- 5pj., -V)) Hot PHl c i4taintainesl at or above I 15 i Poisonous or Toxic Substances I ---� 140,F, - 7_(01.11 Identifying information-flflginal i - , I Containers, t i. Roasts Heid at or.ibavc 130,F F-- - --� 20 ( - Time as a Public Health Control 0L t i Cu amen\amt !t Li i it i lin rs"- -1 j i� d_ I 70LIS ) _ n s Publicl altli Control'_�S1j>a,iucn. 5t,ra � _ -__� � gO,l){lUH) � t mceRrutnt�.meat 7 2e}2.1' F.+t x roti Fr sole( u d 6._e 7- 02-122, chton of Use,_�orle .__ ---� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE r -,'03 t 1 Toxic f oni unci f'roirdririon. 204.11 , Sannveis.C'tite p+ - " -J� POPULATIONS(HSSP)Chcr uc s '04.12 Chemicals fill W hil. oducc rite r— t (3_Spl.II(A) InP leurind Pa iae}.abed Juices and 7-204,14 DrvrjLAt env.C ria i i` �- - - 13c reg i es with lAaraill,l,Ishak." L`.t of Pas tv cored{ l r 7 2Ci5 1 _ L d ntal i wd i u�t�c� tubus m , a i b(!1 1,'(D) 1 R:rw ut Ptrtall l c:u d Animal F�,d sed I 7_ 061 i2in"n r aisc Pe ncirie Cuteui' I •-— -�. _-. ka Sc ci prowl Nut Served r 7 W6.12 , Rcxl n $+ urtm 1 so r — --'— --'- -= 80i 1 i4, �c� r) neer Foca, t ;a_, Nol r�.On.l z I r:!•Khtg Pov+der P�Sa f,r,±4r.i Gild { ' _- -- _�.......___._._-.. .Hisao toi im- CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 21 3 t>(P 11 r Cocsmner e sore Post.d 1br(:rnt.c llopu cn oft -- --- - - - - , t liner ! ! ,xl hx ac R, Cnderux,kedi 16 Proper Cooking Temperatures for j ,n r1t(t rvicc F'ascss ' z '',t inks t - t.I PRFs ( ( ' ._____ -_ - r ! ' P ich n n V 1 a 10L11 �(,le' riF 5`F I C, i i f siu v, 1 t I:=:4 ,tali n for Raw 1 �t c 3inr,xd etc 4c vim11 -. 1 7--ek- L i -,-;_i1_'._frl)(2, c,rcrnFnn4€df.h. 1te 4E.;ai,pe j i ( - -- ' SPECIAL PE_OUIRERENTS _ -'OLt '13)cls ', 1 ilois lmd P;� Ri, qi 171 roiW 3 Vic itf ar„(V se licirr %3f)+3t7 ��;-„)) ;n� a)r, air Ai- D I S< r (� } i e at,rf in ne€ul�tiAxl. tell(p,t alL-s id a-401.11rA3OPu=ri l� t Stn a :rd(, , p'lits, 1 t t.:;�id tit 11 kitchen 013 i tt4p.sliu Id lac j `a t aarL h`IIeAi un, f[5b h'.,�t. + dl)It U ,.HICS'tilt 4OOCJ,.F;2Ei4 >Cl sJSSS lSdtt l :riq't': ' !tldh? ,fx, 0 e 3 -u1_L r. i_ a11L ._.- 0,:—r , i 'a6.�AS iu 14[1') PC,aiffit if, t __. .-._. -t - - 3 of i y i VIOLATIONS t I ATL,, tJ C060 RE7Atd. i'R,�C> CC'S i i c { Ruhe'lftrt tat Nat H rA n '— rr _.1 _ .. ....._ 3-403.1, (A)&i D! � PRI, 1653 t e _ 1 (Tfezn423 Slll t(33.11rf31 i Ota ioufnn- +5r,2htmtr Srandins�, r"r,urt Irl r, r rreal u< tars, act rh c:o aril: e tt< .i,v llfw,ih,rmv iib.s n wt i("Ili n-) chit riff j Alar,(ti Ua.t+ Y', tR4>B 1L 1-403.1 I ( ) f rn n t is !s Ihca d 2[i 1-,O- fi nr rr lu f fle,l, ac'. n e Food Cod.and RiJ 1iC WR 41l f 00.00o 4L i!t1 ) ' [2 Iasi mil Cnsnt,u Por.x ns n1 tsar Item Grood Retail Practices !=� 590,000 . ._ __ ._ , 1 k gist>” iviaa ag nc I wid Pel jnnm Fl > 003_ 7 29 f Axl di o xl P o e t r^i F-C. 3 ' 4 Ig 1 Proper Cooling of PHFs J - - _ - ...._ ' 2' tau rn u rn and tJte�i +s _ _ f 4 'Ca5_ a s -5{!1.iv'(tU ( i un,ittrn Caai, d PH1's Fran E nr"P to i-2e rfa•c ni 1 ta'Iy' t J ,ie PC 4 O0c - , _.._ _ . ___ i-._ -- • 7t'F Within '1-tou slid t rum ib!''t ' - : 1 '7 t lsy of Fa nT_ _ F{; t .8G7 a tl F '1J`F Within tl curs_" C_ 7 00,2 PFiF M1 Frcirn 1inh2nt F mirraltoe,tw redi,.nts,i " kft5`3 7 1.30 Other t4%Ji ins liercl'�` -,;oJ. ,x_' IS`-.S_1lt iS 'Iff CITY OF SALEM BOARD OF HEALTH Establishment Name: C_t_ovo ,ld� Date: o Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified s' PLEASE PRINT CLEARLY a2v -hau of- ey i inl 1, til ,S� } . . _ 14S (MCI 1� - 10 I ,�) , t- 1 M7 3o -,�)r) IY I , I A,r r t I u o W 1i� K- .t D -Mq cel CQ 60 S ` >m 1 n & a ° c SOC o �1� 2 i W, - in1 i- n_i J (i In _ T"Mofi o'c-s t) Y NW1Q 1/ Cwvd. Gn mL I - (29 [' k 1 _ rev) Discussion With Person in Charge: t 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 of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 1- /j c �l`c -- � ❑ Voluntary Disposal ❑ Other: 1 ✓ i ! �> 3-501 )4(C) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Law Cowled to Factors(Ite1Hs 1-22) (Cont) 411-/45`F Within 4 Hours- PROTECTION FROM CHEMICALS 3-5tt1.15 � Coofimt Methods for PHFs 14 Food or Color Additives 19 PHF Hot and gold Holding --- - 3-501.16 $ Cold PHFs Maintained t o 3-202,12 Additives" ( ) H Mmn 1 rs a or 590 004F) 4t!45°F` _ 3-302.14 Protection from Unappmwed Additives-� 1-50LIO(A) Hitt PHPs Maintained at or above 1S Poisonous or Toxic Substances 140,F . ',-MIAl ldentihingInto]imlion-ori�itnd ;_56,`A) + 1I Rt Roast.,Held at or above 130"T. OlJt C tiu<n Ul It Containers - t - - - —a .-- }-- -- --{ ; 2tl � Time as a Public Hoalih Control 1 t_..7-102. ,11 ' Gumnum'Yams Ktrt,i ig<<�al tin r. _ ----�- -- -f --� i 3 � r Stula < _. l In<.as a Pnhiu i9ealth Cunit'al' 3-2(72.11 1 Ite�t �o.tion-Pr��enceutu i�ze" . L. )(Mx 1 lu V sae 7-20'112 Condition,of Lsv" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203 11 _--} Toxic f oltt tmei Proh.. .... POPULATIONS{HSP} ?-204.11 -r Sanikets Crittn�, Chemicils - 204.12 Cflenrc tic for�_ ashes Yr<x1�i c tlatu..a" ! 21 ( 3-801 1 i(Aj l nta.tcuritcd F i {.acl-, ed kucas and f 13tePi 1 es xi[h eimlry lab is' ' r '04.14 Urians Ai n r.(nt u r ! �- -t--- -d--- _ > Sit! I1fRi UKof Pa2r aired _ A05.11 Lum mall xxl criatri Sash ups_ _Ri11 {I)1+Kat o i',-iiah_ CiKik Aot�wl l-txnl and- ? ?06.11 ; F_c:�sl c d .srPe tnide� Glis l't1 i;l S t ro ri ti f. icrvca 206.12 Ra fll 13"11 vtalUi, �- — . . t Y-;— ( i t tt c61 ;', Aidrx t No, 1Z_Ct t-c1. i l;a ,.rgP.rodsr 1 alt reit 'to., T _CONSJtvtER ADVISORY _ 7 2 t •1>?>---f I , n ;rel rcr tri n t'u t al ,'r r xu cum dvq ohm TIME/TEMPERATURE CONI ROLS 1 i rn e f, u `n i ii n r 1�T Proper Coot,mq s mperatures tot 3 t xv 1 , l . 101,I f 1(t1 ,, } a 1 - 111' o + r s c �$ �iltsl r. �Nu Sl}1t 1 . SPECIAL t;Ec}t rtElhCNtS 401 11titt arc 'iav kiijist 121 ttin F T jls I ciilerii, mi!,al,, te.riporai.v and ' Alf.7eUi),� i�.. 3c }`.t�5 nJ,;. '� ; E,=i ! > .S. ! it t .,.iV ,i.t3ka`11'Q Cc ,1 , #.r. FiO,. b1�t t;:rEit„a tu�rh.rtits a11n'n+t:?at - . ..... i i ' tir;i La CFi r;'isTS. i V s Cooldin11 o V9LrATIC7ttS RELATED TO GOOL°RETAIL PRA CT ICES 0111iAlhi 3 1 1111 165` ' c (ltetnF23-.1r1) 403.S,LS; Stit owt,' I+ F 2 Mini S14r'dic, I Cui xt..inon,f xt wwih do;,w ! 11111c, cn c ri wo rid tat rf,r,1-err 1 z (rr^1u• ( 3403.11€C) i (oatncx;ia,ly i'ztx.,:cd dl 1.Ftxai- luarr.t ri_ .:j � ,rgse;,u.,��r Thr ro,+t t'nuc ra_t2 r. C<:R . I ! ' W' F' kiliuiln” LnhWed Pulr.o.s of 3?sx,f tie t Gaal Retain Prarlicev FC_ i 590.000 ._._..._ i-_ vJ+tor Pi.;,bl Pf<r - t _ FC [ 18 24 . -. Fuw,' rod axil zriC FFG i Ck = artagnmEnta d L t8 Proper Cooiing of PHFs - -- - - -i•--- + 2 r m rc er,anC Ute t 1 a _ F - 00 13.)01.Is(A) ( t txrlln, C(k)kdPHl=s from 14TE £t t t. 1 se FC-5 0(i,- - - j t i -u LS'iaim 21fcurs mid Frori rfFF�'s FC 1 r - - t>t 1 Fa i - 6 " i t/4i-- k thin tHini is " a .2d ; r As ois or rypr h rias _. 3-501144 C(i ;Pi{F Miidv Fmin Amciont -_ ° i Si his Ft-20fer e 1 Tmperatare lal,rcdients 1(''41 F45'F 3t� �thr Within 4l'kmrc-+ . ... n nt__ticA . Fn f-;c_ 10 ! .,:if(' CITY OF SALEM .t BOARD OF HEALTH r Establishment Name: Date: Page: of `f nem Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date - No. Reference R—Red Item TV6rified PLEASE PRINT CLEARLY 11A, ,1' > c� ksz�n 2 Uw n tri_; l Q 11160 - W!2 O. C1 n l l 1-ea Opf 1 (if \� n n U1OA t N1 S I( tT VI <8f 110 1 Q 1 C In s U� XK U 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 as described, and to Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that P ❑ Re-inspection Scheduled 13 Emergency Suspension noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. n/ / %? � // ( ❑ Voluntary Disposal ❑ Other: 3-501.14fc) 'PHFs Received at'remperatures Violations Related to Foodborne illness Interventions and Risk According to Lau•Cooled to Factors($etas 1-22) (Cont) 41'F/45"F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Coming Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives 590.004.(F) _ 41 (45'1 3-30114 Protection front Unapproved Additives, 1 3_59L16(,A) HntPHF. 1S Poisonous or Toxic Substances ^' # Maintained at or above ((11.11 ++ Idcn�fo+mation Oi� mai ]40 F. ° 1 7ti1 'I ri(A) Rwsu,Held at or,above 1301;." I Contuner+' - — +-- — ---� L2p _ 1 Time as a Public Health Control 7 It)Z t It ' Common tiama i -, Tim, Public Health Control`_ i 301.111ipa+uicn�5h++a _ -� )U=1fW(fi) — �4` raneeKeuirement 7-202,11 - - 7-202.12 Condition:,of!.Iso" __________,_�) ^_03.11 Toxic Cowain..o -Pcoh;bicor,,>"' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(NSP) Suunveis C rile it C"hwzic I - 11 � 204 12 _ _C`hrnveaiti for� «ha 3 I ndu e C rnr tai' 1 21 -,-1,0 1 I i(A) tinpastem,� d Pry laai}nl;cd Iwccv and I ( 77U4.I4 U, irAtera�.Cote ii - .--� � _ I3�tierr s vola tit etmn tab,,is' 11(B) lav of Pa wiliirrd E ci, /-205.11 Laid ntai ;x,d S un+u3 Lunt+ ante 1 — — ^--- -- (,SOLI IfUt Rmr or Pail-alk,Ci )i6fd Animal Faid and 7-206.11 Rc ++c+ avc Pe nude. C:+re+ a -i---- --- R 5 d Sproms L suss o 7 ,06.12 ' R(,de 13 6 1 S:auo s t _ - YCI 1 �f{ =n c ed Kxxi Par n iAot d -e tiCT ?061 � l r. r+ i i'usd: P .;?.u,�1r,1 <u+d i - -L( F \4�naorm '. i CydSUL : i _ ADVISORY TINEfTEMPERATURE CONTROLS C' nwf c + �i lar(rnz..a c�zo;a•�( Piaper L'notc'In Tem et aturas for ' 1 ! ' loss+c t 'r xlc tt rt me f.. 2� t.nct cc<x p11Fsi C �, Is Pie t. z ,--`, irn .L..— ...__..-_ .........-.4. _ ...._. -------- >i it 2 shin 1 tili.l IAl i y�:: i t Y ., � + I -. 1. -_.... 5+ If .rlell.d+t>h a C in+ t't rh € _ +. , az �._... n n i ` I _ ,_ -- 5PECi lL REQUIREMENTS 1391- 01 min ,- - - - - -- ratcr,B,- ,4f bikl fi )it. tewpor u v and AP + y +• 1§'nom C•x,'.". °.e i + 1 �F.i tl,d� ?i {:.3�3 , U3, i ::SUS i1;Pillai i`i I Corif toll3 1 Fis; +,-a[ ! t'CFsii„ af=.,'!i'(ala a! )r6rtria ,3 F'1l7fi 1 a .S R3 i• ; ,E,tt'a', i4 i );.,•'i:t Fu + ,"`?}r +111,`6= t+. :tt7.- I ! 7t1,(n7t uct :•<, til cat o to t f al"f i, t i t 4� i .t:7.1 a7, . ii+ t tt y r 5 7 17 Reheating to tint 1 al ing VIOLATIONS PE"LAT D TO GOOD RETAIL PRACn, {:S �, -.._._..._.._.. _ ....-_�. .__... _ ...-_. .............. .4 idal hAjiia EJ1 1 [ 1 les"F i WC, _ (Pents23-3A) 4b_^,..1t(b)- 4143uv .vc n5'F2 Mi w s Suloi r rmAnnrnc t?i "if rr;`op to ,nd=i,Ain orr(ivc,f,; , r<eibe ---- 3U ; SU(tip 403A HE i I i2rot a ing L,c, sit Pt rEzon,of Iia=; + , Item i Good Retail Practices _ fC._ 54ft.t7C�G _ o i.-'lanagnmer.1 and Per ons,i FC_ G _.-._ ---.- --..- 74 Food aid Fwd Protc non PC 3 � ( rg + Proper Cooling of PHFS _ t- -- ------- 2-S,- -- a - -- - . `------1------ + ,. .qui mrnt and Utensils F a vDC I s-501.kl(A) �C,4 n Coon dPH1s torn l4)'F a t `- - 6Va'e+ o{ci rG+a�utd c✓ + FC-5 i ( ` t f bt iihin ' Itom a.;d Isom ,`i`F 1 1 27 Phye a Fz I+EI_ _ t 4 EIt{"t N tlzin4 Hou1 �zd 0;i')nQWf of �x; f ttr J d I4(d) 1.acliig PHR:Ntihiie Faom Ambient 1 r '_ �Pa. a R ,t+rrlrs>3t p0.9 _ 5 . i - - -- F .m�rature in treuirattti t+=aluCi4�}' + F-.,Ca othef- `IS `Suili(oai, n „yd1: CITY OF SALEM S BOARD OF HEALTH Establishment Name: as Date: 9111 log Page: of Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item - Verified PLEASE PRINT CLEARLY /\ _ �e- n► t) i s 1) ()r-Ae n --Mt Aqillmw ' 0 h o - In , o - Ufa° U1ol�ov ��r�tiP\ �l Ib,(1 _ ( 96n C) Vl t ° /--b & M 1(Xa(A 4('4S\\1dC. Ir Ir _ r> s L t/ � � , wid-» ky— a - e a g ex 0 --(-,v f P n I _ ,1 r� U tin N nil f hkn hA 1 Discussion With Person in Charge: r Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure Your food Permit. / ❑ Voluntary Disposal ❑ Other: M -501.)4(C) 'PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to Lain Cooled u) Factors(Itaft 1.21) {Cont.) _ 41"F/45`'F Within,l Hours. _ 3-501.15 Coolju�Methods for PRFs PROTECTION FROM CHEMICALS 19 — PHF Hot and fold Holding 14 Food or Color Additives_ 3-501.16(B) Cold PHbs Maintained at or below 3-2f)2.12 _odd t res" 590.(9)4(F) 3-302.14 Protection front Unapproved Ndddives'�� - — 1-5 Poisonous or Toxic Substances 3 ()L 16(A) llot PHI s Mainramed at or atxn'e !01.11 tzt 7enlitvinginfo7nation-Ori Snt' I 1dU'F' " C i fit ) I F .) Ra ,ts He Id at or ahoce 130""F. _ Contlaier, 102,t i �-�t)- �e as a Public Health Control _-{t n Si+i 1 i r as i Publicheal h CunmW I r °OLi I Sega Litz -- 772(E 11 R,-,t�ztcv+ tr s..o ortU c -- '� 90.044(11)_�.__ 11�r anxTtu.u� titrnteuE_ --� ' 7-'02-: ) C'o idmon zit lfsL _ i 7-203 [1 1 i Coit ainet Prohthi got, -1 REOUIREMENTS FOR HIGHLY SUSCEPTIBLE { -- — POPULATIONS(HS 7-204. i , Samt leis Ctitc i z Cheuue is - —r sl ! 3$6111(Al Unprtealmed PI {>ackaged Juices and 7-204.11- ("i mt al fol Wa hu. t nd_uce ( i ma t 1____.�—_— I ffe v t re with Wino l„ah,.h` r 0414 Dunne 1. u int i ----1 40: U�til) j a n. 1a unr t.d t " 71)5.1) bo,id ntal Foto Contact, t. dv!ca o; S'1,1I(D) h cor Patlial3 C,xixzd Animal Fond and 1206.11R'aIm dt ,c Penile.Clifeu) ( I . -----�---- --� I ka S d S,proats til i.Served 7-206.12 j Rat n 13 <S:•aoon, i h ' 9 ( Unopened_Fx—xi,.�Pac-agc Not R scree(!�_ _ _rk )i%dvz Comr ;I;wd20b.1� �._._.— _CON5Ufl9FRAOt/lS_CRY TIME/TEMPERATURE CONTROLS 2 �1 bFF 11 j C'o^.ettaa z tci,{sors P<acted Ibr C41uUID))tion.a( �16 PrupeeCookingTemperaturesfor =iaaiurl i w Iliac m fi,as,Cndercu !sed i 1 PHPs i { Not Oth Ise i're ess )Eli mare i=1(31.1. 1(1,,: i ) it nsP t S.e _ 1 Pah ,:_ m i t e-Intruzd ate 4airc l 5 -15+tc^' 3 fi a--CJ3 ` } stc=t ,,a t.tu.Sut�o_mi_ fol-Raw Shell --- 3-401.1 ttA)(2r 1 £ n.r ina?uaa t a i SPECIAL REQUIREMENTS —.- .— _.+ 'm -401.1!(A.}i1 Rolm,, z,jC z 43-c4t" i F 15 � � I � ,nrxn re to ihiic 1 nuc ttrraD rai ' slid , hihcd.,l ( ";3- P urn l'i)o - _ cr sidni A 1 ilchcn o rttiois hza,Cd lie ;tttu t;r I?ic a,Pr3Ttiac `ccul54' R ,CsiP n nFish, r , o, tea, 4 se . In,,.z 0 v vi,d oo 1:'(�dhQrn f �ca 'x 4(;1.1 C, i V , Mo-iv. hii;•i3G a'_4a; tetter cz,t.�.; ase rise Fa.ritrs_ OK•"-r 7 _ _i-- {{ 12t ) +i iii ! - }5 t Rieheating for Het Hold 9 VIOL ATJ0I ,",REL ATEL) TO GO 00 RETAJL PRACT)CE:r, �- _.-. fr l)i,k)1 _.. 1-1a I�'S'1 i e 1 litems,23 30) l +�-9G3—li(R) Ai.tucsavc- Its 1 3l}:to ti,..tSdM;'' j t'zi '.a,tr .rrr;,wal _.. ixhr +ac,Hij,c n i clz,rr , n aid r; dol fire 1:� c� < )=e (r.nti+° 4-110.3. ' t i z,nm. milord(19zi.,s:ed R f' .—._ b,a7d �r ',q set..,r_.- _nt Fno[I( ielrne d 1f)5 ('ebiR 3403.1 I(E) Ili m Hing 1 0< red Pc7 ro s of e+�'c1 (✓Item Good Retail Prayties _ FC i 590.00V is last x _ , 1 "4anayrr z t a,.d Per its _ FC_ ')03 (g — Proper Coaling of PNFs — ) " i 'x' ind axf Prole t e _ F{,_ ; oc4- -} '-_°iu,,,men, anG ti,e im _ Fr; a 00. 5 5('1 N(A) ) Coe hu CtwK P PHIs 'r'mm 1 US t'tr. 2 Wah.r,`" ice r,}_ r '-,1 0 ' FC 608 f r f ' ohm J Jlour xi Frani )1' 2 t tin: fa ' Ff b { .667 thin 4 Hou 1 2a pc,,:)noue or T oar tvte(45 5 i rC_ 7 608 �t-SOLtaQ3j C r z to c PHE My idc From amFt a 7 mi zruuve 1n rrt anti ti +' i/d$`h 3z nine Within 4 tt.xtr ` `Dar }enCz:iireir .., i.i, i;`Rl Pittui( _.e ificz c f;tiEH. 'c t CITY OF SALEM BOARD OF HEALTH �} _ Establi.shmentName: �/(�l(Z� Date: R Page: o� of nem Code C-Critical Rem DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference R-Red Item TVerIfIed PLEASE PRINT CLEARLY I V P 4p;ti�l, n 1 i 4R � 1 1/t 0 C _ Owl I n t ti� Thr I , + 1"oI rW +Piz 1 4 -1,no, P_• � aX A'A J J V1 ) / F Ili Ll �r V1 VIt V n N nen l LQ Li ,'i v X Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes o x + I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that % noncompliance may result in daily fines of twenty-five dollars or suspension/r`evocation of ❑ Embargo ❑ Emergency Closure your food permit. �j ��n�� r ❑ Voluntary Disposal o, Other: V f r3-5!)Li4lC) PHFs Revived at Temperatures Violations Related to Foodborne fitness Interventions and Risk According I In Cooled to Factors(irelns 1.22) (cone} 41`.P/45'F Within 4 How s. _ ( PROTECTION FROM CHEMICALS -501.15 Coolia� Methods for PHFs h --- _ 19 PHF Hot and Fold Holding 14 food iv Color Additives 3-501.16(B) Cold PHF,Maintained at or below 3-202.12 Add tives'r 540 0144) 41",'45"Y' 3-302.14 Protection from Unapproved Additives' I 3-50 L 16i A) [lot PH}c Maintained at or above I 15 Poisonous or Toxic Substances -'I I 7-lo1.11 . Identifying Information-Odninal -� t4U'F. { i, g i 1 1.16{<#) I Routs Held ut or above i30"'F,a €.Doan rs I Time as a Public Health Control X021 t .}t...Comttot Name 4v,vihi nu to rs {)1 I ) -'-'t E t _ ,Is d Public Health t onn.,r1" - 7-20 1.1 i i Srn i uitn St n i �- - - �--- - - _-_ -f--r - dU.nB'1ill _� V",x tncc l2�aia�nent �.. 7202.12 Condnlnn.ofts� '_03.t i Poxie C o t tinct Poli bt=om* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE FT—204.t 1 Samn ets Crile i CII tic is -1 _ POPULATIONS 7204.1' C"xnucalc Lx `bathe t 1 uh e Cltr i, �t , S"t? t 17� Unp tcu i[cd Pr 1 act z 'ed Jotccs and 1-- - - --� 'lereta c.with 11 n nn itb�is' 1 7 204_14 Dr in,,At entc.C rum t' OS ii htctd nta� t xxlCinti t �lAtbl wants' r, ---�-°- ' + tui Iltlu�K;m �� Parirall f�.rk-dhnnnatFrxnland L7 206.12 Roil c H t S micnr - - -�'-- - -� ;1:11 i�,ud l�ixx' P Lkag, < 5ercdd 06 I Irx nob t%dc k j l"otm ! and - 1 it4 Nol R-__ 9rnm a CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS ! 2 i ry(£: 11 , C.onev icr Au:isort 'tr icd�1=x t onswnution of ^'Proper Cooking Temperatures for { j I ��t r}tltl % r�re� sv tt i I -tit tars e�1.e,! PHFs -_� rc t rvu d ttc St r icc ( S -C" t 1 rcuuf + t ;z. .51d'r va Ill, Rasa '+hc'I C m ;;tua;t C-...r, vu[s to a i SPECIAL. REQUIREMENTS_. ;-41.1!(B)(1 iQ, t Pt n--b i l ku �t 110,f i^i _.�. - S - ; .. -iJL1 (�'y)±_, nni� 1r..j att,at:. 1,,, FIS l i caierrue ntobilr.( wmt tctnpu,i In v and :-401.2 t;AI`3? 1' a'try 1'i13 C ,n . $tn�Icd laE i; rsiu.. tal itchc t o1 ei cions gwtild be t S O1t:tot:r,n ton Fir! . Mfeai, t t:hitcd under the approprsitle 'i:joa l ° Fkll4i l;i tCjiii,-J6>'{ n� 6, s 'e i 1kR'� ' c ijii,d B:_.S, !3c .t., z'.'5 i V utter ... .,C :. �.'.t! .2VE SaC(l4 ()i`i("t t ,•�-I - 17 1 1 Ra hating for Hal Hailing VIOLATIONS Rr_L_ATED 70 GOOD RETAIL PR CTWEE � , )s.ti 1iz +13. IEiE 'r "i I c 1rnt5 ?> 3{}t 113.11",IT M owavc li F<P�Iuw.; Standing rl t l"I i,P) r,n; i 1, tr :.+ mi Jl rr no: tea l! i r, 'm ;`t< s ; 1 1 ilei a f r?d i ' is c ii led t of r. ".ri I, -403.11(C) C im vot_ia it Pt rn,-sed .Y I1 I ->vf- r u ill Jar, 0; tkrFood L >x:. rad tr ("'IR .X '4 ' F _— -- A03.i 1(I Rc n lir 1 nd llo #'tvh<ns nll3trt ltenx1 Good Retail Practices FC 5.90-000 I #t past ;- gal Proteriio* rC s V03 I i (g �� Proper Coaiiog o4 PHFs - - _ tiJ�ni(❑t and UtPf i�4 r 005 `.SOI.1.4lr1J �i r ixE1 ng C'xi4 d I HI f:-rm 111 r to l-.2 Jl itrt u d Vvosfe.- '_=C_7 OG6.. i 701, Withm 2 ( oe.,;.nd From 79lT - f{J7 i c ' E�'d5'F'Nithrt d How,.. ' i c so o is ox;r k i t s i, t 'iGn f-._�___.�__..�__ .._ __. .... 501.i44l) t nt It[v PHE Midi: hoot Amnieut - 1 Ccmi .rauatt Stt rc tt:<;uts lo } rrdSlF OU'<' ..------ I _1 ;0,t_ ; 'it,060 Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tvoe of Operation(s) Tvoe of Inspection ❑ Food Service ❑ Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP Y/N El Temporary ElPre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. rFOOD PROTECTION M AGOJIENT„ "r 1 �r�M ;-7,'{131� r, � � ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ' � Fr ❑ 13 Handwash Facilities EMPLOYEE HEALTH ,r�. a gig.. xt FR6M CHEMICALS'" r `, +`" „w.kas.,,� , , El 2. Reporting of Diseases by Food Employee and PIC I , rt=�� `r� �m• � � a �� -` � "'�� _� - ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals t FOOD FROM APPROvED'S(?UfiCE ISL gVj„�„�',`�,:��M_;�I�' 'TIMErtEMPERATURECpNTR01'S(Pofemlally Haiardous Foods) 7 ❑ 4. Food and Water from Approved Source u �-,,,A•�� :-u��<�.3a&haw»u.��.lcur�zw��.,��:, k�:�' ". .;F,:m.�..0-.�-a. ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling PROTECTION FROM I:ONTdMINATION � '"�z �"' ' rVVA ❑ 19. Hot and Cold Holding .. [18. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing - ,lRE0U1REMENT$FOR NIGHLY SUSCEPTIBLE POPULATIONS(HSP)"-1,.. ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N v` by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 5:5901,uspac(Pomi614 Doc Inspector's Signature: Print: PIC's Signature: Print: Page_of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination , 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Ammal 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* a >lJ icants* _ 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Fax(Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Perscm in Charge* 3-306.14(A)(B) Returned Food and Reservice of Foal* 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 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 Hermeticall•Sealed Container* Sanitization Tent eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shelf Eggs* Sanitization Temperatures* 3-202.1.4 E>>s and Milk Products.Pasteurized* 4-501.114 - Chemical Sanitization-temp., pH, 3-202.16 fee Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinkin Water from an A roved S stem* 4-601..11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* - - Utensils Clean* 4-602 590.006(B) Water Meets Standards in 310 CMR 22.0* .11 Cleaning Frequency of Equipment Food- Sheilfish 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 E ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellsnac Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* Il Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2.401.12 Discharges From the Eyes, Nose and - 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Ca achies* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.O reration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced ox en packaging,criteria* 6-301.11 Hindwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301.12 Hand Drying Provision - *Denotes critical item in the federal 1999 Foal Cade or 105 CNIR 590.000.- - Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, Division of Food and Drugs Salem, MA 01970-35234 19 0-35234'h Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tvoe of Ooeration(s) Type of Insoection ❑ Food Service ❑ Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP Y/N El Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD , ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities , EMPLOYEE HEALTH .4I�$ �T PROTECTION FROM CHEMICAt,S ❑ 2. Reporting of Diseases by Food Employee and PIC U,- 1�_�- 3 •,'"dZ � « e 'LE ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals .FOOD FROM APPROVED _ . ,� -❑ 4. Food and Water from Approved Source "',T{ME/rEMP1vRATURECONTROLS{Potentially HaYardous 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 cioNTAk11NATION" i "° " ®`x El 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 1 REOUIR£h1ENTS FOR HIGHLYSUSCE0tibLE POPk1LATIONe(HSPjp� ❑21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices j"„CONSUMEF#,ADVISOtTY,„mm. pia Ia. »mary371 ❑ 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 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)(sso.00a) order of the Board of Health. Failure to correct violations 5. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 25. Water, Plumbing and Waste (FC-5)(590.000) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S'5901nVWFom 14.0 Inspector's Signature: Print: PIC's Signature: Print: Page_of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Gross-contamination 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Foods* 2-103.11 Person in eharge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other" 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require repotting by foot employees and 3-302.11(A) I Food Protection* a plicauts* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 7304 11. Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char*e* Contamination from the Consumer 590.003(6) Reporting by Person in Charge* 3-306.14(A)(B) Returned Foul and Reservice of Food* 3 1 590.003(D) Exclusions and Restrictions* - Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Ftp* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590A04(A-B) Compliance with Food Law* 4-501,I I I Manual Warewashing-Hot Water 3-201.12 Foci in a Hermetically Sealed Container* Sanitization'ren eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.1.4 Eg gs and Miik 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 Utensils Clean* 590.006(A) Bottled Drinking Water" 4-602.21 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0" Shellfish and F/sh From an Approved SouroContact Surfaces and Utensils*e 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-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources' lg Proper,Adequate Handwashing Game and Mushrooms Approved by Regulatoll Autufhorit 2-301.11. Clean Condition-Hands and Aans"` 3-202.18 Shellstock Identification Present* 2-30112 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* X1.1 Good Hygienic Practices ReceivinglCondition 2401.11 Eating,Drinking or Usin gTobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package Inte it * Mouth* 3-101.11, Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* fi TagslRecords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained'" Em to ees* Taga(Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-102.12 Records.Creation and Retention* 5-203.11 Numbers and Capacifies* 590.0040) Labeling of Ingredients` 5-204.11 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Pians Supplied with Soap and Hand Drying 3-502.11 Specialized ProcessingMethods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6301.12 Hand Drying Provision "Denotes critical item in the federal 1999 Food Code u 105 CNIR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- . No. Reference R-Red Item -: verified� PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: 3-501.14(() PHFs Received at'Pemperatures Violations Related to Foodborne fitness tntementtons and Risk According to Law Cooled to Factors(Itettts 1-22) (Cont) i - 41'F/45`F Within 4 Hours. * _ PROTECTION FROM CHEMICALS3-St11.15 (oolina Methods for PHFs 14 19 Food or Color Additives PHF Hot and Gold Holding 3-202.12 Additives" 3-501.16(B) Cold PHFs Maintained at or below 590-004(F). 41%45°F" _ 3-302.14 Protection front Unapproved Additives` I 3_5t01,16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances -i 7-101.11 ldenttt}mg Info:matlon -Ori mal : s 140'F.j 16(A). Rusts Held at or above 130"T i l"ontuners' - — { r tp Time as a Public Health Control 7 m omt� n� lr:na+�u°ttl t) �<mr tint+ i- ! -- ---3 t SW 19 f ia-,. as a Public Health Control'_ I 7-201.11 7-20111 ko --j t o0`�Qlrtlt_ ,. -, l u ante Ret�tiir m nr ,. _-1 7-202.12 Condllion of Uso' 7-'03-11 Toxic Co l unc' Frob:bi wn. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 204.11 sanilims Criteria Chemic"10 POPULATIONS(HSP) 21 ] i-$ql 11 tA) l;npa tcuriz sd Preracl tgcd Juices and �(k1J2 (benuc de fgr_W a hem t cu.n t C.nec.ria' t2c a to ec with±a tnu y,lab.,(,': _ 7-204J4 6rwn At eotc,_C ntceet _ ' S,.g(}; 11:87 Usi, o7 Pastennudt� F772i-)5 11 ci Rs >.xl r uatjct la:ht:eat:e t_g0} I I(it) Rau or Paitiall r txt:, d Animal Foojro and 7 't0ti to mcicled t.t. i'c nt ule. Crrtu t I i Ra '+ i ynr gt t Sc.rvc . 7 06 12 — - �. Sr_-r I t ( ! I--� =06.73 � I r': i; th: rAcde } � f'cmt t l and j _.._. _ ---------- -------- - _ '�4tmam❑ ._.__._ ._- __ �_..__.----------__ __-� _ CONSUMER ADVISORY I Y {-F(t;, y: C"h,Sut} C 11 t -�; ni'.-. 'arA n! to i:21C•G of TIMElrFMPERATURE CONTROLS Co0;cmo - amnA w set !Itrit e F a t-lx t t` is I 36 � Propr^r Teropaiaiures far I J i - I I PHFs : ro r 4 kli r 1•ilti ) • S S I v i 1" )4d(.1!(Bill!(Billl2s Pd r 1 ` r --' SPECIAL REQUIREMENTS .c Rc, ,t i 177 inn I - - — _ i : ,ori tt to ,' Ik• jb")"L f,.npra .atct I I ..4OI..11 A• 3) j P ui . , Wddl i 51u ,� ! eti:,. ( , •:u ,iu_I rtr-'t ., �>i..rulmn .[:, i... l , j s ! nt t,*L•:,t it iR ri,.it s A !4 ` J t` ., d;'I tit n§,tArL'tlriAt111(i S i 1 i ,! t: 7'= � v-• j .Cs-t. � ! 1.s ,_, ; cayc,;.:: l.�y_ ! .. -(. ' t >s aa.ale l 1[.('r.•.k 1. :[. :! •�'(K + t- FIA': t.s'I: �;i {, )!} i !_17 _ Reheating for i)ot Holding --- 'VIOLA 1°ONS R LATEDTo GaOOD RETAIL PRAC1 iCL,q ' R. t03A 1(t)k.iD) j 1 ill 1P 1 t c _.__. j tltenn 23.30) j '103.11(8) �I' c se-lr'+ _Wlm Sttidia 1 (i'in n.r?n rz r r_nf A !t :ils >4)ret t� +rzi rr , ire I F:1u fooilbr Ili ilh t ur iaeiik e end ii {J e iorc Ili,ledit 'A (tm l r � 3d03.illC) iCmitr•.:a!hPio -d [fF .uf- .rzlneiilr;:,7fln gAerr r =the roertcrrdrmllrt (`yIK 40 F 90^Olt _ t�( l 340�1I(P) _ '( _ n � 2 r iilrt , nePrncuces FG k,as . aa mdnon _l .- Proper Coaling of PHFS 22 Fyxi rd p-xP a)t"oo* i FC i � 5090{4 d,emand Utensils 4 S01' i $01 4A) ftx tin Cx . d PHFs f. n I40'4-to qwt 2 . O_- W 4r+tcr Pt bmcutd N s e Fc S 0Cr wF Within 2 hour,aid From 791: , ?f F=:us FauNEy-_. _ Ff,-r .007 i to 4 114'1 F µ Um 1 HiH,1,. tN i Oow: t t5 r Timc n r s_ i FC 7 MG -_.--•– -•— t {t 41.11 E.LTifil QC j , -fig-501.1•}{8) C y i letrr P18+ 41 ulc Nom �ndyeeut ; 1 T ml.%,rawre lucredww-t it 41 1,/Wt ! 1_3a i]ihrr titan -- •1'w-nom.uincil i._n. uca is-:u.. .c., r<ad < . .f;:: lk •90C;:' - n - CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical ItemDESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date tt No. Reference R-Red Item : .Verified PLEASE PRINT CLEARLY I C 1 i c} Y ` Discussion With Person in Charge: Corrective Action Required: ❑ No ; ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 50J.14(C) PRFs Received w Temicieratores Violations Related to Foodborne Illness Interventions and Risk Acafrding to L7tu Cooled to Factors(itelrrs 1-22) (Cont) 41^F/45`F Within 4 Hous. PROTECTION FROM CHEMICALS 3-5(11.15 Ccxdim>Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Fold Holding 3-501.)6(B) Cold PHF(Maintained at or below 3-202.12 Addinves* 590()(WF, 41`/45°F 3-302.14 Protection front L nappromd Additives" 3-501.16(A) I Int PHFs Maintained {t or above 15 Poisonous or Toxic Substances 7- Identifying lnfoimation-Ori mai 140'F. (01.11 Identif Y 350116(A) Roitits Reid at or.above 13WFs I Contains(s^ -- 1 20 Time as a Public Health Control 7102-tit Cotmmon'V ams Nmkir`Cunt'tinrs` -- - --{— —i 7-20 L i I Se auuon Sun t i t7 I Tim. as i Public.Fieatfh Control'", 202 1Rertct on w--- - -� 79(l. - l r �� a arae P�urc"ueslt _ J -Pr.ac ncC ruld 1, c� -- - - - - 7-202.12 Conditions of Use" REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7 303.11 _ Toxae Cout lines ---probii " —� POPULATIONS(HSF� -204.11 Sann7ers Cntcrlt Chcmiteln- — — T204.12 Chwu &for`ha h� F ad ice t lite ria° ( 1 l i.,S01 11(A) Liap�steurivcat S r 1 r' ged Juices tatd I --- _ I Setera es with Wautn l,aly,,h` 7X04 14 Dr}Inh hent< C n�r t Sul I l(13) tis of Pa fwwind F 205.11 hmtd salt wx1fonto[ l.tivwillits, ti41 ( 1)1+Pt rPuri.11 CtK1, ds'pimalFoodand f 06 11 �RC m d I'e t dr. Ctt itt ic,� 5 + ltitil1. ive0 _ �qr, -t 7-206.12 �F(xlcn Fl t S.:au<'i — Vt,t R s ntd. ._ _ c _— i UIOn t 1'i __..� _. u_ ..--- - _._._. _ ___- -_____..�_--• CONSUMER_ i?;"e°JISORY 22 -r,Ct; -0"110101 Sc,ti isot-4 Ftnt l ,-sr( *z an:pticw of i TIME/TEMPERATURE URE CONTROLS (ret e R v l'adetax Fed er , ]{ i Pieper Coaxing TempetatUres for r,�a..a t t .ta_.-S n,.t ..i. [�zR.t,Suc 4(+1.1 it aI { 'n 6rt I -• _ ___ ---- SPEC AL- P_E_OU_IREM_ E.N.TSI](Bl12, { alt ( cRa .i - t3t1 ' nu "x . - t f : _ _ ---, 2-401.1 L .;1-. rt) Stctmu al(l,fkr�r0.t (F�? ^< tazx.m ,. fxxl,camp.raj v and ' 40LII( 51 ); P, uii,Y }f a ,. .,til fW P Ii E'S, i ,a..:'Sutt13C r'a.iovS iwwId i%, 1 St rRi q=t:. or r; Fish, Meat ! c1e}at,d and;'r fin a"?proliriots:srclions <' 12 VE 1 # , 17 I Rch<atinq for Hot HoWing j VIOLATIONS Rx LATER TO GOOD RETAX PRACTICES -- ; F 911E{1) u}} itll 6 (linin >3 101 Hl'.IIBj tilt utu trc- It }_2 Nimu, S ndr*t; al r rr .t�. �, trh 10 g at ,x t.t 1 me _ ._.___1 tit hr rut lr t lir p rt ,�n r I si t fn arc liS ed sz r man.F,;r_ -F)3.I I(C)— t .n metria E: F'.o.,, >:.d R EC' Fx+"9 ,,4 qac.. r. ,;_hc Food Cxfr a:d"Ct;>Affl 140'F' 'U C1Pc1. >, Item Goo?Ra[a+t Prat'2roes FC 69t+Lt6fi , i 9t)t i I(L) Kr t tat � t,1 ur tc 1 xsu< o f ii�.et _. _ y , t i rAanags me,i aid Peior,-,e; _ ' FC_ 1 003 ` � �2i F-&)d >>d FowPole.troa Ff-_ 004 Proper Cooling of PHFs _ .._ _ .. — 25 qU> m<lit and Utes oi�s F -4 005 '-56� t.i,d(A) {tx,i n�t.a�h_d PHIS it xm 14 `=to - -_ _ f t CJdt�.r r'ft nrGa�.ind ,Na !e i FC-5 _40,: _ 701- Within t t lours and From t 101' o t'n;, l_ s r FacditV FC-6 r 007 1 to 7 FI' "F k ft xi Hour I ^e I o',, t or xi ! r r t,�- FC 7 3D8_ s 501.i4iF1) t ,isttn 1114NLzdc From Ambient I 9 c nl R. OC9 j T nI rtauirc Ir rzc curs is t1 FdS`F i»nr� i %Ik Commonwealth of Massachusetts � k City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 09/16/2009 ESTABLISHMENT NAME: Georgia's Pizza File Number:BHF-2009-000035 28 Norman Street SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0547 Sep 16,2009 Dec 30,2009 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 30, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 i �l f-5 .............. ..... ... ... Dd LL U1,9 In jp � � 9V') -_s--------- IL OP EXAM FORM NO. 4453 rSe" rvSa CERTIFICATE NO. 6540085 ServSafeo Certification To VJOLLCA BENA for successfully completing the standards set forth for the ServSafe®Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). 6/20/2009 DATE OF EXAMINATION 6/20/2014 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. MOM aw-W NATIONAL C 'RESTAURANT ® David Gilbert ASSOCIATION® Chief Operating Officer, National Restaurant Association 40655 Executive Director, National Restaurant Association Solutions 02009 National Restaurant Association Educational Foundation.All rights reserved.ServSafe and the ServSafe logo are registered trademarks of am National Restaurant Association Educational Foundation. end used under license by National Restaurant Association Solutions,LLC,a wholly owned subsidiary of the National Restaurant Association. This document cannot be reproduced or altered. 08121102 v.0908 73"o-q na .oc, a' _ 5ALADS JR�o15 BASKETSGarden r - �n ..465 8 g S Roast Beef ...... ' _J�Creek a a ...............5.75 5 [t�.. t J `5:25 Cheeseburger ..........................5.50 ' Chicken Kabob�"�'. �` "t f 6 75; Hamburger ...... 5.00 OFF ' =Steak Tip 700', Chicken Finger .........................5.75 iChef Caesar e f ' '"'G.25 Chicken Wing................. 5.75 ANY CATERING Biffalo Finger..........................6.00 Antipasto r .. r .6.25 ORDER OF$200.00 f" Buffalo Wing ..........................6.00 r G I Tuna Salad/ ORM E i 1—Chicken Salad { . .... �7� .6.25 n 1 SERVED WITH FRENCH FRIES r a r --' Crab Meai { . ... ::. .-.6.25 S C •+ `.� —Combo ....tri ®'--1F- .. 17.00 ." s 'HOT•- ANDWICHES f 2 LARGE ALL SALADS SERV:D WFFH PITA Bft 6 D Ir Beef.. f v ..3.25 x &CHOICE OF DRESSING r �i�, Roast Beed "` 4.25 CHEESEDrestags: '� Super-Beef r.`�"-" 5.25 �pT , r E .. '.-•... PIZZAS } a sF Cae aq Blue Cheese, Super Pastrami ..5.25 x- ` 00 Island&Line Italian mss_ i. n - �,,,_ ry a, - tt �- ,., Pastrami �"'� 4.7514� • ; 12 99.. SI Hamburgers .. 3 2.85 DEyItDERS ,Cheeseburger ...... � .,. ... ..3.25 Bacon Burger ...... �"! 3.25 PICK UP ONLY --�'y� m_° s ` ""' rSuper Chicken ................. :'.;3.95 „1 French Fries ..... ...C...........2.75"','3.75 t� .Grilled Chicken,...............I�..... r.4.95 t Onion Rings ..-.2.75 3.75 Georgia's Hot Sandwich "F- ♦t !'.:4:75^y. (F 0� , _M....114Sticks �4 75;� 6.99 F Chick"Fingers - "`c' - 4 99, 8 25 ++w WRAPS .;Chicken Wings 4 99'�- 8 25". - Buffalo Fingers ... ...5.257"S.501 . `r Chn:kewcwesar .:. .6.00 Imo+• _ 1 - PIZZA GARDENS�F Buffalo Wings 5.25 8.50 &.=Cordon Btue . 6.25• _ SALAD WITH ed Rou;h om•• {� 47 22.00 * Buffalo Fl .e�?...^......6.00 ROAST BEEF�SUBS�CALZONES t lalapeno Peppers ` / 4 50 i 700 Chicken Kabob 6 00 BLT Egg Roll !_ t' Turkey Club Wrap 600, CATERING ANY 3 LARGE _` r -- - . �_ .... >� + PIZZAS Spinach RoO 2.00 , a 6-*1 , . EXTRAS a„� SIM in e-41101 OR F S Brna Cheese ....0.50 `�f78-ii-1144 �7�0 Feta Ghee . ..B.SB CATERING' {7 2 LT SODA W/ Dressing........0.35 a n 4-16ft ` Pita Bread ......0.50 9 'hlgntlay robunday I ram-.IOpm ANY ORDER OF SERVICEr� BOO $15.00 OR28 Norman MORE AVAILABLE t h t . The Whit e Hen C�.OsINC, FOR- SUMIMttZ VFICA71010 FRoc�l SuL�� QU — AUc, u s r to :I hIZZAS,z" K+{ ti CALZONES HOT SUBS �..... y�1'9.00, Sion tare ALL SUBS AVAILABLE AS WRAPS o0/O Plain ci ease . i #'7"OOf9w.5o0.�ltalian ..........................6.75 12.25 sm��n corse �••9 a Ham&Cheese ....................6.75 12.25 Cheese Steak ........4.75 5.75 pp. g l .S,r Grecian!'.',':......................6.75 12.25 Steak Bomb .........5.00 6.50 1 Tope ng 6 25 i 10.00 Spidachtb Feta...................6.50 12.00 Onions,mushroom,peppers,salami 6 cheese O F F PP• 8 PP g 3Tiam s 750 12:00 7 4 To ins '�".'.""'^" 825 12.75' 7 Veggie..`.":x.......................6.50 12.00 Steak&Egg .........5.00 6.25 Xtra Cheese.............':-.1.00' 2100 .;;Cheese Steak ....................6.50 12.00 Steak Tip ...........5.50 6.75 ANY CATERING Steak.Bomb ..:..................6.75 12.75 Chicken Kabob 5.00 6.50 roPPlNcs - •••• ORDER OF$200.00 w _ �Chiekett&"Binecoli .. .7.50 13.00 Lettuce,tomato,union b Greek dressing Y Tomato Garlic Chicken Parmesan. 6.50 12.00 ,.,. . ". W e Kabob Bomb ........5.00 6.50 Onion Pepperoni "'•'�w°','s,.. Buffalo Chicken'f �^ 6.75 12.75 Peppers '-' 1 Pmeepple "' v g , , <,• Onion,mushroom,pepper 6 cheese S Mediterranean 750 13.25 BLT................4.75 5.75 . Mushroom Ch cken Steak T. ^ ' "0^` 1 t 7.50 l3 25 Ham ✓• �SPmach P y�.�.`Meatball ...........4.75 5.75 �r 2 LARGE g DINNERS *, �,,, $` Chicken Cutlet 4.75 5.75 -"4 Hambur er Anchovies '+( u. •••••• .% g 1 '�. l "'.} O Sausage PastnmiYeal Cutlet...........4.75 5.75 a r� Broccoli Salami Gyro Dinner .. , 50 ptLEggplant ..4.75 5.75 CHEESE Olives Bacon a Chicken Finger ... 7751 +Sausage ............4.75 5.75 PIZZAS Eggplant ,� W Chicken Wing ..".A. f��!':. 7.75--'was' Buffalo Ftiter ......... 8.25 E S � �.Buffalo Wing .......... ` ;^-8.25 8 COLD SUBS - $ 12.99.. I'EGIALTiY`P.iZZAS Chicken Kabob .f s7s" `- ALL SUBS AVAILABLE AS WRAPS •+••.�; � .steak 7.p w 6.75.x'C y ' PICK UP ONLY •. `j'Cheaseburger i �'"" 775 i r+ Georgia s Chicken �` 8 50 13 00 Roast Beef "�':-" - -'"` 7.99 § Italian i'.,. 4.75 5.75 - �y. Tomato,.pepper 6 chicken .,, pastrami Dinner ........ .:C .......:""'.7.99 American . 4.75 5.75 Chn:ken&Browoh 8 25 12 75 -,% WE SERVE OUR DINNERS Ham 6 Cheese 4.75 5.75 ` YGolled_Mtken b broccoli WITH GARDEN SALAD 6 FRIES OR RICE a. v i "-+�•i•s... Satami 4.75 5.75 FREE Grecian„"`.."rw"t"':':"..8.50 13.00 -;y.Fy Turkey .. ' 4 75 5.75 ' Tomato,onion black olives feta b gad_c'""�. -"-•-- .,.,�,y-��-+- ;"'+' a`4�7 eat Lovers ..... 9 00 14.00 's7."* `�';•• ° ` ASIA: Tuna ...�""'- .4 75-,.5.75 I�� ambo er sausage,ham salamb pepperoni .��. GARDEN B g PPP �, sc•Y Veggie ... 4 75 X5.75 a editerranean .. 900 14.00 SPAGHETTI or ZITI J ` W r,,, `' Chicken Salad 4 75 5:75.., SALAD WITH Spinach,feta,'chicken,tomato 6 black olives"' -. ^ With Sauea ...... 5.00'"^•a".Ct'ab Meat {"t ..4 75 5.75 Hawaiian i ` a "* "t-750 t12 00 With Meatballs ... .5.75�"•"T•' "'"•` ^XS lCi�.. ,.if #�.`_'y; ANY 3 LARGE 1.*Ham.&Pineappylei„i;r e�t1.ry: ----"'^'r••• tir1"4n,,. With Eggplant .... to q 5.75 �• "* Y � + !" Veggie" ... ......8.75 13 50w,'+w.%'lth Veal Cutlet .. sa - ax .5.99 CLUB JANDWICHES 4 Tomato onion peppers;mushroom,broccoli ''�1�� b black of e With Chicken Cutlet .... ...... 5.99, ' Hamburger ......... PIZZAS • Buffalo Chicken Z50 12.00 With Chicken Broccoli ..:: _ _ y, ........... _. .... 6.50„�KCheesebur6er .............7.25 s t Ch¢ken fingers 5 or sauce .,l Georgia's Spacial ..........9.25 14.25 SERVED WITH GARLIC BREAD�^ Turkeyi ..7.00 �. m;pFREE , epperoni,pepper,mushroom,onion, �,a wa1'•�..ila. Tuna :' ..7.00�: ; � w-•sausage 6 salami !•+tid w BLT ..... ��•` ..7.00 mil , t Roast Beef ......7.00 � w Chicken Salad ti .......7. 2 IT SODA W/ Chi00 i ' `� • � � `�� ANY ORDER OF w i mww.wee,iowklerWia�vNeroxx•wiarol $15.00 OR 3 �„ mwsinwrcr wmi meornrnionorwsuc • aceovwr•mmp.xa weruvae •... .. MURE UNOF POSFSAr Nb1al/ I CITY OF SALEM BOARD OF HEALTH Date: August 5, 2009 Name of Establishment: Georgia's Address: 28 Norman Street Owner: Violet Bena Phone: 978-740-2800/ Cell 978-304-9285 The proposed new owner of this establishment presented a Floor Plan and Menu for review in accordance with the State Food Code. CERTIFICATION Violet Bena will be the Certified Food Manager who will work full time at this location. A "Person in Charge" or "PIC" must be available at this location when the Certified Food Manager is not present. The PIC must have knowledge of sanitation techniques, holding temperatures, operations, etc FLOOR PLAN Hand sinks are well located near food prep areas. Hand sinks must have a wall hung soap and paper towel dispenser. These must be stocked at all times. The hand sink must be used for hand washing only. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. A three bay sink for washing, rinsing and sanitizing all utensils equipment, dishes will be used. MENU/FOOD PREP Reviewed preparation of chicken kabob salad and tuna fish sub was conducted. All food must be held at 417 or lower, or 140°F or higher, at all times. Therefore, meatballs, sauce, and other hot items should be brought to boiling before being held hot. Food may not be added to containers in deli unit or hot-holding unit. Instead, a sanitized container with new product may replace the existing container and the old product may be placed on top of the new product. There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used when handling such food. F UNDERCOOKED FOODS The advisory is printed onto menu. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. An initial inspection must be conducted prior to opening of this establishment and a year long signed contract must be submitted to inspector at time of opening inspection. Please keep receipts/invoice for inspections SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station and for the patrons' seating area near window. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the 3'd bay of the 3-bay sink and spray bottles or pails may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. Outside area of premises, including the dumpster area and grease holding area, must be kept clean and sanitary. _ a Please call one week prior to opening to schedule an opening inspection. David Greenbaum Date Acting Health Agent �'� e,��-tee i �r D 9 Violet B na, Owner Date CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 11 ❑ Voluntary Disposal ❑ Other: r 9 x-501 J.4tC7) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk - .Amwiling to Gra Cooled to Factors(Itehis 1F22) (Cont) , i j i 4I'P/45'E Within d Hiiurs. x _ PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives --_- 19 CHF Hot and Cold Holding 3-501.16tB) Cold PHFs•Maintained at or below 3-202,22 Additives* 590.Oig(F) 41°/45°F' 3-302.14 Protection from d Addlltves*_ 3.54 I 6(A) Hoi L'HF� Maintained at or above t5 Poisonous or Toxic Substances _� 40'F 7-101.11 Idenulvmglnm fo. ation Od na; Contuu ` �� _ "t 5tH 6(A)� Roast.,Held at or above 13WF_*'__, +- 2 Time as a Public Health Control 7-102,111 CommonName R trk Cua nner", L — - --� -- Sol L torr as a PublicIIealrh Control" 7-20[.11 S a eW<n Stufa - - — ' _- _ 36.00'rHr _ A i Ince 2cytn remeut --� - 7-262 1i R•ct futon Pr:, co a t L c -_ - — --- 7-202.12 -walnitm:�of Usa' -- 7-''03-tI Toxic Containers -Probihwirmcr� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP) 204.11 Sann oris Cti tenr Cttuntc 1s 7-204.12 Chemic k for w r fn r l,x�i c (uteri t' 'L S?)1 t t�) t!nP feu iced°rc, pae}r);ed Jtnces mrd I - - i}cFet ize.with N umne f A, s� 7-204.14 Drvn Ar et tc,(nte�t 3 `•--r - hti I l(B) U' of Pu w n/ d t _ Incid wal t x,,d r r i f i 1ub� a + .._ S-Ste i I I e!)+� 5 or Patnail C i><>t,�ti :4vnnal Eald end �' �U6.!i ReS�rn d t t� Pc it ide .C.t i t _ _ R.i Sc d `+ :ut, ti n Scrvca �7 06.12 Tiackiir�oilen13,11t t cri,t, _ --- 1 8o1 1 of 1 Ll"nnud t4irxi Pac aa�_No� R -sencd, 1 2011 1? l rae t..b 1'oalter t._.C e ntr,i a,rd -- -- ,biomtaring' CONSUMER ADVISORY _ —22 T31,J; 1 i T >rsu nit Aa isoiti Posted for Ccnistimption(a . TIMEITEM_PERATURE CONTROLS_ _ 3 fh rin<.I 1 +ai - a arc rs c- lrnderaur x�ked le Proper Cooking Temperate eS for I i ! j s ',:nt C)ih<i Esc t'rtxcr., 3 ;u lrtit vinare ; PHFs � i�{Ol.l.; 1tL(_Z) [7,9 9 55 {—5S- f, r< tauufdt it.•Senvice 1 7`7 35sec� i -:>t;2 11 i P• /,.d F q Sikiwinite foi Raw Sheil — c OI.Z,t 1)t Qrm inu ee3 s h len h Gain, 1 nn n. i5� ` t c• l SPECIAL REQUIREMENTS 401-li(B)(1 2) j 'wk i ik,�etRo �! t: r 12111x•1 .._ _+ ,. � 9t<1i-113 Vi..ria nt c: 34U1.t1tA)r-') � Rtnr_.i,1:4 ,c 'SA...±ta � I 5 E t` Se two temp 4(!1 iA 3i Stun Wildu44mc, til fc( YI !s ( ( ahnlc4 t,ri Ilch n o Iatio rat v and ) � cher n! satiaas hetad Ix f. -@tetltcrel3rialc, ,tet lions ii 10 j J�,i_' 'I 6 4.t iia <, :.;>,, .'.a = •i�U . .. a- I<) t tIIT?a' 1 IIC. t`_9 Yrr.., .. e it)1.1.r jr 4 l �fk Tnt _ . r i 17 Reheating for tan lin!finq VIOLA TIONS RELATED TO GOOD RETAIL PRAC`€fCZ§ -03.1 if 17f(13' lftl 1P )4 ilfetin;2 .30/ - -- l ' q Swmd._—l-u.. a1t +(Cretm rr +..-dt.)tr 5 tr izcr 1v(_r-` rle-.tMcltit-`t n/r0fd(cttodCer]_P- t 11r 3 ° , culec3la1[rrr, I�,il:feCk <Y Rtr ut z r 1 i 403,11(C) iRrr },"id yo[ UUt : 4O31(12lunmrG un'sU jeonof lice( Good Retail Practices FC 592402, s " k rastsx' � ;,A.a.n.a9Prno1-and-perm rJ _'i Fo) nFood oErtv �FFrGProper Cooling of __ t -+- -- --r-- --- - '.. . , - -- -- rn°a Nnrand Us ssE , pq n 501.)4(A) PHFS Lit u7°FtJePt ti and G0051r� F Within r hors tnd From 7) FC 3 -� - -_--i) • Y - - S t :i F/45-F W tl in i lfou 2e 1 'as x t '1r ox tr nr�nt FC7 (565 -� _ - ;-501.14(B) Co<ht q P11F. Mali: F ions mbient � 9 S1,. II R quirFrti 003 I -- i To mhu'atare h rr.urenrs.t --Within 4 Hwrr,. `Ucro.t4 cnn:raL en sr;h-f.dri i9991oodf ,r101c tc 5,T)O`}f;. CITY OF SALEM BOARD OF HEALTH ` t Establishment Name: Date: Page: of } Item Code C-Critic al Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date f} No. Reference R—Red Item ,Verified PLEASE PRINT CLEARLY 7 �}e f(jY P _ 4- — f — t iJSt tP 1`r`r IL fff5 i Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure '_ Y" your food permit. ❑ Voluntary Disposal ❑ Other: ?-501 14fC) PRFs Received at Temperatures Violations Related to Foodborne illness interventions and Risk Auvrding to La"°Cooled to Factors(Items 1-22) (Cont) _ -41=F/45`F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.75 Cooling Mcihods for PHFs bves°"Color Additives 19 PHF Hot and Gold Holding Iq � Food i 3-501.16(B) Cold PHI'.Maintained at or below 3-202.12 Ad h590.004(F) 410/450 1 3-302.14 Protection from IJnappnr.ed Additives` 4 �� I$ Poisonous or Toxic Substances —� - ,[ 16(A) Hot PHF�kinintained at or above _ igflF_# 7-lol_l l Identifying lnfonnatian-Orwina{ -,i-St`rI.76{A) Rai,ts Held at ot-<�t>ov f iD°4 . FtAantai en- ! f---t ---- - -- --� ; 20 i Trme as a Pubbc Haatlh Caniroi 7 102,11 ' (..O`nmon ti snu^ !4 ora ki d C nm n urs - -t -- — 7 2ot.11 �Se�u ruc n Stuia �. '("' ! tray. a5 t Public lleatrh Control, -{ -12 -- ---' rc�,:1Q4rHi Fr tiana�Ccut_tirenieuE -� (72.1.1 1 Rs,tncnn Pr once and F e -- - ----- -- 7-2011 Coildu on of Use -- � --� 7 103.11 '.1'0xieCt ,Game Pronihitions� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE _ _ POPULLATIOATIO NTS NS{HSP} 7-204.71 Samnrery Ctlmen, Chu aic Iv- -- 7-304.12 C'ixnutals tlx v_aa hhw 1 Cul e Cnte.fi rSt7l.I3fA) Unpr tca ircd Pr pteFz2ed Juice-a and �I 7 ?04.t4 Dein. Ai .uta Ina ca'.. t t _-- -.— l3eUer r.e.icnli N rrnml; �--- ---- : 40'• I'(d) 3 Us ttm Pa ti iysd F t,�- 05.1 t tncad ural t xd r onium 1�mb ica 9, _ ; a gCal i i{�)r�k;i�. r Patti ill CrKil, d Animal 1a and ) 7 206.1 I Cte.. i d 3c Pc ttsrdt�'QitP ! --- - ----� _ R; 5 d shout ii Scrvc.a 7 :.06.12 rR<xl c ht s enon - t_nwpcned bsxi bacaz. Nu R carved. r 206.13 1;acn+ag Pi),,,dr ,}.5;1.zrnlrcl trod - mr.,in,' -� CONSUMER ADVISORY ( oni:Uroct '1c'>:iscn4 s'nr.3 i�sr(:rat:aenution of_7 TIMErrEMPERATURE CONTROLS naa,1 I xx dist c Paw, Gnder >ks d s 16 Prager Cooking Temperaafures for I �u f)th m esti i'rckc -a`. it isiu .�PRRFs r _ 310t.l.rlti ('; E <� 1 c imnd s. utuS t,1ct t sSl�i _)� d is [,H.#<.Rao: 9t,elf — i-dOl.11t l)l� Cn,.aimr.:.i1�h_ 11c�acd (:ant-- f-. •-� -i�'�`-__ �. a SPECIAL REQUIREMENTS _ 401.I NIFI s 1 2) 1 t'u 6 it 3 is � Ro �t- 1 ( 12 r,z)ir ---..._ ._- _ __.�... R amc t iix e-- , u t_ i F t : j aicn tt txobil,,ftxs renkp rai v and scc -§ftLI ttAjr3) P,mi Wind< an Stu ecl PHf,: rc.Citi n tI 4ai.'ttin opcu tion , ho(ild he S n„> t`t-rn,ut.�n[,fa:.h dchited f del tie yrpronnsltc aeons s t '.f tt , 7--`x S1ktiY t t,.:'u l i ! - i t fl' �. l o - I? Rah” iinc3 for trot Holding VIOLADONS(;ELATED TO GIOOLC RETAIL PRACTICES .iti3.1 is 3}' tiJi 1, ttti �b 'k t (Ittiala,23-30) -403.11(b) ttr..iravc11i-r .2A9iau_ S[.mdin, C"W-i ';ndn')—;,,,;i"i ,,:ck down GUri :ct§e I �7inre' t +rxa,t-nr liper W14 nr ru;;?I sra:t,e � 3-d03.71mf.,'j � Com:noi:.ia 1. PLLn,,Scd L 1r 1--:_+� .. tunr .m Oi st, „S sec . �� : `rtir! �otl C3ae rancll2;Gt41t i 4b 9 c �tl JUI --103J d(1) �2 ,�tmn,t C rssi,tt�Porte< ms nt tiCr'; } _Item t Good Retail Practices _ FE � 59D.000 r1& T �anaR as!” e r and Perr rC `0> ^- Proper Cooling at PHFs —� 24 t �d d Few Pro E t t _... QFC 5 GC' -- 2h 'Quer rt and lite ��s f�1 n w � 5i)L1�1;A} If<x(lint Ctx�i,:d PHFs bond I iO'F to i __ ._ ._ i i 2� t'Natot P� mbinfd od t o o cC {> i 101F Within 2l iour<and From 91 �.2/ y_s C3c�itk- '-FC-6 607. I to 41 IJ''3"F Within in 4 Hoar- r i i 2A Poi,ionouslir Tnmr Im,1Lriais 1 P 00' -501-t4i6; ('o0iii,;PiiF 47dc From AnFitni .. - --- '� t G fit,`-r Within 4liair. f s y `1 fn JSatir*.C:Rt1 r., ;;St �: I�:v�it •`[t' Y,)S� t�..(t{i(= �— - 3+w..., q t«m.r•-, .n,+ra� �a +B' I `"3" '� <ti - r ° 4 a rr iyEOInn10nWCalth Of (I8S68ChU8ette� 3 "`-. r s� r i ' x x.• t "»M b a g City of S Ie7n a Ki beliey Ditscoil ar � +i �'r .a.-F�+ �• �'B08r'd of ealth �;c .,�x.r ,�� '•*� `�+I° ��r 1� n d, „ We £fir kE rs r +1a `y.120 ashington St F et 4th Floor, r SALEMY t ( a nu s,'�'xa "§ Temr�orary F god Permlt a ,° P " :.x rY.. f t.��ri eara� _�, �f Y ♦ �i r[� wa�.r k '"� d( a, >� e -�$ ss.+t'K r�' t c`^ a'r'r{ ��x A k . a 081062012 Y� fF a �ry � F DATE PRINTED 7+ j r s .w ,+. -41,i s -�• +• � ,. w �+, *x �' �a R f ,�+"', X ter$ x1 t; 4 " irZzt1' it h •Ts i� �Fi ,y*.{,rZt•+.. a'. Y _ Xe xx. v m➢� ESTABLISHMENT NAMEYr r ` �rga s P> a,04 «E d "� 'e L"-�'a:"+ a •Ys 'i a vs 2g OLnIaIl$CCCet 5, =g„ ix xk , + '+ xx } +�'fYla Nu�int�°BIiF 2009-000035 a r fir+. 4 "� a ,t^§ e r s-:r t� ° � + �`-• „ +"' + t eA•n �� '. F h'4n'. A° t j ' x �� '�1v1AA;�19��# r �"� t�' SA f k S T .*n �` V g CIC 1'iY 'fi U. * x� N s ' ^ tr.` r '' �" 'xty"` ^rxy.�i' $f� A ' LOCATED T ` �.�e . _"= o-" �'?''iJi..ut`;�`-"F '-. tY s ,�r*A A-M Ai97�r.. �r`', ''a iY4 •,a+ s. x • trxa W ,_ h� N Rg Z'r}S M1t' �rxtt st x £,,:c 5 r€. Pernut T" e? ' ` ' Peem�tNo t n Permit Issued Per �t Ex fres Fee Restne lana I dotes ' ' i TEMPORARY FOOD:{BHP Zot2;0564 Aug 6,3012 Aug I ,2012 $0 00 °EDEN I` x Salem'i3 Favorite Pizza 3 R4 aCAn tas��LOCATION S818m Yt z z r 'F -x_ a .� zK'a t �t » OomM FOOD�'O BE"SERVED" Sow "SN s.Q 1 �c r4 »t TOtSIF +v x a�f` Al' p art m Mss. t oyer? iL 3h S� r".1T ice" rr.vay (.r},,.. j ,. 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A PERMI EXI'IitES, ugast 6, 2Q12 "" - "` abs- .� ✓"` .. r, r a a s z i x * z hBoard of Heath m °`sltcz.,x.a .. �- °i .w3 5Yx e.E' # '""�`}'•,.x c`°""t.�. 3' !t 'y w } & r x'",+.ti r > -+xn �f �.. ,.= .s ,r r a J k ,A fl 4 t >J r r3 't'i• y�d,�.t�,� ' hH n' h Srw� -{y-.',d J th^kyt,. T* €Sa.� Y3�`,�..,� A K'�- '.,. 4 f C+.vim' 1." �(�rs✓y m+z Jt PLf•#, �#^.' Y i ft 3 F• -+w-'q - 3j ti 's,s P, +' v,, Jg -✓ a s ",. fk w kt.. a r s -zi .w i^r n -� +, ' .+-x 4 ^art^ . "`s` s• k ",Page r x :�^Tt {t-3 ✓ �°F.Y ,,,, '1.e�• � 1"^ � � '^z f ^ '�,+`��•�s s i� + �+ '°r +v 2 3 F 'fit ..,3r ,�,; § n ,>r y� a ^ �1,•b 2 ''*-fi. + Y " -x t q � sol , h,d t~ n t � a �.g� �e x '�•«� :,�E to }` " F"i;} q�' h �.n r E .: N Y � _: x.tx; F s'a ; -.m r -_ .n °� � i 1 �d` '-L.s sks•' x `T %a.} 'r > t ? a k s z � { r S4„�. '�q''s E'4 �k wf 4-_ '' M...'.s 'a t, tsh t"arc"yf.vp° �a l .n,.° r,�"/ yxlpCs 5` ; F3.r p h j # K +,t T3 CITY OF SALEM, ANSSACHUSETTS BC7. m OF HEALTH 120 WASHINIGTON STREET,4n'FLOOR (7I 1. T'EL. (978)741-1800 KtMBERLEY DRISC Fax (978) 745-0343 MAYOR ITarndinosah m.cO1n L.IRRYXaNIDJN,32S{RTd IS,CHO,CP-FS 131:i,V;ri I aCiSNT CHECK PAYABLE TO THE CITY OF SALEM,NO CASH FEE: NON-PROFIT=$25 1-3 DAYS=$300 4-7 DAYS=$600 OVER 7 DAYS=>7 DIVIDED BY 7 X 6OO=THE AMOUNT DUE (EXAMPLE: 14 DAYS DIVIDED BY 7=2x 600=$1200) APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT r�r�___ NAME OF EVENT a r� LOCATION ( 1 DATE(S)OF EVENT i� - ZC� NAME OF APPLICANT UIm lat GeAs" TELEPHONE# qZ K ,53'9 ZZ-Z.3 —iT- ADDRESS ((}} TOO NAMEOFBUSINESS �1h O TELEPHONE#b1g) :T4o- 7goo ADDRESS :z Nw-ma.n . {{ (�f'y .p 0_57 CERTIFIED FOOD MANAGERS NAME:A-pw L, CERTIFICATIONM *A PLAN OF THE ESTABLISHMENT FOR THE EVENT MUST BE ATTACHED TO COMPLETE THIS APPLICATION* FOR ESTABLISHEMNTS OUTSIDE OF SALEM MA: *A COPY OF THE CERTIFIED FOOD MANAGERS CERTIFICATE AND ESTABLI$HMENT'S PERMIT MUST BE ATTACHED TO COMPLETE THIS APPLICATION.* TYPE OF REFRIGERATION: iGAS ICE DRY ICE _OTHER METHOD FOR COOKING/HOT HOLDING: GAS _OTHER METHOD FOR SANITIZING: CHEMICAL )� OTHER SOURCE OF FOOD: NAME: , <5 f t 2-'2 a ADDRESS_213 J IY IDIYL_ FOODS TO BE SERVED INCLUDING I GREDiENTS AND METHOD OF PREPARATION: d&fgL I HAVE READ THE BOARD OF HEALTH,"REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS "I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REQUIREMENTS. I UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. PURSUANT TO MGL C62C,S49A,I CERTIFY UNDER THE PENALTIES OF PERJURY THAT I,TO MY BEST KNOWLEDGE AND BELIEF,HAVE FILED ALL STATE TAX RETURNS AND PAID ALL ,SST_ATE TAXES �REQUIRED �'} UNDERLAW. rf�ll�*' A.�`^^ C1IIJ "-' q3z) SIGNATURE DATE SOCIAL SECURITY OR FEDERAL ID# CHECK#: DATE AMOUNTPAIOI_ „_ APPROVED BY._,__DATE: TDr,ADAPPI VL11 nn,I IDn ATCn R19111 rJ CITY OF SALEM, NIA,SS ACHUSETTS &).ARD OF HE_jLTH 120 W.�SHINGTON STREET,4"`FLOOR KIDIBERLEY DRISCOLL TEL. (978)741-0 800 F,3x (978) 745-0343 MAYOR Ir a rn du I@ saLei n.com LI IZRY RWD1N,RS/111',J 1S,C 10,CP-FS HE;17:P}i AGl>N'r Guidelines for Temporary Food Vendors In order to ensure that safe and sanitary foods are served to the public, your temporary food permit is issued based on the following conditions: • Your Certified Food Manager certificate,temporary food and propane permits(if applicable)must be conspicuously displayed on site. • Only the foods stipulated on your temporary food permit may be sold. • Foods must be obtained from an approved commercial source.Proof of source such as boxes, receipts etc. must be on site. • All potentially hazardous foods such as hot dogs, commercially pre-cooked sausages, hamburgers, prepared vegetables, must be maintained either above 140°F or below 41°F. + Only mechanical refrigeration or crushed ( cubed ice is allowed as a cooling medium. Foods shall not come in contact with water or undrained ice.Packaged foods may not be stored directly in ice if it is subject to the entry of water. • Cooking temperatures are as follows: § Commercially pre-cooked products-140°F • All foods, drinks and condiments shall be handled and stored in a manner that prevents contamination such as using clean covered containers,storing equipment and food up off the ground etc.Trash bags are not to be used for food storage. • Running water with liquid soap and disposable paper towels for hand washing must be available and set-up prior to food preparation. Bottled water with a pull out spout is acceptable. Check with the Health Department for other acceptable methods. • All food handlers shall wash their hands after utilizing the toilet facilities, smoking, eating, changing tasks, and changing gloves or when hands become contaminated.All wrist jewelry and adornments must be removed. • Bare hands may not contact ready-to-eat foods. Suitable utensils shall be used such as deli tissue, spatulas, tongs, single-use non-latex gloves etc.Bare-hand contact shall be minimized with foods that are not ready-to-eat. • All equipment, utensils, containers etc. shall be in clean, sanitary condition. Where there are no warewashing facilities obtainable,a spare set of work utensils shall be available. All carts must be thoroughly pre-cleaned before set-up at the event. Feople handling the food shall wear clean outer garments,hair restraints,and utilize good hygienic practices. Vendors licensed to sell scooped ice cream must store scoops individually in each tub of ice cream or provide dipper well with running water Smoking is prohibited within 10 feet of a cart or food storage area. Employee must wash their hands thoroughly with soap before returning to work. Garbage and refuse shall be disposed of in a satisfactory manner.The premises shall be kept clean. A stem type of thermometer that has been properly calibrated must be available for testing potentially hazardous foods on site. The thermometer must be cleaned and sanitized before and after use in a manner approved by the Health Department. Refrigerated units must have thermometers A labeled spray bottle of sanitizer prepared at proper concentration must be on site and used on all food contact surfaces, utensils etc. Proper concentrations should be determined with pH papers.Concentrations are as follows: §Chlorine sanitizer: 50-- 100 PPM§Quaternary sanitizer:200 PPM any of these conditions are not set-up and maintained, your temporary food permit will be immediately revoked and you will be Acted to stop serving food. you have any questions regarding the above conditions,call the Salem Board of Health at 978-741-1800 prior to the event. lave read understood and agree to adhere to the above conditions. —6 ni it Holder Date v .no4o01 qn_�� .,rrronarcn ar»ria