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GIOVANNIS - ESTABLISHMENTS c OYaNE,'S i wiversai one, www.myuniversalop.com phone; 1-800-756-4676 UNV16162 MADE IN USA i 1 x Y 01a, Cammnnwealth of Massachusetts City of Salem Board of Health Kimberley Dliscou 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2011 ESTABLISHMENT NAME: Giovanni's File Number:BHF-2003-000007 44 Jefferson Avenue Salem MA 01970 LOCATED AT: 0044 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2012-0092 Jan 1,2012 Dee 31,2012 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES (December 31, 2012 Board of Health 7 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. CITY O SALEM, N ASSACHUSEITS k BOARD OF I IEaLTx 120 WAST ILNGTON S'I'REE:I',4°. FI-0i iR '111'. (978) 741-1800 KINfBERLE'DRISCOLL FA\ (978)745-0343 NUAYOR haenrin(a)salcm.corn LARRY RANIDIN,RS1RJ:' Hv,Ai:n i AGHNT 281_APPLICATION FOR PERMIT TO OPERATE`yAFOOD ESTABLISHMENT C� t NAME OF ESThBLISNMENT_ Vii1},t� L�Li��—'LL# � ADDRESS OF ESTABLISHMENT Ue - FAX# ' MAILING ADDRESS(If different) EMAIL-Business': Website: t.JOtJ'tJ�tiiNGj� )OV�iNN)f OWNER'S NAME \ f PtJ P l� /i) C qtr p TEL;--(a "S �ADDRESS_)JkL�L -Y C( Ytu �C(31-� i Ci STREET ��JJ /�' CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) �V) 1 t�✓t CERTIFICATE#(S) (Required in an establishment where potentially ly hazardous food is prepared) t / �� EMERGENCY RESPONSE PERSON _14SOA C-in /�t-J HOME TEL#_W_ 9_ 7d J T 1 DAYS OF.OPERATION , i Monday Tuesday 1 -Wednesday ( -Thursday ,j. , Friday Saturday i Sunday HOURS OF OPERATIONl Please write in tine of day. IN"I -tQ7 ' lDgM-lop 1441 ti�iH-1O)�Wf'►&6y'-otG1144!)fxila.! -cx Gltl.1(444-o) ill"+t 'fir!` I I (Forexamplellam-11pm) TYPE OF ESTABLISHMENT FEE (check onlvl RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ----------------- - ------- ------------------ - - -- -- - �.. RESTAURANT YE5 NO t"an 25 s"ats _$. an (Outdoor Stationary Food Cart$2 25-99 seats =$280 more than 99 seats =$420 - - --------------------YE ...- -... ----------- ----------- ------ -------------------------$---1-00----- BED/BREAKFAST! __- ---------- _------- ------------------------------------ - YE NO -----_--- -------- ----------_------ ...... CHIlDCARE SERVtGES/NURSING - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM,YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YE $135 ALL NON-PROW(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C.Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax rllunp and paid all state taxes required under the law. / J gnattue Date � ) � Socia Security or Federal Identification Number r Updated 5/23/11 POODAP201 Ladm CheckN&Date I1 sJ' QTY OF SALEM, MASSACHUSETTS Bo\dRD OF Hrill;nI 120 WV SHING'roN S RI_H'7,4'" FIJ a IR KINMERLEY DRISCOLL TIL. (978) 741-1800 MAYOR E\1 (978) 745-0343 lramchn(a),salem.com 7.,uun'RA\IDIN,RS/Rra IS,(:I1 1,C114S HIS:\I;I'I I Ac{I(N"I' MEMORANDUM Date: December 7,2011 To: Food Establishment Owners From: Lary Ramdin, Health Agent RE: 2012 Food Permit(application enclosed) DUE DECEMBER 27th Enclosed is the 2012 Food Permit application. A check and the completed application must be received in this office by DECEMBER 27,2011. You will be issued a $100 ticket for lite'submission'of application and/orfee.' Partially completed applications will be considered late and subject to ticketing. A few reminders: J. s . . • All City taxes and water bills must be paid in order to receive a 2012 permit. • You may not operate after December 31,2011 without a valid 2012 permit. • Food preparation employees must cover body hair with hats, hair coverings nets, beard restraints or clothing that covers body hair. • There is no bare hand contact of ready 'to eat foods. Gloves must be changed when they become contaminated, such as when the face or hair is touched. Then hands must be washed, and new gloves put on. • Exterior openings must be screened or protected from entrance by insects or rodents. • The 2011 Food Permit is valid only for the owner listed on the application. Change in ownership, requires a new application, a plan review application and d a review of the floor plan and menu of the establishment by the Health Agent. • Any change in the establishment including a change in the menu or renovation must receive prior approval by the Board of Health and a plan review application must be filled out. • The Food Code'requires thafeach establishment having a seating capacity of.25 persons or more shall have on the premises someone trained and certified to remove food lodged in the throat, and to have insurance adequate to cover such employees. Please see the enclosed flyer for convenient, local choke-saving classes. • Thank you for your cooperation. r ( IMPORTANT MESSAGE ) FOR /—�y 2,_ OATE��n TIME v han�11/3 OF PHONIP AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBN F AREA COCE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU I RUSH RETURNED YOUR CALL I (, WILL PAX TO YOU ESA, -,y1��A nc I,1 DIKC PYLg��t4� Q � � SI13NEC9/ FO IN U.S.A. NOTES i it 1 rI,' ( IMPORTANT MESSAGE ) FOR 1��,\-)-� ��,��, ��'��',,,,,,,,,,1 � 5 GATE Ill TIME M AoL25 OF PHOI\'F AREA CODE NUMBER EXTENSION 0 FAX 0 MOBII F AREA CODE NUMBER TIME TO CALL TELEPHONED I PLEASE CALL I� CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL I WILL FAX TO YOU l� MESSAGE k�2 bI Vld 13 c1L C� i \=wocf,fUKt', ��fiifl v + SIGNEC(, ,y, � FORM 4009 bm MADE IN U.S.A. NOTES ��' CITY OF SALEM BOARD OF HEALTH 4 'l Establishment Name: C� )Qa#) 1 S Date: dJ I IO Page: rf of ( Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No." Reference R-Red Item, ; PLEASE PRINT CLEARLYI/ Verified _ AZPt� 1 )ryM r(. C OVq V)In [lF+ iVP-C-Q!'"CAI MC- -.n �,,IV-n C(5)(1c� 1 { r ?SVI C {� RAY IV/1C41'?5'Yl rIN?1c t n I . Ni rJ1 r' [ A ,�P V'P in _(/ [ I ��yy�� CC"riVl £'SY�'nnA- t.ICX� nV.,�-P.yt,�o � crICII <.iA_o __HAomP.� 7 +t- I-) or ig.t-r.7-,. 0,( I�Inc_ _ �Cr.l��p Ca )( 1 5 Y)Y�OhP lii� l.tlirt� C( n 4`)OS _ !l � (].t / TTn %1 - - 4tn 1-�- WI11C.V1 r iin n .�i� t 0 r� (n)`pt�.l"P ) t)Id ° -�a,.��'(D 11_ C.C�Ct r lo( , 1 \,rI �en 4, ,v,4 .D- kt r ne fvl40 Gf 11��?Pr I ?fYl (lrtni^P P4iIA'�,l4 �nxC ntC _- _ _n kock'- �_I1_<kv/ 0&1*, OtJ(AOf .5lC-( Lad .Lrnv " '(n (T. W0r1 r_) n._ - ,ln Vyl I v,fryi (n o r G r-�i ')?� (C �P t(�- +"rrx n C tt —t�n r c +1/1,17 . I � 1 I � �n� If'rvt i'tY n j Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ res I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction tt violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension s comply with all mandates of the Mass/Federal Food Code. I understand that I noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of :3 Embargo ❑ Emergency Closure your food permit. \/ l 4 ❑ Voluntary Disposal ❑ Other: Fill.so PVIF,e Rec,odcd iii Tensrividorres Violations Related to Fondbcrne Itiness ln&arverrfions and Ri%h i I Fhwtorq(ilem P=) (Con Ll PROTECTION FROM CHEMICALS Food or"lor Additives 19 PHF Hal and Cad Holding N PW Nbaintind atm scow 3-302A4 j Palectim,Wmir kba"nmed Additives' 30MANO j hit PHR Wmimped at in mb,w Poisonous or Toxic Substances 1 1461' -thrybd 3-501 )id AI pmi„ct Held at oraliov, i';} 1-, Comilla", Time as a ubtic Hos1th Contraii U)III coeurion Name-- W��rIing 20 i P 3 sm 19 Thw as a P014,iinkh Qmad- Vn6an"C Reqairemalu t--m2 if le,"t[iClion pr--.cPat ;Wu Ua' 7002A2 QmA6m,4UW` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE mall T(,xic("o,itamer, ...Proli:beiou," POPULATIONS(HSP) :.20.1.1 1 Sajrtizev;.Cnscmi - (homic;ds' 1-1 ONO! I hA) I WPUMUnied PIWIWILkag d JWLCS and 12N :2 Chamicals hx IQ hiny lindwQmW e,( I 1 Bevel e;kii isal Talla 7-2 014,14 Drying Agviltr.Crite:ia' 3xut 110i, I the M PmenmTJ Eqrcz° 7 )n6dcriaf Fi0id (76nact, f.obnantsl 300 IUD; Ric or PmuAf Umiad Ammal Kxd and R�Qrwmduwlt�ak, Chum, d so a,No 7-,:06.12 Rmicat 13,61 ,Sumlon,- 8,;!A"Cl f I bmwied WO Pm?aW Fm:, Rc anal, 2W 0 'Trackinglanodr's. Control iand Monitoring, CONSLIMER ADVISORY 22 1 oV,', I i Cklnlmic(Adaoi. P,tcd 11;r Com,-irmpri"ar of TIMEItEMPERATURE CONTROLS flia! ,i!� Xav, URdarcxikVdca 16 Proper Cooking Temperatures for Pr;�%nsed 1"1-1111ol'ite PHFs S W1 I I V1 r.gy- 155'r 15,No,- PcNj�cio.- IQ>mu"hatu Scow, 1411 Ime, NOW? M qyam.d Epp '11mitm Ay 110% Shell j-WLjhAy21 i Comicinw,j Foh, Me,,z:.`e Girm 1 Animnis lit F !5 Sec. - 310LIKEllyl Pal% aiiG Roam AW 1: 121 Win SPECIAL REOUIREMENTS ?41H.114A 'n it,lit jjiP.,!t,j tiP_fjt, _ {`:'F 15 5901AAAmni Whumn of A) (D) in catvnq, mvhiii: k:iod, acid V401.11(A)(I) PokilTr,,Wild6am.-t, sTuired PHRi, i tc,,idon-1:a1 6tchcr, ,houbj bc MUM,twown FmW Nom i3i ritham anor me am"moo scrim's P,mh,v or WamenI651W mc i abwc�, ifc;:!aicd to fi,,(Aborn.: iljtics� 040LIUCKh "No4ramor urml I0J,t1eaK, inicivetwop—iod risk factors Oili(•r 1.15'1- ;i i ti91 L069 violat i orlrcial mg to gok nj ral at 1 14WJZ i R"W suad 14wh rMAN U,a E prtmficc� !to 1!J iR'&HiM undCr g29 - spocial Requireft'atS !-40JAIcAi(11j(b) All Omei P111 7—#T 1'i r� 17 Reheating for Hat Holonq VIOLATIONS RELATEV TO C40(J0 RETAIL PRACrICES 3403.UiA)i;iD"� PHI,, 105-T 1,;sec. 11.39) ml I um) Nboomme. mi,r Numu sandan; umd my mmWQ'zw vwqm,;?o. ul,rch do no:iciao 0)rlt, Inc 1,210�,a9,iom, O!J rccA jqr u rs oca be COnicnaiMly P"NaS,,• IouXi i'i 5W=1 AW Wl 04C 010i 105 cum I(Fi Uishced Ansm")fReel tar Miami aviih;cUvs W _AAar!a9mlort ace Petionrail PC 2 X -0 proicct,cr, - -1 III Proper Coaling of PHFs I cva and Fo, PC .00-1 1 i_,C013 3 it 1 IA) (Wing COoPd PPIR Iron! 1,40'F to ----- ------ pn"N*iiate FC,-5 56t, 701-,Within 2 1 icor�and Frian 791- 27 M7 to 4!'F/,Ic F Wtthn 4 itim. 28 1 or!1W iv, lLt��Js FC-7 (X-8 14 C.rim,firg Piffi, Made Iv)ul Ambrew Tmlio(asae higretiicaig i,,41�R4 i'F 10S t N.TXJ0cf +� Commonwealth"o Massachusetts "f City of Salem Board of Health Klmbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: Giovanni's File Number:BHF-2005-000007 44 Jefferson Avenue Salem MA 01970 LOCATED AT: 0044 JEFFERSON AVENUE SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BNP-2010-0022 Jan 4,2010 Dec 31,2010 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES IDecember3l,2010 i1 i M Board of Health 4,; G ✓) \ 1 r This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 4 » CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"r FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL Fax(978) 745-0343 MAYOR DGREENBAum(a)SALEM.COM DAVID GREENBAum, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT/� / NAME OF ESTABLISHMENT ( n'il'(�i'mv); �� `L" TEL#_ G��'7 7/ 1/ ADDRESS OF ESTABLISHMENT G(.p FAX# MAILING ADDRESS(if different) EMAIL- Business': BI ZZ.20tref i Website:�t7U1ia�. fr f.j ✓1(I�I �Sa �i rC'e C(1LA/ OWNER'S NAME _� ;`0 I�ra.� C TEL �' SSC ' L,-I 10 ADDRESS /� �IAT1�1 St �i.1r.i +4✓��/r) lelil�! . STRELT-€ ^"fir CTTY - STATE ZIP CERTIFIED FOOD MANAGER'S NAMES �G Ct7 �7 ( ) c i l � CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is pr/e�'ared) f �i EMERGENCY RESPONSE PERSON J a-(�J A l7"P a �1�1 HOME TEL#--? I' HOURSF>;QP,.ERAATI(JN F Monday I Tuesdaye' �fNetliestlay 7)iyistlay sl Friday Safijrday i a SiiiiCay? HOURS OF OPERATION I Please write in time of � �) o 1V^jo / )' / / (For example 11 am-11; 1 TYPE OF ESTABLISHMENT FEE (check oniv) RETAIL STORE YESNO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ---------------------------------------------- ----------- ---------------------------------------------------le------------------------------------_ RESTAURANT YES NO less than 25 seats �A (Outdoor Stationary Food Cart$21 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES O $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 NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax ret d paid all stat t es.required under the law. Si e r v 'Date -- --7 Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date_J.S -7/ 6 / 0� $ wo, 0 Cleaning and Maintenance List 01-20-09 Back of house: Base Tile by dish machine missing and fix hole in wall. Base tile missing by carving station. Paint ceiling and walls in kitchen. Replace tiles on floor by the grill. Replace gaskets in drawer units and fridge units Clean and paint sundae glass rack by dessert area Walk-in door gasket needs to be replaced Salad cooler needs new racks and floor needs to be replaced or something Clean all shelves including back prep area(under slicer) Floor by beer cooler and freezer coming up needs to be replaced. Victor is cleaning walkin and freezer. Store extra pans we are not using for the winter out back in train room. Check and order replacement thermometers for all freezers and walk/reach ins that need them. Grease unit on back prep area leaking. Both Salad and line ice cream freezers cleaned Fan guard on salad upright unit next to 2nd ice machine needed to be cleaned Ice machines cleaned thoroughly Clean and paint all shelves in dry storage Remove ALL non-food items from dry storage including bleach, rock salt etc. Toilet needs to be secured in Men's room Both employee bathrooms to be cleaned out thoroughly Mop sink area cleaned and painted Organized electrical room remove umbrellas (back train possibly). Steam table drains need to be fixed, pans covered at all times Broiler condiments need to be moved (onions, mush, BBQ and Teriyaki) Bacon to be kept at 135 degrees. Rice and Potato warmer at 135• Sanitation solution changed every 2 hours and PH log done consistently Spice racks and all shelved cleaned nightly Hole in Pantry ceiling needs to be repaired. Check Duct tape repair job in pantry area Under range top needs to be cleaned Kale and Cabbage needs to be kept cold (iced poss) Potato rack needs cleaning. Slicer needs to be updated to a 3 sec blade stop. Front of house: Re-organize to-go area clean shelves &get rid of anything that doesn't go there. Organize liquor room again still lots ofjunk back there. Wooden stand up beer cooler behind bar needs to be cleaned thoroughly. PH strips need to be used for sanitized water behind bar and recorded in a log. Speed rack behind bar to be cleaned (front and inside) Ice bins cleaned thoroughly Re-organize area under soap dispenser in the bus stand (no food product under soap) Organize &clean all shelves in bus stand. LIS bus stand shelves cleaned and all condiments brought to early side to get used. All S&P shakers cleaned All sugar caddies cleaned. Temp check for front and back of house (FOH including salad bar, soup warmer, etc.) Remove all clutter above service bar area. Remove clutter under TV by the 2 micros. ;ti`K;^•'��j •,-e.-. �,/.:-r^.-..lrtrsrRvili`,r,'i.;/nY 4�k+`T.e T'r�.lh :.-.p"6,.:,..jr ,.r..+.n r.,..,rn.�+;rwr,wh�{.v, 'FA k+P,w.+s .,.. F .-,� r .• TINY •- , Massachusetts Department of Public Health Salem Board of Health t , 120 Washington Street,4th Floor r Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT 4 ,Tel. (978) 741-1800 Fax (978) 745-0343 Name D ¢ Type of Operation(s). Tyge of Insoection )/,)4 I ©i Food Service outine Address Milk Retail u Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP YM ❑ Temporary ElPre-operation I ❑ Caterer ❑ Suspect Illness Person in Charge`(PIG) Time ❑ Bed&Breakfast ❑ General Complaint In: 7 ' ❑ HACCP Inspector �,, 17h i;Q� I Outj' Permit No. ❑Other Each'violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. . .'.FOOD PROTECTION MANAGEMENT,`�_" ❑ 12. Prevention of Contamination from Hands F1El1. PIC Assigned/Knowledgeable/Duties ' P- " • ` " ' 13.Handwash Facilities EMPLOYEE HEALTH" PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC I [114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ter. _, -�FOOp FROM APPROVED SOURCE "- �:"� `� ' , Y ,- '_ ` El 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source •TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) " + E] 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating 3 ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION' [(19. Hot and Cold Holding ❑ 8.'Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(NSP),. ❑ 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices ' CONSUMER ADVISORY 11 °"'"` "" I I ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C x 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>(5so.004)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28- Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. _ 30. Other DATE OF RE-INSPECTION:/ _ l,^ 5 5HOlns IFom 14 Ua �[�(( r�\ - n -_11 Inspector's Signature: Print:. I PIC's Signature: Print: I Page Pages T4 - / -v J 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 Responstbility' 3-302.11(A)(I) 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 I 13-302.11(.4)(3) Raw Animal Foods Separated from Each 7 EMPLOYEE HEALTH I Other* 2 590.003(C) Responsibility of the person in charge to I ( Contamination from the Environment require reporting by fond employees anu 3-302.1I(A) Food Protection" applicants'" 7 3=302,i5 Washing Fruits and Vegetables 590.003(F) Responsibility Of'A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To Tice Person In Utensils* Charge* I Contamination nom the Consumer 590.003(G) Reporting by Person in Charge* _ _ 3-306.14(A)(B) Returned Food and Reset-vice of Food* 3 590.003(D) Exclusions andRcstrichons* i Disposition of Adulterated orContaronated 590.003(E) Removal of Exclusions and Restrictions Food _ 3-701.11 Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* _ 4 ( F000 and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-R) Comp]ianee with Food Law* j 4-50i.1 i I Manual Warewa.hine-Hot Water 3-201.12 I Food in a Hermetically Scaled Container* I Sanitization'feninerahares* 3-201.13 ( Fluid Milk and Milk Products* 7 4-501•'12 Mechanical Warewashinn Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Mill:Products.Pasteurized- ( 4-501.1 id Chemical SaniGiation-temp.,pH, 7 3-202.16 ( Ice Made From Potable Drinking Water- concentration and hardness 5-101.11 Drinking Water from an Approved System- ( 14-601.11(A) Equipment Food Contact Surfaces and Utensils Clean` J 590.006(A) I Bottled Drinking Water* 4-602.11 Cleaning Frequency of E ui meni Food- 590 006(B) 4Nrater Meets Standards in 310 CMR 22.0"' Contact Surf 9 face,,and Utensils;' 7 Shetltish and Fish From an Approved Source 7 4-702.i iI Frequency of Sanitization of Utensils and 3201.14 Fish and Recreatinnaily Cauglrt Molluscan Fo,rl Contact Surfaces of Equipment' 7 Shellfish, (7 4-703_;1 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NESP Listed 7 Chemical" Sources* I to I Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 12-301.11 Clean Condition-Hands and Arms* f 3-202.18 Shclistock Identification Present* ( 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms" ( 12-301.14 When to Wash* 3-201.17 Game Animals* I I it I Good Hygienic Practices Receiving/Condition i 2-101.11 7 Eating, Dunking or Using Tobacco* 3-202.11 PIIFs Received at Proper Temperatures* I 2-401.12 Discharges From the Eyes, Nose and 7 Mouth* 3-202.15 Package itU 3- 1,12 Preventing Contamination WTasting* reventng ontamnaton hen ( 3-i(tl.l i PrKxl Safee and and Unadulterated* ( 30 _ 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shelistock Identification''` ( 590.004(E) Preventing Contamination from 3-203.12 Shelistockldentiiication Maintamed'" j Employees Tags/Records: Fish Products ; ( 13 Handwash Facilities 3-402.11 Parasite Destruction` , I Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-'_03.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 15-204.t I Location and Placement* 7 I Conformance with Approved Procedures 1 5-205.11 Accessibility,Operation and Maintenance Confer/HACCPlans Suppliod with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced os)�gen packaging. criteria"` 1 6-301.11 Handwashina Cleanser, Availability 8-103.12 Conformance with Approved Procedures" 16-301.12 Hand Diving Provision 'Denoics critical item in the federal 1990 Fond Code of 105( NR 590.000. 1 CITY OF SALEM I1 BOARD OF HEALTH Establishment Name: r_L1 1u nII "s Date: 3/ 7 y + G Pager of f Item. Code C-Critical Item DESCRIPTION OF VIOLATION!PLAN OF CORRECTION Date r No. Reference R-Red Item I - ., - ,. . _ Verified - - ' ' 11 PLEASE PRINT CLEARLY - I.1(n S�l.lt-' / faP ( ciVC(S +tel t IJXAM)'Or "P.,\ 1J4— (h , ).SIG / % SSI. t4� / �-LtiF:"FDr ��V �I,S.$.�/1 4 r:--c�.J..(Ivr�.Pi. Cin% ? /„�,t..nn,../�,, 44Ar, J( - ) f in sia /67C f I- O! 0. 1 le'7- A)01 4 ` LP 1- t• IL IC l�D' //Vrn.�/.v 1t / / 11/« c� .l f �✓t.Oj,(A"(ii l/nt , F— lie t (i11 16r-1 —L I Iry c.4 r ^I } y r I� . YN Ji1SZPr.�oti L �_d �101.ul�rna �ri ! rinlc( 7 �no / � rhl( (,h.? rI°ft /Si�w =t� , JaI 7�n�111,t.1.�'1 �.'�r/-1-✓�C/ .a'/- -�(D ��nit4 j e, Nso� �/. �Lt+n wi/1 ,7n)J_ I _I- Gf / �, If 4u 0WF- ai��7 Tra t�JC/N� ✓YI �ln.fr /, Ca ��oc� l v/ - So2 li�� / �� tJn,� -D Y1 .� `J4 to Liz)S I "-W=4L /l j ( n ryiyie /I n,)4 ovor] t 1I 0 / _n4�*)nv1? UI44 17n14t)c 3 P L`I¢e1c1 /_r � d tt O'r/.nV-14- 'KO.Q/�(L r (-- ��`1 l/rn fQdrl� �1u�. .z3' 4o1 rc-+/C 1 r/l�r l Cl t) if' l i�✓l� (i Crn_4< .).0 ce l.. l� �., 41 1, A. s .,� 21 c� I t/ rA =t�; j Discussion With Person in Charge: Corrective Action Required: I ❑ No g1' ies I have read this report, have had the opportunity to ask questions and agree to correct all ploye ❑ Voluntary Compliance ❑ Em fusion t?estriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars o�S�revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal D Other: r it i �— Violations Rolitlea to Foodborne Wriess Intirvinnionc and Risk to!,:,v Oitlod!o Factors(items I-v) lCoot) ivilhxl� M��LhW� !•�r PROTECTION FROM CHEMICALS 113 f PliF Hot and COW Holding 14 Food or Color AddWylgi )l)i. fit B; col'? `vlcin;,J"L-J at(v In!%liv dell ilv\t;,` iqo 3-302,14 Ph.,xcugv 1,001 ki.,jj It I ;{<,:1j Pc*,, TIFq �q,)T atiow 15 Poisonous at Toxi�Suostanccs 1,10 I kkm�l: H41;li nwte ; x,0.1. 21) ! Time a,;a Public Hoafth Control RQ1 I (i-anj,,n Work::,g Cowaw-:W in.,..a�a Publiv I tejlh Cixrtivoli` 7 `i}; I I so'cit:'a'icit—srol apc" 10 RCNniCwJl - P,t:Scliccalrd Lw, 7-202.12 I coudiu')D:ot i lw, REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 21 'i sm'!1,'At Stmt(and 7.'i}; 12 ('�elpicfik for oa,hj,�,Prxkrce,Cliwi,a` 1 Ual vka...int.lzb�!,.' 7 '04 11 I)I'vag�Aljkllc,,Crv�rw�' 1 7 20'+ 11 t11"kat:n1al #oyj cvl:lom,IAZIIJ ,aw o Rqu.dl i Animal RX.J:1:ld \ka {'ritella, 7106.12 1`'.WC111 E:'2 I L3:nl N.xl Noi fi, I"icking 1 olije,<, CONSUMER ADVISORY Coostim"K P'Nt'd (,,r k"'womptwo of TIME/TEMPERATURE CONTROLS RW, That ate P,,v, i-IndertAx,lod 01 16 PrWr Cooking Temperatures for PHFs \ol Odw, -ist: 3..101 11 A(!)(-:1 Fi.,gs- 15 j F 15 S-:, i3 tit,"%�f%% Sit,11 10 1.11(A)(2, Galliv A;liurtil i S�:F i5 sec 3-40 1,11�ftl;f 2) i T1.it I% ;irid DM R,wq I w I-, I SPECIAL REQUIREMENTS d I 1� I- 1�1 9'::J 0,lot A I)I j Sr,,-t roo 590 i"X}9f,%) I D) in i Wi, i cawrat,e:, trobtR 'oxm. ki:mpi,ratY acid 3-40I-lI(A112) --1 Potlit",Wild(ianle, �Aofycd ril-NI'dwiWai 61ch,:v op.j,rims Kik,,::l(P bt' FiSii, t:n<hn the or Ratlic, 15 wc. abQvc If,fcWtivnic fflncv 3-4 0 1,t I C)1%-,i Irfltail ilto.r"icals 11!.Ql veildoll,and i,,,r. Itjcwr.z- Otbcr !-i5"#: '4 \io!atloij�1041 :us. U)"Qi Ki r0ail :i-X01.12 j1;jW -�ooTW! I i!w,dd he debited widcr #29 - 1.101,E .Ali()dlcj J,tj[L� l4jrq I.j sCC 1 173 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETA1 PRACTICES 3-,iO3,IhA)&(J.)) 16i'F I i sc(. ;, -I Oterr3l 23-30) %ficrtw aw. li;Y'P-' %1;;vuw Si,wdin�, .,qy 11"ti- t-l-! Id4lb fig, ;:t! rebur 1"114'. ill"'m"'0 rNQl jot!ors lWfd above (un b" 4 i;3 1 IW) n u0k f2Ti`KNfi 1...o'd al:h,rt,Poiwya 34-j! I t'l:) Ronaliva. Ln"'Wed pwtion`:ur Hcri IM I FC 2 1w 1 24, .'^-d�,rfl F=! R, :)04 18 Propm Cooling or PHFt --- -I .-a.._---- - ---—---- --+i: -------t �%41 PHI s Ii-on 14)=P t(, i! .— — f P, I \1"idwI2 Hojr.wal f•rfill 7( 1 27 }'erns...`-'at :Ji t K -t3 M7 Xb or 1 3-50 i.l41 B) Cc�,Iiiw NiFs Nla& Fzota Amble 0eq Tcmp.'(uvit^l3!;;rl:,14tias 1;:SPI PA5CF vvltl,�ifl�!HkAtn� I%;I, ws,'n,W is vlt 4:k;,:i 1, cood GO."or 105" "Ik e1q!,, CITY OF SALEM I / BOARD OF HEALTH J Establishment Name: Date: 31.30 / .ir, Page: of ? t I Item. ,) Rodeo-Critical R (em . DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION i Data No. Reference R-Red IteI m �' � •" • � I PLEASE PRINT CLEARLY Verified� • , 12� IBS vJ tr l)rlt�n ./ j Aj1/wTf� / I I � AA I" fz� rr aT G!�-.�Il r (kie ; /-v 1,7 p m tAJopt - I I I r _ 4- t� C +;t�tn3 , )�/+11 ).a�r�t �j�fr�lr7r_I Axa I �qT /2 . 1 P\ - a ,�- �i i/ I ✓Il o A_ 1 r c ,�� n C1( (�,, n12��1 J� ,r>�.( ` elf 1 I �, f-4 1 ,� - ✓I CLSl1�t GIS e 4'ccf (t of a+ I. tiltif,vsS G_+,��LL /y-, 4 ` A),7014 A , r I h 17 Discussion With Person in Charge: -- ]Fc- Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employ Restriction/ violations before the next inspection, to observe all conditions as described, and toExclusion comply with all mandates of the Mass/Federal Food Code. I understand that XK Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ^ —' ❑ Voluntary Disposal ❑ Other: ti Vicuottons Related to Foodtarno flfness Interventions and Risk to L-dv, C:N)l,,d to Aturtars(Iterns I-22.i (Cont) F/�5'F%ilbin�! Hvias PROTECTION FROM CHEMICALS :15 Co,diw-, 'Vleffitd��r Plitt, PHF Hat and Cold Holding 14Food or Color Additives I C.0d PHF;'Avmutineo at -20:.12 w,'Y P 1 4 V!45"1 .,30-114 front Ulnippro,ed Ad,ji!tv,_,q 3.;n+ 16 Ai 1{,y PTIFc Maunwmd:' et or irboee Poisonous or Toxic Subsut 140T I I lot If Container,' HOd,4o- Time as a Puluic H03"h Control lo'-Al (UMDIOPN,tnte riffle xs a Pilblic !Iert1i CommF 7-3{}5.11 7_102,11 Pc,triotoii - ,jt(J L>e* culvillion,ot 'Uw` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ro::ic Onuairim. POPULATIONS(HSP) 7.204I i I smuliw"',criltri:l—chrtaic.,N- 7 is Wami'le 1.zbel� riing A%genl<.Cnwria' sol litlo 1 sit of patvzl;iIed E:ie:1" 205 i I Ink.aferual Kx&_'vnlock Lobiicaltl�;, 3-SOI.i I i D) R:iw or PailvilJ,, Ookd,Ntjunal I:k),d.,nd 7.206 :3 iiav, ;,=cd Sjvoiw h,•t 7 '06,12 Rocfcfat Bait Sia;zow Ure)pcnea paciag" IN"I Ircsenad 7.20( l.t 'I Tacking P-,,ai C,mrtto!and CONSUMER ADVISORY Ck�numAd .�-� � ior mmuancues of TIMEITEMPERATURE CONTROLS 22 j I i CI I Proper Cooking Temperatures for {tau. cmdey,.:x4xd t'l PHFSto Lliplumu! 101 11 At 1)1,2) I-, t5j,i' i5 Sc," 11,30., 13 1 z;;f:m;y".f l'o Raw shell Gainc Aniaiali- 0 1-4o1,1 l(Bylp,21 P(K k aj�d B"et Ri);%,l 1}0='t121minr SPECIAL REQUIREMENTS ViL�kAi(ow,ot-Svkmm �'A)AXO(A)-(D) in 't.,zI)1.11(,.ku R�ioilc,, ll�lick!_A !�,5'V I Pncrfitz. mobilt, l,hxt. 1.-aipl,rw,y and 3-40 L!1,A} ij Pwluy Wild Game.Stutter P1417t,, re,:,io al-'d kitch;:n opel::tirjtn?Auw.ld lie Stuili a„ ontallaa, vish. pleat JcNled under it' iofkxAlx)nl,- lihcst livao II 'c'tf Steak; 451 I 540.009 violatitwq lclaluf•_to:"ood retail 401.12 Raw Animal Fkcitdt, w a prl;,"fices 'hould be dcbitl_�i und-r #29 - %00u cage 10'J' .Sp,:cjal ll(A)(1),151 )%It Oahe.i MF,; - ).45 1 i5 cc, 17 Reheating for Hot Holding t VIC!A TiONS RELATED TO 0000 RETAIL PRACTICES 3 401.1 ItA),kil)) 165`i1",wc, - (It,ins 23-30) 165')'' Ni.me Sunidin, C'up dam! iffz:al rw:ajoql;, wkwh do,im rciatc lo?he ,twdhf,�rnc Wnc>, twt,t venl;mv wid ri:,,k la,!ory livi'd above wrl bp 3-4,')3 11 f ommrcizilly RTE hxd - wund it,tht joiion,,i, iec!vm, th, t ow!Code ned llj�CAIR 40 1," _;,11),1"'t h) 3-1031 Rc:11mming, Luft rd Po(zi+,mof 13,t1' FC 690,000 Poj,,f,*1R i g -�d P.rswrel FIC 2 1 0015 Foocwa000Ptoiction PC-;l .064 .st Proper Coo;lng of PHFs qu; Fc. - i 00-1 c(4,"d mfFS rrm 140,17 1, - '01 t4(A) co'bw Fc, -5 006 7(el;witilln 2 1 jovrc wid From 7:)`E Fa,,!)d Fc-c 007 L,4!'F,'45'r 1°ithn 4 F-(, !��Qnw�ot 3 Sol ;,wl) CvMing P HFb Made Rout Ambient Rwuvewel,tF i within 4 1 lkur,' Commonwealth of Massachusetts F e City of Salem Board of Health lGmbedey Drisooll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2008 ESTABLISHMENT NAME: Giovanni's File Number:BHF-2005-000007 44 Jefferson Avenue Salem MA 01970 LOCATED AT: 0044 JEFFERSON AVENUE SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1 Notes FOOD SERVICE BHP=2009-0232 Dec 29,200$ Dec 31,2009 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES IDecernber 31,2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revolutions,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS y • BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978)741-1800 KINIBERLEY DRISCOLL FAx(978) 745-0343 MAYOR IDIONNO&SALEN1.CONI JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT G NAME OF ESTABLISHMENT I ovc.t%i K TEL# 9 i1 I ADDRESS OF ESTABLISHMENT 49 7P-(46r ]n G Vf, . FAX# lel G MAILING ADDRESS(if different) -SC IAAIO EMAIL- Business': V )r, Website: ref: 51v1AI GtovaY)n;S r Cony � OWNER'S NAME J \FILV. �6 i S TEL# SCI-COI D ADDRESS' wn�rfMu .C� G ,1rWI�CrO� VL1G STREET J / CITY r STATE ZIP P CERTIFIED FOOD MANAGER'S NAME(S)-CaCDvt &,.+rj CERTIFICATE#(S) 4CIO3 (A 8 (Required in an establishment where potentially hazardous food is prepared) J . 1 EMERGENCY RESPONSE PERSON SGCrli" l r. +e`y HOME TEL#-nJ-3Sci-q8--)Y I DAYS OF OPERATION Monday I Tuesday i Wednesday. .i,I Thursday ' ;.' - Friday` Saturday. I- Sunday j HOURS OF OPERATION Please write in time of day. Gwt pm,, I J c;« ' )0(1dd) )0j/14 )D� -�G I Uq� - � (For example 11 am-11 pm) - q4 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - -------------------------- -- ------------------------------------------------less------------------..------- ---_-- RESTAURANT YES NO less than 25 seats �$140 (Outdoor Stationary Food Cart$21 25-99 seats =$2 more than 99 seals =$420 -------------------------------------------------------------- --------------------------------------------- BED/BREAKFAST/ YES O $100 CHILDCARE SERVICES ADDITIONAL PERMITS - MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state to as required under the law. // //sID9' Ou Signe Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date a Massachusetts Department of Public Health Salem Board of Health120 Washington street,4'° Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 NameDate Tvpe of Ooeration(s) Tyne of Insoection rlCxiann S Xw s� � ��I5�0 3 AQ-Food Service ❑ Routine Address /ice "�'(�_ /� Risk 111 ❑ Retail ,®-Re-inspection Level ❑ Residential Kitchen I Previous nspection Telephone 'Flt ❑ Mobile Date:a ��'p� Owner ' / / HACCP YIN El Temporary ❑ Pre-operation 1lQ L 1� Z ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) TimElBed&Breakfast [IGeneral Complaint 15- El HACCP inspector Permit No. ❑Other I p . Ir�Sr , " l10�� I Out.,V Each violation checked refoukes an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT;"" "" " " ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties "" " ' " " " " " El 13. Handwash Facilities EMPLOYEE HEALTH" r .. . .., . . , .. , ..� : PROTECTION FROM CHEMICALS [12. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE,� ., ,,..._.. •..., ._ , " ) TIMEITEMPERATURE CONTROLS potential) Hazardous Foods ❑ 4. Food and Water from Approved Source (potentially )" , ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling ` PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing r F"REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing El11. Good Hygienic Practices CONSUMER ADVISORY_ " "" ' '" " .. ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N. by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food X26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing `28- Poisonous or Toxic Materials (FC-7)(590"006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: y ( 1 S 5 Ins FFOm 14 mo Inspector's Signature: ` /�/J/ Print: PIC's Signature: ( \ / Print: ^TA�,f ^ "n�.MXXX� LA I Page4 ofgPages aV n� 1C I �T 1 - Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S ( Cross-contamination 1 .590.003(A) Assignment of Responsibility" 3-302.!1(A)(I) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Conked and RTE Foods* 2-103.11 Person in charge --duties Contamination from Raw Ingredients 3-302.11(A)(') I Raw Annual Foods Separated from Each EMPLOYEE HEALTH ( Other* 2 590.003(C) Responsibility of the person i n charge to Contamination from the Enviumment require reporting by fool cmpioyees and 3-302.11(A) Food Protection* applicaDW 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibilit}Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In I Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.1 4(A)(B) Returned Food and Reservice of Food*---- 3 590.003(D) Exclusions andResvictwns* ( IDisposition ofAdulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food" ,l Food and Water From Regulated Sources ( 9 Food Contact Surfaces 5'10.004(A-B) Compliance with Food Law'" 4-'101 11 I Manual Warewashing-Hot Water 3 201.12 Food in a Hennetical1v Sealed Container* Sanitization Temperatures* 3-20 t.13 Fluid Milk and Milk Products* 4-501.1 t_' Mechanical Warewashing-Hot Water 3-202.13 Shell Eg-es* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized' 4-801.1 l-'. I Chemical Sunifization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water- concentration and hardness. 4-G0 .I 5-101.11 Drinking Water from an Approved System' ( 1 I(A) Equipment howl Contact Surfaces and 590.006iA) Bottled Drinking Water* Utensils Clean' - � ( 9-602.11 Cleaning Frequency of Equipment Fad- 590 0U6(B) Water Meets Standards in 310 CMR 22.04 i Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.1! Frequency 3-201.14 Fish and Recreationally Caught Molluscan ( Food Coin of Sanitization of Utensil and F ..ul Contact Surfaces of Equipment Shellfish" 703.1i Metho&ofSaritizatiion-HotWaterand 3-201.15 Mdlus�an Shellfish from NSSP Listed 4-703,1 I Chemical* Sources* 10 I Proper,Adequate Handwashing Game and Wild Mushrooms Approved by t_3o1.1 I Clean Condition-Hands and Arms" Regulatory Authority ! 3-202.1'8 � Shellstock Identification Present' I � 2-301.1<' Cleaning Pnu:edure* I 590.004(C) Wild Mushrooms'" j ( 2-101.1°. When to Wash" 3-201 17 Game Animals* If Good Hygienic Practices g Receiving/Condition 2-401.11 Eating„Drinking or Using Tobacco* 3-202.11 PHRi Received at Proper Temperatures' 2-401.12 Discharges From the Eyes, Nose and 3-202,15 Package integrity" Mouth* � 3-101.11 Ptwd Safe and Unadulterated * 3-301 12 Preventing Contamination When Tasting"� 6 j Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.16 Shellstock Identification * ( 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained- ( Emplovees* 13 Handwash Facilities Tags/Records:Fish Products and 3-402.11 Parasite Destruction- 1 NuConveniently bers tnd Capacities*Accessible 3-40'_'.12 � Records.Creation and Retention* � � 5-203.11 Numbers and Capacities* 5909 5-205.11 i and Placement* 04(1) Labeling of Ingredients' 5-204.11 c - - Accessibility.Otx:ranonand:Maintenance ? Conformance with Approved Procedures i IHACCP Pians Supplied with Soap and Nand Drying 3502.11 Specialized Processing Methods* Devices 3-502.12 I Reduced oxygen packaging.criteria* 6-301.11 Handwashing Cleanser,Availability_ 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision 'Uenutec critiud nem in the federal 1999 Fond Code ar 105 CARR 59(1.010. I 5 i CITY OF SALEM r OARD OF HEALTH Establishment Name: G Oyc",n l tS y�� c �y `]2r Date: r9//�—�s?� Page of a t Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - - Verified ` PLEASE PRINT CLEARLY 4-- A/0,4) rjp",in { I ' I s 6 I t I I 1 � I 1 1 ` I ! . I 1 l I . I � c I 1 I 1 I 1 � I Discussion With Person in Charge: Corrective Action Required: I ❑ No /Res� YesI have read this report, have had the opportunity to ask questions and agree to correct all °luntary Compliance Ll Employriction Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension t comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty- ive dollars or suspensio. revocation of ❑ Embargo ❑ Emergency Closure r your food permit. 1 ❑ Voluntary Disposal ❑ Other: r ilICI PIU-i, at Tegqperdijre� Violations Related to Foodborne flinairic Interventions and Risk A,Covii,qg,to Lati'("X'W w Factors(items I-M (Cont) 3 Ii F w;IM"-1 Klups. 1.51 1 'S ("Aflintl ro,PHF, PROTECTION FROM CHEMICALS I PHF Hal and Cord riotding I Food or Color Additives 3 ]("B) Cnid Iii5naull"Exi La'-hIflom, Protuciion frow laiapnrit%ed Nddnlvcs'' I i IS poisonous or Toxic Substances i 140T OrizJnal Heid t ut dc-it- I ArT, contaim-'rs'I 2iI Time as a Public Healit,Control 7 102 11 (ommon'Naol- . W„rking 7-201.11 i 'Separawat -Still arc, 7-202.1; Reft,icti"n - 7.202.12 Condition,of 7-203 It REGUIREMENTS FOR HIGHLY SUSCEPTIBLE 7 204.11 salwizev,i,Crilct`ia POPULATIONS(HSP) 7.1(.!•#.12 forClillftia, 21 3,"4i ,111 A) I Unpzi,ieurn f;,,J fire- Kod li�nc c,,end 7-704,14 Digit!{, Ai'ew,.(Tllcrm' 1 !u 131 i t c 4 7-205 it Inddifnitil K,,A t7tIitam 3-g:)J i W)oR,Iw,fs Pawaik Aritnal F,kid md 7 206.11 R,;Ioct,d CaoPeIflio'le",criterm� Rau Sv"d Splo, i3 '}i:: ii 7 206 1-3 1 Tia: Nfwde,s.fl,�t('kwtr,I and t 8c 1,111 (ill"pCiled VoIxi Pat Liox V" R.cZm;d tiion i I i,ri it CONSUM.ER ADVISORY TIMErrEMPERATURE CONTROLS 22 W,1:fory III w'-d ;�,r 0 nuutoption 4 11tat jri.Ra, i 16 Proper Cooking Tempetzftaes for Voi�.etat,t0 Elf,,ml,ae PHFc 3 101 11,V I Egg, 1552F l5s,"t, Pw 111,1",11, Egg,'- lom t w&ttr: 'i ".1i:V 145 T15, 1 : .'.7;;'.11 i't:;n::rlztN! !i4T SA's6wiv fIf Rim S101 Cormilinoted I, Gana: 3.401.11(B)(I)k2) Poll, vinn B�llil Rwsl I ;O-F 12.1 inm� SPECIAL REOLRREWNTS 'i,a)(y,* t:;) T), Viei4i;;)n: cf Simm,q in t 40 1.11 IAd i) Ralite', liijei.t tit M, I �5 F I� I i,leriq_ rinit'ih, 11x,11,t::ororal} :iiid 3 4f)1,11 fA)( i) Poultry,Wild(Ionz, Snitt',rd PHP,I. rr;sill':ni::it 1:40wo 0pfCaTi(io,,shouts he dehal,A2 tu'a"'l.the appiI rmtnC iei:11011S Sloffint Cfmi.m,ir�, Fith, Moat, voultry or lirliow,-1 65 1. I,5 ' it 3401�1 hc)�)) lVil"le-mil,30c, Inlao lwt4 sicak's ai'd mr. E;,wPir" Oth,t 145'l- ViOlal[Oilc ichitt',11" to 'etaJl 3.401.12 Raw Amoral J4,lo,C(,jLkt(I Jo a Aturlld Ili,'10hi"tNI inlkik:r f29 - _ \litrov.alr 165 tl(A)(I),b) All Ottici Pill 145'1 15 se. 17 Reheating tot Hot Holding j VIOLADONS RFLATF& TO GOOD RETAIL PRACTICES 3-103.1 I t A)M D) [6Ii'F 15 (1 tems 23.391 3.403.11(8) Nlwri)F,aw. iOP 2 Mina!,swa,lira, do ?",I re;ta"',)7ls 3..#0311(C') Cowntciciallv RTF irwit I I e• If n,aI 140 1P ?401 i I Remamin, Um;xe i Porntmfi or RtIvf 1 latera i tioadRacillplacticas 690.000 a:,d pef;of a,,; i PC: 2 I 18 Proper cooing 01 PHFS Food Pro,dior j PC 'i C9)4 Co cd PH 's from 141'I'lf, 1 .1, Hourq�aid Fofn� PnV6,r.,t Fa�Ja; 701 to 4 CT,41i�r Within I Homf, I 00b 26 Poi;,,rmu�cr T,xi� ;7C l 5f)I 14f H i C"wfirg,PHIP,Made Fioni'lilubleal i Jr- 009 Temperature lqo,lieot,ii,41 - ----- %N ithin 14 1 limrf,' :ral,at otil.ill I lolliq ft! I Y'J9 I I(,xt: ,a )1)+ I'lk 94::',it k: Massachusetts Department of Public Health. Salem Board of Health Division of Food and Drugs 120 Washington Street,4'h Floor g Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date /� Tvpe of Ooeration(s) TYge of Insoection C OVOA/) ;� p).�,11OPJ -9-Food Service Routine Address J I it I s M V� Risk ` ❑ Retail lU Re-inspection a4 LF ` LI,v Level ❑ Residential Kitchen Previous Inspection Telephone /["A -1_^ � ) I ❑ Mobile Date://6/0 Owner7H LF // II HACCP Y/N El Temporary El Pre-operation .�rkv,,P k K-a4 z l na I ❑ Caterer ❑ Suspect Illness Person in Charge(plc),- m rQ _L, Time ❑ Bed& Breakfast ❑ General Complaint In: El HACCIP I Inspector �n� n�J I.,&=,A'(It / Out:3- Permit No. El Other Each violation checked reiiu`ires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ,' ,,. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El 13. Handwash Facilities EMPLOYEE HEALTH .,PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC . .. '_ ' ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE," .. � � �- .. i TIMErrEMPERATURE CONTROLS Potential) Hazardous Foods ❑ 4. Food and Water from Approved Source (Potentially ) ❑ 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 (J t`rP� - ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing .REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices , CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions f immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): ` of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection' immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below c N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(sso.003) order of the Board of Health. Failure to correct violations '24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. _ 30. Other DATE OF RE-INSPECTION: ) s 5WInsIdFom 14 me t�i'/Y C 1 5- D�6y J Inspector's Signature: t Print: Le�n k i PIC's Signature: Print: G Ss., ✓. I Pagel oilPages I Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 18 ! Cross-contamination I 1 590.003(A) Assia:ntent of Responsibility* 3-302.1](A)(11) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Pec;on in charge-duties I Contamination from Raw ingredients 3-302.11(A)(2) Raw Anitrurl Foods Separated from Each EMPLOYEE HEALTH I Other, 2 590.003(C) Responsibility of the person in charge to I Contamhation from the Environment require reporting by foal employee.and 3-302.11(A) Food Protection- applic:utts* 13-302.15 Washing Fruits and Vegetables 590.003(F) Rcsponsibiiit} Of A Food Employee Or An I 304.11 Food Contact with Equipment and Applicant To Report To The Person In I Utensils" Charge* I I Contamination from the Consumer 590.003(13) Reporting by Person in Charge* ( 3-306.11(A)(B) I Returned Food and Reservice of Fowl* 3 590013(D) Exclusions and Restrictions* ( I Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictiams Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* q Food and Water From Regulated Sources ( 9 Food Contact Surfaces 590.004(A-B) C'ompli:mee with Food taw* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Ford in a Hermetically Sealed Container' I Sanitization Temperatures" 3-201 13 Fluid Milk and Milk Products" 4-501.112 Mechanical W"arewashing-Hot Water 3-202.13 Shell Eggs* Samrization Temperatures* 3-202,14 Eggs and Milk Products.Pasteurized' I 14-50!.114 I Chemical Sanitization-temp.,pH, 3-202.16 lee Made From PotablL Drinking Water" I concentration and hardness. " (il 11 Drinking Water from an Approved System* ( 14-601.1 I(A) Equipment Food Contact Surfaces and 5-1 Utensils Clean, 590.006(A) Bottled Drinking Water' I j 590.006(33) Water Meets Standards in 310 CMR 22.0" 4-6J .11 Cleaning Frequency of Equipment Food- 590.006(B) and Fish From an Approved Source Contact Surfaces and Utensils" 4-702.11 Frequency of Sanitization of Utensils and .3-201.14 Nish and Recreationally Caught Molluscan � I Food Contact Surfaces of Equipment* Shellfish" i 4-703 11 Methods of Sanitization--Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed ( Sources, I Chemical* I to I I Proper,Adequate Handwashing Game and Wild Mushrooms Approved by --- - 2-3t;L7 i Clean Condition-Hands and Anus" I Regulatory Authority --- � ! 3-202.15 Shelist<mk Identification Present" 2-30112 Cleaning Prccedurc* 590.004(0) __ Wild Mushrooms" 12-301.'-1 When to Wash" f 3-201.17 1 Game Animals* I I it I Good Hygienic Practices I g I Receiving/Condition 12401.11 Faring, Drinking or Using Tobacco* � 3-202.11 PHFs Received at Proper Temperatures" I 12-401.12 Discharges From the Eyes, hose and 3202 15 I Package Integrity, I � 3-101.11 Fcac5aa�and Unadulterated 3- 01.12 Preventing Contamination When Tasting" 6 112 Prevention of Contamination from-Hands I Tags/Records:Shelistock ( 3-202.1$ Shellstork Identification' I 590.004(F) Preventing Contamination from 3-203.12 ShellstockldentilicationMaintained- I Employees+ Tags/Records:Fish Products 1 113 Handwash Facilities 3-402.11 Parasite Destruction' Convenienty Located and Accessible 1I 3-402.12 Records.Creation and Retention* I 15-203.11 Numbers and Capacities* 590.004(3) Labeling of Ingredients' ( 15-204.11 Locution and Placement* 7 Conformance with Approved Procedures ( 5.205.11 Accessibility,Operation and Maintenance_ 1HACCP Pians I I Supplied with Soap and Hand Drying I 3-502.11 Specialized Processing Methods` Devices - - - 13-502.12 Reduced oxygen pad,as ing.criteria" ( 16-301.1 I Hand 6-301.12 Hand DDiv nrying Cleanser, Availability 18-103.12 I Conformance with Aporoved Procedures ( 1g Provision 'Denotes critical item in the tfedetal 1999 Pond Cade a 10 CMR 59otfia). I CITY OF SALEM BOARD OF HEALTH Establishment Name: �1 J�/Gn/� I Si��s7 Date: ��/f� Page: r� of 3 Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTIONPLEASE PRINT CLEAUate i No. Reference R-Red Item / ^ RLY •� Verified s 3 L 1c,l.os� �_ b) I " I � 44 al�5�sti �Ir`r (x.� �.)r\v�� 0 A K)0j ��1�� 1 c=slime IQ4— k,6r k, „u c ii�'f[A:') NB.IPr R, . ,/ OAA �iYr�Tn., (>[a�'-`. I�S I.✓� �17 �:'� IN�t•�n� U(.1,' � n J1,t.(,nc.c' SII" L_1,-4\ iYY'\'L-Vc�s -�o�� Rt PVA,(J,4Att-ham_ _ r �A rl lov" CMI n .n-I- 14-V D r_ (Q (�l /1(�Ivtit h_4- ho rclnc /14 o tort,). A � _ _ �.�p,) ►.; '�e raz' I ro_1a,4,--d 4 0 I_2�-4r--�Ja• la V UJ 4%w-AA JAADL -- t!WD,r7o-i a'a 1 1 ( rl "✓ e` �1 �..t S)I f7lt�ln 1Cfbvy�GV{ Cho I\S 1�AQ 2N Grillr/1C rY San -, i/� N , ti ! I�trIC10/lv/I �f�G n,i1 J Q•��2. '/� �"� .SR4cn AlLClWCaC V,e 1 . • S � _)n.f riJ�l/)r- ,(G- Ili � I Discussion With Person in Charge: Corrective Action Required: 'I ❑ No Yes I have-read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to �/ Exclusion P t/ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that lv noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. f ❑ Voluntary Disposal ❑ Other: Factors(items 1-22) (Cont) 41-1,14YFiVifins Violations Related to Foodborne flinoss Intertontions and Riqk mi'td t,: PROTECTION FROM CHEMICALS Food or Color Additives 19 PHF kat sod CQfd Holding I ("Ad iUFS Nilwilt,ow'd et qr hel"w `900;)-i3 : 7-302,14 Protcttion fimar IJnal,nrwedAddinvcs Poisonous or Toxic Substances A) I I"I M':in!'ined at(ir Qho4e li)(Al Hvid it or nb'>vc I 7 102,11 1 Coninion-Nam, Working Cornan%er�,' Time as 3 PubbL litiatth Control 7-20 1 H S�nln�uun- snirase. as a vuplic 1 i"alth("mir"l. Rciuii-tion-prk"'.knix and ti:n' L 2112-12 Condition, 103 11 Tmi,,Cijmainc.iz.- REOWREMENrlS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 21 i 10 1.1•s(A) I L,tim;:w-n i,ed Pic pi,i.i,;i�cd jim t�and 7-204.12 ("helincrili,ford w I ni, I I 7 204 14 13;Fin :Agent.,.:Agent.,. rtreria" -80 i,11 th) I 7-205A! lncid'nW f;-XI I zni(i'*ants` 206,11 op"314i N *,S.rvvd. -i-20(,.)2 Rodent Bc:l S1,11(om 1,--r�d Nwt Rt,,,�r%cd ' 7206 }z 1 razi,ing P,,iv,kr;, (-')nfrol and 11m,totin-, CONSUMER ADVISORY 12 3<10 I '-.orilurii-i Ad,is(icv Po,te�' Cor Com tic of nw,"TEMPERATURE CONTROLS 2' That�irk, Cnder,;k,,lxd c) Proper Cooking Temperatures tot I tt pHrr i -,:"[ 3 40 1.11 A([ EL�,- 155'F IS Sci,, Palb" ,,.r..,,.• F't'g•-I it -f 3e} .`.:.:,b.•-s,,. S;ibsww�. fol R-kv shrlj rfflm�jiatc'�Crvlcv j Ai(2 Connwnoird Fi-h, Nlcut i 15 sec. SPECIAL REQUIREMENTS i-A01.1 U[j)(1 li2l j Nit I, w'd 8esq Roam 1 0'F 121 rain' I iD) (1! S-111wn in 1-4101 1'k,k)f 155TI5 I citicriog, lwo, icniptiritiv and i Poulo-,Wild Gawc.Sniffed IqTs, shonld he Cciqt mun",Fish Nlo;IL' denlccl w0cir tit:appropriate •; imons 11,.Uhry or Renta-165`1' t" 'N"Ve i"Ir Ijlc"d lo lnil'c: wiiition,' and ds!, ln,:tom 01,hcr 14i'P ;' to glokxl r"lail Raw'Anin,iii Cwkr '!in llr;wlio"s '110,11d IV lmd'�r #29 - %ficlowave 10'- speLial 401 111 A)(I)f b) At,clthcr PI IF,-- 1';5''.* 35 se, 17 fireheaturit;for Hot HoIrPsqWOLA TIONS RELATED TO GOOD RETAIL PRACTICES j D) 16YT I (Ileum 21.MI) if)KI 1(b) Microwaw- 10"F 2 Miraiw siandni(' 6wi a1«:r:POti-, which do in); 444[' ;')1h;' Time fi)w1he"me 11;!'S' ?.tkjn,ior1-i,,.iabove cim be 1-403A Jt('? Coalminchill'y flq'ess<j'r'I I: Ku�l - fiwnd lit Codi-'wd 11si C31N m F Coon hirtai! -F Pracfi��s PC X 00,006 23 k4alwi, .1 FC 2 003 18 Proper Coollng of PHFs 24, Fc-yland iouo ProlKin, - -- -"" 'k -�117 q�—i"-I Tn(in i sn u I c—n i,-!s-, 00� -'-�(IIA IfA) Krol e'' cook,d PRF" i"mil le),C to -C 5.11 wa!�!' 7i)"7:Within-`Ilour,;mid I-roin Fauiiiy_ I L"41,1195 1145 P Wition A K%m. Fvso;ouv-r Tim- Matenaia FC-7 t A08 Conlin,PIIF: Made Hom Anibitnt t,:4 A'ItInn a lkmx ' P CITY OF SALEM 's ---� BO/ARD OF HEALTH Establishment Name: Dater ' 3 A)�3 Page: of Item Code c-Critical Item \ DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference - R-Red Item 1 Verified - I TTPLEASE PRINT CLEARLY / IioK 1, c� +MI (A91AJa VP /)!/0/-14 C4r1/1<�f !k' C cQruz� 1 !\C i1 rrtLy M Jit r+� YQ/�IrCce.>7 D-7, :2�z ; ( / E"7JA� ��hto— I /�� GL( l,_ Ire C70Ii.r' Akoa r S-ri ,� - t (( �� t1 1 / WIC �.M(Vrn n 1-F (,.�nPk-li1 :,(O/ N@tc�+ �ln�n ,rtt �t�-,r� �ve v ) t/ — v (Ani ,v-\ CY) ,I.N^ U 7 _ k), pwq 4 n�ri Noe-J- -4-j 6 S-6r�e 14 w c t� -�-,2 , s � (S� fI r / i I E -tel• ` ti 1 UC 1J� `iYr`QL -A,6,'lc \J-4 �� / cr. ii , lc 4, t a le f Jnr[ �,�Z_P lG — n.l�-,- r- i'-*�c"ta,� .,L a In �, i1 L n� �9.1 H A A n a -� / rr�V>Lr, MQOa OJ _V, r A AI LAr✓t'S ,n^ 4,") -,f , — / f �� / r (Air � �n Gr �� i7� /J J/i(G A )0 CX11S IEU /J�11 G+ �MC c) eV1t7n / �.� Discussion With Person in Charge:' I Corrective Action Required: ( ❑ No � � Yes s I have read this report, have had the opportunity to ask questions and agree to Correct all ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion � violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled ❑ Emergency Suspension 'r i comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. - - ❑ Voluntary Disposal ❑ Other: i Violations Related to Foodbarne Ifiriese ustetwitirons and Risk v.oqlw,to wi,:d-w Factors(itom 1,22) (Cont) 4 R,!w z �'V 1,15 M, Chlld,,t,)r Mi", PROTECTION FROM CHEMICALS j la Food or Color Additives I 19 PHF lim and Cold"ding 6rg 1 coi.i I'llr" 3t'll,N71,w 2(12.12 A,1,46x-+s0 A 1'14 ;-302,14 PowLtjEx] 1rum Poisonous or Toxic Substances ldeirit:Nwi! Infonmlion 5, i 6f Al R',;w"I 10;d at 0- �t, 20 1 Time as 3 Puitht Hoililb Control 102,11 (oininon Name - Wkvkine.Cowaincrl,' I S�P:aaiivm -Stolap,�' .01) --202. Izcq,ict!"m-- pf u.ncr.vl,!Usr 7-202�12 cmldjtitw�ot I I�, 7-2w' I i RECOREMENTS FOR HIGHLY SUSCEPTIBLE 1 7-204.11 sanilim s,CrItcri., - cht:m: A,- I POPULATIONS(HSP) 7--104�t 2 Cliellli(;,)�14 Ww'hing 1,!,U�ticej(Ilitoki�,1--jtiPt Vr,,,jd:,lixd Jincts sntl lzkA,* 204 14 D;yinz Aiient,,,Crtmia' 115 1 i IMi&II1,11 l' ",\Q, ii:bi I raq�nimxd i I,l'i I h,w"r 11,11ball'i CArA-,(i -,lmimd a! F�Xmd 7-206.11 ue,iricf,ed UNC pe'rik idel,, 7-206.12 9,to statiwl�, 'I'lacktrig ;4,qi CONSUMER ADVISORY 22 "t A;j I_ I I „}rofTIME/TEMPERATURE CONTROLS 16 tin der.it,kcci o: Proper Cooking Tqmperaturps tw to l-,lionnazz PHFs 3,101 F.gg,,- I 5j+ k; Ell - 1-11 Si tbtw, tea ShOi 3-40IAIIA)(2) g', �S�r ,i "I colmi'mult'd Vi}Il, Mo;llr& Gallic Amwal„ 1 ii"F 4';lac. - 4171.1 1 i 13)(1 tQ) Pofk ,-,od%,a! Rovst - 1 30'T 121 min SPECIAL REOUIRFli I -it4stc, hlwlf,�d Mt.iti, 15. SB ESt D.) ill -40 i,A)f 2 0 and 3 401.1 I,A 1::3) Wild Gamc,Stuffed PH ri, A 1-,telmi op,,I,ttimA ir}tdd he �Iljly-mv Coul:Iiiii1w VIM', Meal, tichilzd und": 111C appropi tat!.'.cw'ion% Foultry,'w 65'F, 1.40Lk IfCji3) Inum Bev."SICA-S inwj vc-ovo-wand r=e;; kimors 590.,')09 l6uWW!I:rdaRi" to:,okxi leluji I ?-4v i.I Raw Anioml Fo Kl,,CtMk'd III a jnzafici-� Jiooki he denim' ur)(1vi 71'19 - Mv,"w.RV'f lfk"F �pet:w! Reqvirl'm,!n� '-401,1 IIA)(I)(b) I All (diet PlIFq -- 1,15'17 15 SN, 17 Reheating for Hot Holding VIOLATIONS RELA MD To GOOD RETAIL PRACTICES 11HE 105'+ I� wc. ' I (Ilum23-301 3-W.I i($} ",Ticrox av:,- 165"F: Nfilille, siqnain�,, iii,':u`11?1a ra..,I, I w:aplits, whic".t<p"ll; re1,Ir,7:o th" Time, z 1, ,,odoome Wites%l wie,(w�,ms Z'nd Jet,loo ,,tn 61 3-403.11�0 COminerl rally.pw,�S�,�d RTI�Ft%�M, n: ,f;he Food 105(""1" 140 Mom I Coca,Ret.-ii Practiov� 3 4t)3 I (F) Remaming Lwliced PLwi,,nli,J Btx i FC 5.4q.&W 4i 23 IMvacezr.ol 3,j'Fsr,otneI FC 2 003 gg Proper Cooling or PMFs L 2,i, f:�,)q.mq F,-IyI prv",�tior R- rM."Iron, 1411-FrO Piwnbi,,L�WN,4sfp I FC -!i i orc ak,*N Ci-,7 70'F Wahm 2 tklirs ono From 71 F to 41 i 145'F Wiflim 4 I-iourt, 2e. -r T,)xi, Msa,r,4!3 7 ,)u 13501.1 )(13) PHF,Made Front Ambient 1 29 TonpeWtIlle t(t ' tithe,— -— ------ Wilhin 4 1 Iz au� !0: ( %V,5911(V;'I Commonwealth of Massachusetts s • City of Salem Board of Health 1(imbe11ey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo&Retail Establishment Permit DATE PRINTED: 01/07/2008 ESTABLISHMENT NAME: Giovanni's File Number:BHF-2005-000007 44 Jefferson Avenue Salem - MA 01970 LOCATED AT: 0044 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0239 Jan 4,2008 Dec 31,2008 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES IDecember 31,2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 14 of 25 3 CITY OF SALEM, MASSACHUSEM BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR �>tirnv:dx' TEL.(978) 741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR ISOOTT SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT a�� ((tY r't'lo ^ ePP-= TEL# ADDRESS OF ESTABLISHMENT `-Y� )PY' eor� 0111 r' 11 to ` FAX# MAILING ADDRESS (if different) EMAIL-Business': Website: OWNER'S NAME C-{>°t)P Vow'_ TEL# �n7 L n ADDRESS At*'01/8 ' �1:Y' 8TREE�� 1 1 ,M�/��" ZIP TS REST � CITY STAFE ' CERTIFIED FOOD MANAGER'S NAME(S) tltA Pftu CERTIFICATE#(S) �GO3w? (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON Co IYGy ✓1 HOME TEL# ��' /�`7 ' P7 S DAYS OF OPERATION Monday Tuesday Wednesday `/ Thursday Friday Saturday Sunday HOURS OF OPERATION Please wnte in time of day. (For example Ilam-11 pm) V -10 I0 TYPE OF ESTABLISHMENT FEE (check onlvl RETAIL STORE YESNO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANT YES NO less than 25 seats (Outdoor Stationary Food Cart$21 25-99 seats 280 more than 99 seats =$420 BED/BREAKFAST/--------------------- ESNO $100 CHILDCARE SERVICES . . . ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES O $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have fled all state tax returns and paid all state taxes required under the law Signature Date / , Social Security or Federal Identification Number Revised 4/24/070008 adm Chec &Date $� 20 W S Board Floor Street,4 "Massach'usetts Department of Public Health 1Board Health � 120 W Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Q ^ \ D t p Type of Ooerationisl. Tyge of Insoection r_1 )n �m I')G( S UT f�1 It I e 6 g Food Service ❑ Routine Address I Hyl�N /] Ridk I Retail ❑ Re-inspection `M��ritJlllll J�t-If� nl Level (/�� ❑ Residential Kitchen Previous Inspection Telephone ` I / El Mobile Date: � = c1= .9/l� Owner I HACCP YM El Temporary El Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) /� Time ❑ Bed&Breakfast JTGeneral Complaint El HACCP Inspector }� I I Permit O El No. Other �N ��J/11�K�� O Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT • ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ,_,/ Ly 13. Handwash Facilities EMPLOYEE HEALTH ' PROTECTION FROM CHEMICALS `•' El 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE • ,." El 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)- ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices - CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail-Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected; To Foodborne Illnesses Interventions I/r immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): t� 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 Boad 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)(9590.090.0 044))) cited in this report may result in suspension or revocation of ✓25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you J 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. V_ 30. Other^ DATE OF RE-INSPECTION: S 5901nVe Wam 14 neo Inspector's S(gratu Print: I PIC'sSignature: N Print: / �c.11l 1 \\\VIII nn ul Page of�ages fid i M ;11 (1 w y Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT I S ( Cross-contamination I 1 596.003(A) Assignment of Responsibility* I ( 3-3011](A)(]) � Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Faxis* 2-103.11 Person in charge-duties I ( Contamination from Raw ingredients 3-30111(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other* i 2 590.003(C) Responsibility of the person in charge to I Contamination from the Environment require reporting by food employees and 13-302.11(A) Food Protection* applicants* 13-302 15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An ( 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* ( Contamination from the Consumer 590.003(G) Reporting by Person in Charge* I ( 3-306.14(,A)(B) ( Returned Food and Resenice of Food* 3 590.003(13) Exclusions andRcatrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions I ( Food 3-701.11 Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* 141 Food and Water From Regulated Sources 19 Food Contact Surfaces 4-501.111 Manual Warewashing-Hot Water 59U.U04,A-B) Cumpltance with Food Law'.k 3-201.12 Food in a Hermetically Sealed ContamSanitization Temperatures* er" j 14-5011 L I Mechanical Tempeashinn Hot Water ( 3 . 01.13 Fluid Milk and Milk Products* _- 3-202.13 Shell Eggs* Sanitization Temperatures* 13-202.14 Eggs and Milk Products.Pasteurized* I 14-501.114 I Chemical Sanitization-temp.,pH. 3-202.16 Ice Made From Potable Drinking Water* ( concentration and hardness. 5-101.11 Drinking Water from an Approved System- ( { 4-601.11(A) I Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* I . eClean* ils 4-602]1 Cleaning Frequency of Equipment Food- 590 006(B) Water Meets Standards in 310 CMR 22.04 I l Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source I 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish' 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed ( I Chemical* i Sources* 110 Proper.Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-20218 Shellstock identification Present" I 12-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* I ( 2-301.14 When to Wash* 3-201.17 Game Animals* 111 I Good Hygienic Practices 5 Receiving/Condition I 12401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* I 2401.12 Discharges From the Eyes,nose and Mouth* 3-101.111 Food Safee and 3-202.1I Package and Unadulterated iry* 3-301.12 8 12 Preventing Contamination When Tastin * * I 6 Tags/Records:Shellstock i 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 13-203.12 Shellstock Identification Maintained* I Employees* 13 Handwash Facilities Tags/Records:Fish Products ( 3402.11 Parasite Destruction* I Conveniently Located and Accessible 5 3-402.12 I Records,Creation and Retention* I 103.11 Numbers and Capacities* ( 590.004(1) Labeling of Ingredients" I 5-204.11 ( Location and Placement* 7 Conformance with Approved Procedures I 5-205.11 ( Accessibility,Operation and Maintenance iHACCP Plans I I Supplied with Soap and Hand Drying Devices 3-502.11 I Specialized Processing Methods* 16-301.11 Handwashing Cleanser, Availability 13->U2.12 Reduced oxygen packu),>ing.criteria�' 8-103.12 Conformance with Approved Procedures* I 16-301.12 Hand Drying Provision `Denotes critical near in the fedeta] IQ99 Foal Codenr 105 CMR 590000 1 CITY OF SALEM BOARD OF HEALTH 7 Establishment Name:�tl X1//,1{'1 nl � t/l E Date: II�/U t Page: 4p- of a Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Data No. Reference R-Red Item - s - - "- Verified ' T PLEASE PRINT CLEARLY I � f / Dm�t /� GJ ,�j0r�r� ( (.bl,lw��arti 6�cutj-7,� / l��t h�uf _ eh�M-1(r4y1 rlrl - Ila )i-fh Y_O. du fn 04 r �3n(y � i y�rI1 ( (g�/I I I I Iyr-r7 , JI-n n //n`vPA (A AN ()h �a 17 �s 11J(; V , o hSewrd 1r) pmt �n0a. qu a inn I I �4�141)1 l l» ll% l ijr1C Nnd ,S(nt ho -f h I I I /n ary Lurn2r21) 7' nr-n_ _ qw/L -<-n bo-khv� hlnrlc 4 Q(ry -1-1-W /16,'d/ 311 Xq Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes k ❑ Voluntary Compliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-Inspection scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. r ❑ Voluntary Disposal ❑ Other: { ;.5,;1,144' PIT Rvcei,'CJ at Teinlo,:rawior Violations Related to Foodborne fitness Intementions and Risk 'lco,,diry to f.v, r'„oled to Factors(item 1•=l (Cont) i I`Fi,15`1` Wittin,j H,nioz PROTEC'nON FROM CHEMICALS 5_1_C,x1[i0,,NTCUWt f�,lr PHF� i t4 I I PHF Hot slid Gold Hoiding ! Food or Color Additives 11 IdAi 3-50! lf'(W Cold P19F,Manit,;tind at m baik".' 3-302,14 1l!otecl0m)frola I -, 13m PHI-��,Jainmwnj.,t:x ab')w 1 Poisonous or Toxic Substances inRa 140 f Cwqjncr�' lidjakor;ibo,r 13W1% 1112,11 Common Narrit. W"6il,r Colluliner' 1 mi Time as a Public Health Control 3 tint 1:I rtrnr as a public Health(:,rarol ml 11 S,pw au'l—Sint Pr-em nce.qO I cel I Condition,of I fsol t! Toxic Cowaiveqr— RFOUIREMENTS FOR HIGHLY SUSCEPTIBLE 204.1 "idnil;veri.cril"ria—chcIlIkAN, i POPULATIONS HISP) 7-1g4.J` (haiiuuilf foi-Wa,hiln?,Vf'xjucc:Clitc6a" Y); I'(Ai Clip•i:lcuiiiuO jolcdq uorl Povfft�r,, %Varnmp I 7 104.14 Drtirl' 'XmIt'.Criwki�' 90t ilill, 1,��O'Pa�tamived 205,13 buidvinal F=t,.,d Contact.I uhiiolnils' I 1 14;0 11 D) Rdtv or Ka-6,11 , Animal Fwrj wid 12 P,o�r ntt'j ';Jjrooi�Not S�rvcd. 'K(;! I!f('� 1''Tlop�neo P"Xxi :-'O6 1,, fn!Cking po�%dvzz' Pt m Cowrol and Nit" CONSUMER ADVISORY 2' �"j' I i oost, It TIMEITEMPERATURE CONTROLS Amwil fIid' Pla['trc (?:iii undercut'-LV( or Prober Cooking Teroptusiru,es for PHF6 \'v" is';Dliriaie I'v I v2 915 i P 15 st:c. 15 F I 1�ef� fn��, iiiih�iilui� ioi fl.;Aw Shell Commillw"d Fch' & (ialw —, --I 3-401.1 P'nl, and beef kwst - 12i imn, 1 SPFCIAL REQUIREMENTS of Si�k'lwn in I(A)f_)yR,mic,, jnjc,;:d M"cit" 135T 15 fry%!' Iviopurmv and 3401A IiAi!1) Pmfltry,\k ild G,wie, Stuilid PI IF,, iJtehll op;.'ItItiollc"ht'idd 1v Sl„ffjn�Contalml I I oahilv.d un0ei (Li apfirupriatc eCAlOns Poiflory ot Katiwt-165 [' 1` c(;. (;:!wed to jllnws: _40 I 11('..)"31 "Mloli,'Ilo' It`' Intact IT,d ri,,I. ijC.torc Otb(T 14'�1- 5%,V) vlolatioll%roatin" to oo�yd rt'naji pl,"okt,\ buidd he doblied bn&r #29 - t--171.12 Rlm, �vunul Fool,(',�&�.d In a 3-401A I(Ai(iiib+ Ali Oihri PlW:: 1491, t4 cc 17 Reheating tat Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTWES P13.1 hA)' I,)) NIF.i t65"F I we - (Henic;11-301 10"k,I IfBI! Micnma,,:- 10"F 2\I,nnte Sfandiiq, I criii qi':nd In'.1,tilll:ol w;:irit do ga, vi are vo Ow I awtitmi.mv.110 ri,Qwzor, liwd abola, wn Lr 40? I i C.) C:Irlrmroniifv flax"«..j RTF h wd IIrWen";n I"'. Flyl)tl t'od"111t(j H61 Ronamin., Un--lwed Potdnm:(if ,U,-el , iters....f 6—mo-lifelau oiacti;`ej T-FC -590- WO ManKe'Qen 0:4d Pa PC X 18 Proper Cooling of PHF& 2e, Fvd and Food Piolk—tv, FC 3 i4t�F �1 -2 Eoilamin,and Ulenaiis FC- 4 005 501, i(A) V-Jiei�i,Piu nbinq and lo4asto i Fc-5 WS Wf7wilhin 27, 1 -.007 - - r-,T- qiar'W3 Fc 008 P�'�)P(xjs"t T.'ockf. 501A,413) R"�q Cwlin,PHF,,Nla:h fromAmiicni 29 W9 Tcmporawre lits?redwrit,n,4101,14i F J Wilhin _N 0044 JEFFERSON AVENUE Giovanni's City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-9111 Food and Food_Protection FAIL BLUE Owner: Comment:True unit has uncovered foods. All foods must be covered to prevent cross contamination. Steve & Katezina Konis PIC: Equipment and Utensils FAIL BLUE Jason Gentry ! omment:White GE freezer requires general cleaning. Inspector: John Gehan Fronraeverage Air unit requires general cleaning. Date Inspected:Correct By: ;—�—D-,-ke� en requires thorough cleaning. 6/26/2007 Meat Level: slicer requires general cleaning. font coke refrigerator requires general cleaning. Permit Number: BHP-2007-0164 Physical Fac/ility'"� FAIL BLUE Status: _ o/E mment:There are multiple water stained ceiling tiles throughout the establishment. Owner stated AC leaked and caused the Open stains. Repair AC and replace all stained or damaged tiles. #of Critical Violations: 0 Time IN: Time OUT: i Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 26,2007 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) i City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 26,2007 ) Page 2 oft , 0044 JEFFERSON AVENUE Giovanni's City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: I Violations Related to Good Retail Practices (Blue Items) 744-9111 Food and Food Protection PASS BLUE Owner: Comments:True unit has uncovered foods. All foods must be covered to prevent cross contamination. Steve & Katezina Konis PIC: I Equipment and Utensils PASS BLUE Jason Gentry Comments:White GE freezer requires general cleaning. Inspector: John Gehan Front Beverage Air unit requires general cleaning. Date Inspected:Correct By: Duke oven requires thorough cleaning. 7/16/2007 Risk Level: Meat slicer requires general cleaning. Front coke refrigerator requires general cleaning. Permit Number: BHP-2007-0164 I Physical Facility PASS BLUE Status: Comments:There are multiple water stained ceiling tiles throughout the establishment. Owner stated AC leaked and caused the SIGNED OFF stains. Repair AC and replace all stained or damaged tiles. #of Critical Violations: 0 GENERAL COMMENTS: Time IN: Time OUT: i All violations from June 26, 2007 have been corrected. Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 16,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) M� City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 16,2007 ) Page 2 oft JMPORTANT MESSAGE ) FOR q . DATE 0 ��ME o� A.M , Myr OF ((// PHONE 9111 AREA CODE NUMBER EXTENSION O FAX O MOBII F AREA CODE NUMBER TIME TO CALL TELEPHONEDEASE CALL CAME,TO SEE YOU WILL CALL AGAIN WAWS TO SEE YOU [[� RUSH i RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED '-- FORM 4009 MARE IN U 5 A b i NOTES I - I 1 IMPORTANT MESSAGE ) FOR M DATE=��—i OF --�-ver-eirr fJ-Luf i3Ce,r�e+- PHONF AREA CODE NUMBER EXTENSION U FAX ❑ MOBII F AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU I RUSH RETURNED YOUR CALL �I WILL FAX TO YOU MESSAGE i4d AO_ 7fjl�rlS_ l 4 .¢- --mac/ 74L �721( e . ✓2On n epq g ` SIGNE01 FORM 4009 ��■YYYY��1��Viii MARE IN U S A NOTES CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: /$e��/ / ?-2�Z)7ZPage: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION iaate No. Reference R-Red Item Verified PLEASE PRINT CLEARLY I , /r1%/ s��alr� 4) Ai6k -iMV 1�s��ct7vr�. �%� I I I I �a�zr�/� `��f ,/'y�G(�. �� DU✓��r� ,Sr.��zl7`7i?t°,�. fz� n� all /AiV/C 71 Q- Z -I al I . I - - _ 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation Of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: `J PHF}x,-,xjv-d at Violptinns Related to Foodharllp iiiness interventions and M6,A Acev,Jta--,to Lau'Cooledu Farfors,11tems 1-22) (Cont.) 41 Nlnthin.1 qwr�, I 15 cooliag INIctluxk for P"'[Fli PROTECTION FROM CHENCCALS -w 14 Food 0.1 Color Addithle> PH.F;lot And Cold Holding 10(1;) Cold PI IR, 3-202.12 Additives" ( 19001)-1!F) fl-05, F, 3 302.!4 Proi-clion f-Ort, lji:approl�cl Addinvci* 1,tri(?,) Uri PHFs Maintained at orahote poisonot's at *I,CX;c substances 1 -WR 7-I(I I.I i Ident uf3uig o:7-- Ch tqi nal zOl.!6(,A) Roivsls Hold at or abo,,c 130T. G atawers, rure.e as a Public Health Control 7-102 11 Col".11,up ?Iain: Woltillg('omailatr.,' 7201.11 i ; 'i0`�:9 Timc as a Public Health Con!�-A` S�p,rarion-Stoaak,,�� 500.004t E'I var;a1we Keyllrellitnit 7 202. 11 Restriction-Prc:.L�;,v,cul 7202.12 C,l)(111 Im";(it I 7-203 11FOR HIGHLY SUSCEPTIBLE G T oNjC(�('jjtajIje[tr fifollillition" REQUIREMENTS (HSP) 7-2e,4.11 sanitize,-,,Colt] 2 1 i-80JAI(A? ' Un,,as-curi:.ed Pre-packag,,-J Rm e;,aund 7-2114 1 for W;v'hirL rrnd11,!e, CHr.,�61,- Bevo:w"es with Warlulu,libels`' 7204.14 .sti ,C nteva 7-205.1 I "irid,intal Ford Crnoa:-,Lubtt,:Lai- ;Dl 1118) Ise of Faetewized}^gs' 7-206.1 l 11:c,Iriued Us, Pe-,tivicks,(-:itc,ia' 3-8•-:1.11(0? Raw or Partially Cml d.Aninlal Fl-,lld ard Ra" Seed Sprouts Not Setvrd. 7-206.12 Rw�,w Hait slatlon!., �'.0 I.11(C) Unopened Focyj Packave No Re-serwd, t. ?20U.!3 Tra.:Iotig Fw"&".?"Jt G-ADuoi xal ' lorlit:,ring- CONSUMER ADViSORV TiME.NEPAPERATURE CONTROLS 22 3-603.i I Comunier Advisory Posted for of AnInIal FOOdL"I'llia ore Raw, LTnduc-okci of 16 ;'.*oper Cook5ng Te�niceralumi lor Not fehmlw flroc,nLsed to Elinonate 3--101.I I it 17(2) 15.i'F 15`co- �cr,icc I 43'F!5v!& 31-110 l? Pasteur/ed Eggs Subsuivrt: for Raw Shell 3-401A](:U(2) '00IT111111led Fish,Mcart L, (ianw A:wuals- I i5'F I` w- 'l' 3-401.i!(B)kl)(21 Pork aid Boot Roao - !2: mine SPECIAL REQUIREMENTS i 101 1 i1 A)t2) Rnutes; lciccted NTS::,- I.ijF L", 590.009iA)-(l Vioixioris of Section 590M09iAWD) in, se'. catering, mobfic food,lenjpurary and re�idcntlal kitchen operalions should he --4,*,j 1.11(A)ff. poultly. Swirvdl PTIF's, SmiTow.Containing FiF!;. M�at, dchited under the appioriTiatc sections Poultry of Barite.-165°F 15 set. allove if related in foodhorne ilfncs> 3-40!.! 1 W]I iniac:B,-et sloldK;i irtterwtwons and risk factors. Other 1,451' 590.009 violalions relating to good r--tad --401.12- Rlm Alunial Pools Cjozed in 1 ]IraLt -es should be debitod under#29- Special Requiicments. All Othet PHF:. 14 WC 17 Reheating tor Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11:AWDJ Fl-]Ft. 161-F 15 see. - (Items 23-30) ;-403.11(B! NFrr-iwav— 161°F 2 L'vI;:aae Slandaw G;hical and,wn-l:rincal viokoicn,;, ithwh,h...... j,e!qre to Ili,, -f rn:e" juo,115o,r.,-i;Gams inter venliury wid i is.1,fi7(telrs lis,pd abmic, (,m N _,-403.11(C) Con-anurcial 4h P:o- -essed WFE Food fal(nd ill c/u,follem ing Sr cli0tv.v thr.food Code aud CWR I(JJ 1-107' 590.000 3-403 (E i Rrnio:nirl,_'UrBficed Portions "If Hoef ! item Goad Retail F6 500.000 ilanacteroeril and Pentinne 23 t I 043 IF Proper Cooling of PHFE _4 Food and ForAl Protection FC-3 i 0011i 5 E - 4 !Y Ai �2, quipment Poll Utensils FG 001� 6 3-50! i, Cnolinl,,Cooked PHF, �,ouj 140 F it) 26, Water,Pkoilcinq and Waste FG-5 .006 70:F Within 2I-tours and From 70-1' 27. Physical Rr.ifilv FC 6 007 to-11 F/45'f`Wihm I Hour!.. I 28. Poisonous of Tow Mnr.erlas FC 7 1 .003 3-501,!u(B) Cooling PI 1B Matte Icroni Atubi-ni 2 19 Soec6 Rcquirpments 0, 30 0. Tcrnpzi,-�urc Ingredients!,,4!`F/��5 f, Other CITY OF SALEM, MASSACHUSETTS BOARD OF HFALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL, 978-741-1800 FAx 978-745-0343 Kimberley Driscoll www.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTWI-1 --TEL# ADDRESS OF ESTABLISHMENT --7ZW Jb J .090!°: FAX# PJ I A MAILING ADDRESS (if different) ENn s❑ -- Rusinass. / N Ow"r'C, e OWNER'S TEL# ADDRESS 7 STREET / CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S)�G}� (%Gr' � CERTIFICATE#(S)qD36�/J? (Required in an establishment where potentially hazardous food is prepared) „�'� /^ p EMERGENCY RESPONSE PERSON c-S 1/�� y E//Y/-� HOME TEL 1 DAYS Of OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday NOURSOFOPERATION Hao 10:00*At 14:0o Rh 10:00 Rt"i .lo'oo 4,rr 14;va>3tr4. � Please write in time of day, f� tforexamofellam-riam 10.100 ” lg%,Q0P44 10.00604+ 10'00 pp? .10..4pop1Y1 lo:oaJ'•in, //.0o'-�'p� TYPE OF ESTABLISHMENT FEE (check oniv) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT OYE NO less than 25 seats $100 25-99 seats = o more than 99 seats =$200 -..... - ... ... -- - ... ... ... --- --------- . . ....... ...... .... _ ...... $11000 . - 0,,.-- ...__... .- .... --- ---- BEDIBREAKFAST YES NO _.......... - ------_.- --------- ._. _ ....-..... ... .. ............. ..... - --- -----I ---._ ---- ....----- -- ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT, SOFT SERVE YESN $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES N $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 62G, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and ueltef, havq f 0e�d�all state tax returns and paid all state taxessrr utred under the !aw SignaturDate Social Security or ederal IdenLfication Number e - - - -- ----- -- -- ---- - --------------- - - --------- - - r 1q- - --- ------------ ---- - Revlsed 1 FOUDAR2007 adm `�CheGk#8 Datelr� ^1 - . _ _�� 7 ALV0, !W TZ t �rd of W3. -4-12OWashington Street,4th FloorZ--�,,,�., Kimberley DI., A_ SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Giovanni's File Number,BHF-2005-000007 44 Jefferson Avenue Salem MA 01970 LOCATED AT: 0044 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0164 Dec 20,2006 Dec 31,2007 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 Board of Health 9�16� 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 6 of 16 .0044 JEFFERSON AVENUE Giovanni's City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-9111 - Food Contact Surfaces Cleaning and Sanitizing PASS RED Owner: Comments:There was no sanitizer on food prep line at time of inspection. Sanitizer was made at inspection which read too Steve & Katezlna Konls strong. Sanitizer to be rewadily available at all work stations with proper concentration. PIC: Jason Gentry Inspector: John Gehan Date Inspected:Correct By: 11/29/2006 Risk Level: I Permit Number: BHP-2006-0465 Status: SIGNED OFF #of Critical Violations: 0 Time IN Time OUT. Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 06,2006 ) Page 1 of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection PASS Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comments:Walk in refrigerator has uncovered foods.All foods must be covered. immediate corrective action) There are personal drinks being stored where food prep takes place. All personal items must be stored in designated employee areas. Equipment and Utensils PASS BLUE Comments:True unit behind grill requires general cleaning. Same unit missing thermometer. Provide visible and accurate thermometer. Sandwich unit requires general cleaning. black microwave requires general cleaning. Back slicer requires general cleaning. can opener requires general cleaning. No sanitizing log available at time of inspection. Log to be maintained daily. Mop stored incorrectly. Mop to be stored so that it is hung and allowed to air dry. Shelf beneath gril requires thorough cleaning. white freezer on food prep line requires thorough cleaning. same unit has no visible thermometer. Provide visible and accurate thermometer. Physical Facility PASS BLUE Comments:There are many water stained ceiling tiles on food prep line. find source of leak and repair. Owner to fax over invoice to BOH from company who completed new roof. GENERAL COMMENTS: All Violations from 11/29/06 have been corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 06,2006 ) Page 2 of Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 06,2006 ) Page 3 of P "�" �' r `� q��lJl�J■�■tel■r I■J®C1li=J■J F- r I 1D!❑■ J■J■❑■_1■J®1■.J■L-1■J■ ISFIMI J■te101-11t MI-IMILI ■ J !❑■J ■❑■J■u ❑■u®! a ■CI■DI■u■(- ■❑■ ■ ■J■�■�■J!u!u■❑■ui �2 e P1�� WITH SAUCE. . . .. ... .. . .. .. .. .. . . .. .. .. 4.35 DEL/ CLASSIC(20-25 People).. . . . .. . . . . . . . . 54.95 f S R_0_ASTf BEEF WITH MEATBALLS. . .... . .. .. .. .. . . . . . . . . 5.35 . Road Beef,Imported Ham,Turkey Breast Genoa Salom4 Provolone, r WITH EGGPLANT. . .... . .. .. .. .. . .. . .. . . 5.35 i' Not Ham,American Cheese,&Choice of Cole Slaw or Potato Salad ' WITH CHICKEN CUTLET. . . . . . . . .. . . . . . . . . 5.35 r FINGER SANDWICH PLATTER. . . . . 19.95 36.95 � RA 12 or 24 Sandwiches w/Chicken,Tuna,or Seafood Salad WITH VEAL CUTLET .... . . . .. .. .. . . . . . .. . 5.95 BUFFALO WINGS 1II moYm+ tmem. •L II = (8o Pieces) " . ' • . ' " ' • . . . 45.95 2 LARGE CHICKEN BROCCOLI ALFREDO. . . . . . . . . .. . 6.50BONELESS BUFFALO FINGERS(50Pieces CHEESE MOZZARELLA X( Pieces).. . . . .. . . . . . . 34.95 PIZZASDinnerPeCHICKEN BROCCOLIALFREDO W/ZT (zo-zs People). 55.95 ' I PIZZA, CH/ . . . . .. . . . 0I$11.9Q +TxI GARDEN SALAD . 32.95 LAMB SHISH KA-BOB. . . . . . .. .. . . . . . . .. . Z95 GREEK SALAD. . . .. . . .. . . . . . .. . . . . .. . .. 40.95 ae - I aR. TEAK TIP . . . .. . . . . . . . . . . .. .. . . . . . . . Z95 =+ FRESH CUT FRUIT SALAD(8-Io People). . . . . . 24.95 ROAST BEEF . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.35 i i PASTRAMI. . . . . . . .. . . . . . .. . . . . . . . .. . . . . Z35 FRESH CUT VEGGIES W/DIP(8-10 People). . . 24.95 R O'F BEEP 1 2 SMALL 1 HAMBURGER . . . . .. . . . . . .. . . . . . . . . . . . . . 6.35 CHICKEN KA-BOB SALAD(2o-25 People) . . . . 70.95 -�� 1 1 CHICKEN FINGERS.. . . . . . .. . . . . .. . . . . . . . Z50 ZITI W/MEATBALLS(20-25 People) . . . . . . . . . 50.95 / CHEESE 1 CHICKEN WINGS . .. . . . . . . . . . . . . . . .. . . .. 7.50 ANTIPASTO SALAD(2o-25 People) . . . . . . . . . . 49.95 TV PIZZASI F/SH F/LET.. . . . .. .. . . . . . . . . . . . . . . . . . . . . 6.50 �/ 1 6. 1 BUFFALO WINGS . . .. . . . . . . . . . . . . . . . . . .. 7.95 f �� ® � ///"� �/ r i . 1 99 +Tx 1 - BUFFALO FINGERS. .. . . . . . . . .. . . . . . . . . .. 7.95 e rs May NY Be CamlmN•, M=me orN. : SMAGG MED. GA26E 5ERVED WITH SAL AD S FRIES FRIE5 FRIES. . . . . . . 1.75 2.35 3.45 ® � �p�' 'rlA ONION RINGS 2.10 3.10 1 F's 1 GREEK. . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . 4.50 I- MOZZARELLA ST/X. . 4.25 7.25 1 $_ OFF 1 TUNA . . . . . . . . . . • • ••• . . . . .. . . . . . . . . .. . . 5.50 CHICKEN WINGS . . . 4.50 Z50 WHEN YOU 1 - GARDEN . . . . . . . . . .. . . . . . . 4.00 CHICKEN FINGERS. . 4.50 Z50 Sun. - Thur.: 1 PURCHASE I CHEF. . . .. .. . . . . .A6406 FRESH 6• . • • 5.50 BUFFALO WINGS . . . 5.15 8.15 � ® � so am - so pm I ANY CALZONE I CHICKEN.. . . . . . . 5Et2VED WITH • • • 5.50 • BUFFALO FINGERS. . 5.15 8.15 ' I 1 aN'NM4CmrtbN.liMNmedh, PITA BREAD F Fri. 9 Sat.: so am - =0:3 o PmCRABMEAT. . . . . .. . . . . 5.50 PIZZA ROLLS. . . . . . . . . 1.85 CGTEPWC•] _ CAESAR SALAD. . .. . . . . . . . . . . 4.50 i EGG ROLLS . . . . . . � 1.85 ,� • " o „ CHICKEN CAESAR.. . . . . . . . . . . . . . . . . . . .. . 5.50 SPINACH ROLLS 1.85 ..- Q SPINACH PIE. .. 2.00 STEAK N CAESAR. . . . . . . . . . . . . . . . . BAKLAVA . . . . . 1.75j ... 1 LG. 1-TO P NG� - CHICKEN KA-BOB . . . . . . . . . . . . . . . . . . . . . . 6.00 ,. 1 PIZZA & A 1 _ CHICKEN KA-BOB W/FETA . . . . . . . . . . . . . . . 6.00 r XTRA FETA CHEESE... 0.50 2 LITER COKE STEAK TIP SALAD. . . . . . . . . . . . . . . . . . . . . . . 6.00 EXt EXTRA CHEESE or DRESSING..0.25 • 8. STEAK TIP SALAD W/FETA .. . . . . . .. . . . . . . 6.50 LYARMNG MRRMVIODR5'COMPLYING W/THE DEPARTMENT OF i99 +TX i LAMB TIP SALAD. .. .. . . . .. . . . . . . . . . . . . . 6.00 L MEAT,PHEALTHW ADVISED POSESANISNW YOURHERCOO Moy lNr Be[omgta!•HmMJ Irme ORn . MEATPUBLHEALTH WE ADVISE HATEAnNORA TOORUR UNDERCOOKED _y+� = LAMB TIP SALAD W/FETA .. . . . . . . . . . . . . . 6.50 , I LARGE CHEESE 1 PIZZA & 16 PCS. V j CHICKEN WINGS _ R• �{ti., ,:� 4 44 /eNerson Ave:' • 3a/em, MAI 01'970 ^^�� q!) TX ML Orvbf _ Q DEF 10 MDM00DMDMDM0MDMr IMF I L JCC lri JrJ.i.IN 1■I EDUDNONONi.W-DE1 MLJM-J®-1� ® ��7®i �1�i��I�®J®��J � a� � u®u�■��■� ��i ��' OWNNi1'S E _ i ' Not or Cow MUMS puzz 'low8.15 'EXTRA CHEESE. . .. '. cai ,g . _-5 9.15E . ON WMITE OR WHOLE-WNEAf WRAC SMAu LARGE x PLAIN CHEESE. :':' '. `:`: ; .,_ 5.15. AMERICAN . . . . . . . . . . . . . . . . . . . . . 4.3S 4.85 - �AS9'�Bpi SAIAGG" .LARGE} ' a ', a t t. f 5.954 9.'15 ,, t'3-WAY COMBO �: I ":r: . t'7.15.12.15 W' BLT . . . . . .. . . . . . . . . . . . . . . . . . . . . 4.35 4.85 2-WAY COMBO il`'r!3T ti :!?. 6.75 10.15 4=WAY COMBO-:' ! : .°: MEATBALL. . . . . . . . . . . . . . . . . . . . . . 4.35 4.85 7.65 12.65 2 SAUSAGE. .. . . . . . . . , m. 4.35 4.85 Q !'� CHO/GE OF`FQESH TOPP/NG5.' ONION PEPPEILS =•MU5�/ROO.M51 dYAAf = j HAM & CHEESE . ; ,y ._.` . 4.35 4.8s 1 2 LARGE BROCCOLI EGGPLANT .544AM7. 54USAGE • HAM6URG • ANCHOVIE5 • PA5TR4& VEGETARIAN. . 3.45 4.00 1 CHEESE ' ITALIAN. . . 4.35 4.85PIZ1 �q 11799 SALAMI. . . . . . . . 4.35 4.85 . _ I 1 � TURKEY. . . . . "°� - . . . . . . .. 4.35 4.85 k. 1e,�. - ,�1 1 '- 5d1ALL GMRGE 6.95 �n VEAL CUTLET. . 4.50 5.00 CH/CKEN KA-BO`B ^,. . . . . .:'.'6.75 10.15 SPINACH. . . . . . . . . . . . .. . . . . . . . . . . . ==. Spirmdr,Feta,&Onions Topped w/Cheddar&moriarella PEPPER&EGG. . . . . . . . . . . . . .. ... 4.35 4.85 BUFFALO FINGERS . . ':".' '` . . . . .'..'6.75 110.15 VELI. . . . . . . . . . . . . . . . • . 6.95m EGGPLANT . . . . . .. . . .. .: . . . ... .. 4.35 4.85 HAWAI/AN. Mozzardl diedtor lend i . 6:75 , 10.15 onium Peppers mushrooms Broaniti&Cheddar&MaaareBd � HAMBURGER . . . . . . . . . . . . . . . . . . . 4.50 5.00 -k Pineapple,Bmn,&Mouarella�GeQdar Blend € W i. " ° HAM. . . . . . . . . s,&pep m otedi . . . . . . . .. . . . . 6.95 TUNA FISH . . . . . •• • . . . . . . . . . . . . . 4.50 5.00 , I 2 SMALL 1 VEGETARIAN,. :"4.* ': . . . . . . .":'_. 8 75 13.25<' Ham,Provolone o1iiom & Cheddar&MouaM/a CHEESE Tomato,MurAroom;Onioax Peppe�Olfves&BroKo6 - '/,^'a .# _,;-.,�_g 17• °.A' -'}-_ CHICKEN CUTLET.. . . . . . . . . . . . . .. 4.50 -5.00 1 E 1 �`�'a b ^. +^ , ., '' :;p . 6.95 PASTRAM/. : . . . . . . . . . . . . . . . . . . . . 4.50 5.00MEAT LOVERS,#:: -. ._ .:: : °:;. :? :'' 8.75 ,13. ' Hot Baoh Salaatl,Provo/off Mortddelf4 oetaet,.!'epye•'s•Cfreldor,& v y 1 PIZZAS.. Baron,Soushge,.Hann Pepperont'MeatIou &Salami i' .•- v ,.,,,, . ROAST BEEF. . . . . . . . . . . . . . . . . . . . 4.50 5.00 a .,�,., - .. Monarel/dL1':, ,',� l.,l;;- t 'w 1 1 f t1. . - :� ' CRABMEAT. . . . . .. . . . . . . . . . . . . . . 4so 5.00 .. $6.99 . FIERY CHICKEN SUPREME:: . .,c',..8:7,5' 1`3.25' CHICKEN PARM.. . i`:. . . . . . . ... :. . : ... . ..... 7.25 o 1 Pepperoni Oniosst.Peppem Tomato,;&BBQ'Chi �aw+` ^""' sacra mpnmrelhy Pro_voka_C U.eAJar,&MonmeRa:1 Lama 9. CHEESE or MUSHROOM STEAK. . . . 4.50 5.00 y `-_« - - - B/ANCO : `::': . 8.75 13.25 BROCCOLI&`CHEESE.':"":` :"` ° ' 6.95 =Q PEPPER or ON/ON STEAK. . . . . . . . . 4.50 5.00 White saun,`OBve08,eodiq;&spices;5; y; Broccoli,mouarella&Cheddar STEAK BOMB . . . . . . . . . . . . . . . . . . . 5.00 - 5.95 Q �Q SOUTH OF,THE BORDER. ::. . ....'. 8.75 13.25 BROCCOLI& CHICKEN . . . . . . . . . . . . . 8.25 STEAK&EGG . . . .. . . . . . . . . . . . . . . 5.00 5.95 la/apenas Mivet Hamburg,Lettuce,&Tomaro,w ,.'wx. ,q y* GrEed Caren,Brottok Moaam1k,&Cheddar`�" STEAK TIP. . . . . . .. . . . . . . . . . . . . . . . 5.95 SCAMP/P/ZZA.::'.:::: . . . . . . . .,:. 8.75, 13.25° .yf `STEAKBOMB .'. . . .'. .:..,. :. . 8.25 SOUVLAK/. . . . . . . . . . . . . . . . . . . . . . . 5.95 WHEN YOU Gorlic spices,Moamd/a Cheddar&shrimy t; pa p;; x° ' oaio PepperX Mmhrooms salammi,'E' ,mss I"i^,; CHICKEN SALAD . . . . . . . . . . . . . . . . 4.50 5.00 DIET PIZ7r9:" • • : •'• • . ,y. . .�,`..; '.':=' . '.'S.00 steak C6edeor,&Mouore!!a ° Q I PURCHASE CHICKEN KABOB(Lg.Available in Pita). 4.50 5.15 ` n " Lo F%LAGERS':: :. o . . . . . . . . . / J I ANY CALZONE 1 DIET VEGETABLES-mmhrvomc'onianr'&'Peppin. . . . o BUFFALO FINGERS. . . . . . 5.00 5.95 1 1 BUFFA . . . . . . 8.25 � 5U65 AVAUA815 A5 WR4P5 OR PITA POCKETS. SUPER BEEF . . . . . 4.65 1/4 LB. BURGER. . 2.00 j 1 LG. I-TOPPING 'w - i ROAST BEEF .. . . . 3.75 W/CHEESE. . . . . 2.25 ' � PIZZA &A � 4. JR. ROAST BEEF. . .2.95 K/NGHOT DOG. . . 1.95 ,� 1 2 LITER COKE I •>.. ?^ I SUPER PASTRAMI. 4.65 SUPER CHICKEN. . 3.25 , I 8. 1 PASTRAMI. . . . • • • 3.75 ED i 1 99 .Tx 1 CHAR BROIL FISH FILET. . . . . . . 3.45 CHICKEN. . 4.25 , r a LoLARGE CHEESE 1 Mr, e.l�arg+e�.vai.et/o�prodtictg,from.., ' _ � ' PIZZA &. 16 PCS. ' c/ L_•: �� /�_ a.. ti CHICKEN WINGS Li WDEFIff C1®Ci, - - - - - - - - 1 .r X0044 JEFFERSON AVENUE Giovanni's City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 744-9111 PIC Assigned/Knowledgeable/Duties PASS Q RED Owner: Non-compliance with: _ Steve $ Katezina Konis Anti-Choking N/A PIC: Steve Konis Tobacco PASS Inspector: Janet Dionne EMPLOYEE HEALTH Date Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level: FOOD FROM APPROVED SOURCE Permit NUmbeC �' Food and Water from Approved Source PASS 0 RED BHP-2006-0465 Receiving/Condition PASS RED Status: Open Tags/Records/Accuracy of Ingredient Statements PASS 0 RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS 0 RED 4 Time IN. Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 08,2006 ) Page I of ' Item Status Violation Critical Urgency v RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Se gation/Protection FAIL Critical RED Foodborne Illness Interventions and Risk Factors omments: raw meats in true freezer stored above other foods.all raw meats to be stored below other ready to eat foods to prevent (Require immediate corrective cross contamination. action) Food Contact Surfaces Cleaning and Sanitizing _ FAIL Critical RED 01 omments: cutting Boards stained and scored resurface or replace. Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS ❑d RED Prevention of Contamination from Hands PASS ❑v' RED Handwash Facilities PASS RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS 0 RED Toxic Chemicals PASS 0 RED TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS 0 RED Cooling PASS 0 RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Posting of Consumer Advisories PASS ❑ RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 08,2006 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food r]d Food Protection FAIL Critical BLUE Comments: personal food stored with customers food in true freezer.personal food items to be stored in designated area to prevent cross contamination. Equipment and Utensils FAIL Critical ,& BLUE Comments:True Freezer had temperature of 28°f.freezer to be maintained at 0°f or below as mandated. Q o`0 CG`S acme unit needs thorough cleaning. OC vbelfield freezer unit had temperature of 24°f.freezer to be maintained at 0°f or below as mandated. �/hC{ r' Sa�nitizing solution reading above 200ppm.sanitizer to be maintained at 50-100 ppm for proper sanitizing p,.ran covers in walkin had accumulation of dust and grime.thoroughly clean fan covers. r/e// alkin shelving had accumulation of dust and grime buildup.thoroughly clean and sanitize shelving units. at,Plumbing and Waste PASS BLUE QPh,s,cals FAIL BLUE s:there were stained ceiling tiles observed throughout establishment indicating possible roofing issues and leaks.find leaks and repair.all stained ceiling tiles to be replaced after leaks have been repaired. hood needs cleaning.clean hoods. 4�5 acked light cover in back seating area near delfield unit.replace light cover. Ma agement and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes FAIL BLUE 4'/e Aments:there were old units/equipment outside in back area of establishment.please remove or dispose of properly. GENERAL COMMENTS: 646: City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 08,2006 ) Page 3 of Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 08,2006 ) Page 4 of �, .. V �--- � � � / �- � J/� �� f�� / ---`' � Jam/ ,! �� / J�� .� �-�1 -�---"--�- �' �` -- �-�---- _------1'` i I I I 1 I 1 1 1 1 1 I 1 I 1 I 1 I I I I I I 1 1 I I I I I I 1 I I I 1 I I 1 1 t. Commonwealth of Massachusetts « City of Salem Kimberley Driscoll ' Board of Health Mayor 120 Washington Street,4th Floor SALEM,MA 01970 Temporary Food Permit DATE PRINTED: _ 08/1072006 WHO'S PLACE OF BUSINESS IS: Giovanni's File Number BHF-2005-0007 44 Jefferson Avenue Salem MA 01970 LOCATED AT: 0044 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit Issued Permit Expires Fee Restrictions/Notes TEMPORARY FOOD Aug l0.2006 Aug 11,2006 $0.00 permit for the best of Salem pizza Total Fees: $0.00 PERMIT EXPIRES August 11, 2006 Board of Health j 11M. 9LIS110 06 11 : 41a SALEM YMCA 19787409168 P.2 CITY OF SALEM, MASSACHUSETTS' HOARD SE � T20 WASHINGTON STRREET,T, 4TH FLOOR SALErn, MA 4-970 TEL. 978-741-;800 FAX 978-745-0343 JOANNE' SC07T, MPH, RS, CHO Kimberley Driscoll HEALTH AGENT Mayor APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT _ter FEE: i- = S2t3LYfip -ol�et ��'�i 4-7 GAYS= $300 MQ DA S-_ Otto 1 CHECK PAYABLE TO TH CITY OF SALEM,NO CASH NAME OF EVENT Otto tO(A LOCATION /� (u m„�,, DATES)OF EVENT_ / I v ct^�GaL11 L,j�y'wQfIM''S'7fdl' P, z u.Ctmri'.T I- NAMEOFAPPLICANT [!�Gve,.✓v�-ir" S TELEPHONE'# �r,7 r[CY, ADDRESS `Iy 5-e izm k-C. NAME OFBUSINESSS v'f'^ffV``5ri t Is TELEPHONE#GJ 7�' 7Y`t`�1 ADDRESS LI''1 -1 PYFtA<1_ A- {t CERTIFIED FOOD MANAGERS NAME_. .4-"1`I1 �-^a(1� CERTIFICATION# �f h A PLAN OF THE ESTABLISHMENT IS'. ENCLOSED DRAWN ON THE BACK TYRE OF REFRIGERATION: —GAS —ICE DRY ICE —OTHER METHOD FOR COOKING/HOT HOLDING: GAS ----OTHER METHOD FOR SANITIZING: CHEMICAL OTHER SOURCE OF FOOD: NAME. ADDRESS, tt `,J FOODS TO BE SERVED INCLUDING INGREDIENTS AND METHOD OF PREPARATION: P-Auv, I HAVE READ THE BOARD OF HEALTH. "REQUIREMENTS FOR TEMPORARY FOOD ESTABLISHMENTS" I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THOSE REQUIREMENTS t UNDERSTAND THEM,AGREE TO ABIDE BY THEM AND UNDERSTAND THAT FAILURE TO DO SO WILL RESULT IN REVOCATION OF MY TEMPORARY FOOD ESIABLISHMENT PERMIT. PFRSUANT TO MGL C62C. S49A, I CERTIFY UNDER THE PENALTIES OF PERJURY THAT t, TO MY BEST KNOWLEDGE AND BELIEF, HAVE FILED ALL STATE TAX /jRETURNS AND PAID ALL STATE/TAXES REQUIRED UNDER LAW. -I _ u SIGNATURE DATE SOCIAL SECURITY OR FEDERAL 10# ----------__"--------------------------------------------------------------------------------------------------- --- ---------------- T[MPAPPL PCNSGptI(lSIpZ PEPWY4 -GMECPM&.9wYE Page 1 of 2 y << Janet Dionne 6) V W I0 a From: Bud Konn [abkonn@verizon.net] Sent: Thursday, June 15, 2006 11:16 AM To: Janet Dionne Subject: FW: Class Score Analysis -Class 538201: print email landscape. Hello! This will verify that Jason Jentry has passed his ServSafe testing and will be receiving his certificate in the mail within the next week. If I can be of any further assistance please don't hesitate to call. Sincerely, Bud Konn Konn Hospitality Services, Inc. konnhospitalityservices.com konnhos oitaIltvservices a(�verizon.net 603-736-9977 From: certification@nraef.org [mailto:certification@nraef.org] Sent: Wednesday, June 14, 2006 10:03 AM To: abkonn@verizon.net Subject: Class Score Analysis - Class 538201: print email landscape. National Restaurant Association ;+ EDUCATIONAL FOUNDATI N Class Score Analysis Class #: 538201 Course: ServSafe Food Safety Manager Certification Instructor: Adrian B Konn Exam InstructorID: 157065 Sponsor: Konn Hospitality (oldID = 263218) 64 Old Town Rd Ext Class Address: 64 Old Town Rd. Ext EPSOM, NH 03234 Epsom,NH 03234 Student Overall Person ID/Hold Code ° Domain Scores SSN �° D1 D2 D3 D4 D5 D6 Cert.Number Score GENTRY, JASON W 3563958/ 80 28/38 4/5 10/13 9/10 1/2 2/2 029603856 6/15/2006 Page 2 of 2 4903648 Total Number of Students: Summary Number of Number of Number of Average Average Average 1 Student Students Passed Students Failed Passing Score Class Score 1 1 0 80 80 Dl- Foods D2- Clean/Sanit D3- Facilities D4- Personnel D5- Temp. Mea D6- Allergens D7- High-Risk 1 D8- Legal/Regu D9- Facility La} D10- Training Er Examinee in bold are on Hold NT=No Test NR=No Registration NF—No Fee NW—No Work Hours RG=Regrade 6/15/2006 rPA comet pu- 1 cl 0a OKI I - 1 I 1 I - � - - � - - - � � - - - - I � - i - � - - � - - I - - - j , - - - f - i i IMPORTANT MESSAGE ) FOR CLj A.M. DATE / TIME M _ Tl�'Kfloi /o✓NA ' i OF PHONE AREA E NUMBER EXTENSION FAX ❑ MOBII F AREA CODE NUMBER TIME TO CALL TELEPHONED ✓ PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU ... .RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED �ps FMAAOE N oos - - i NOTES i Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 DATE PRINTED: 02/06/2006 WHO'S PLACE OF BUSINESS IS: Giovanni's Roast Beef& Pizza File Number.BHF-2005-0007 44 Jefferson Avenue Salem MA 01970 LOCATED AT: 0044 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0401 Feb 6,2006 Dec 31,2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health A� Page 1 of 2 r.; CITY OF SALEM, MASSACHUSETTS 3 m BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAx 978-745.0343 MAYOR W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT- NAME OF ESTABLISHMENT ( o tr1/G!//Jn/') I S Im -cT-EL# ADDRESS OF ESTABLISHMENT I�GI I✓ ��rn �v MAILING ADDRESS (if different) OWNER'S NAME TEL# ADDRESS l Gl� //Grl ! ` V CITY X71, STATE /-T S ZIP CERTIFIED F06D MANAGER'S NAME(S) CERTIFICATE#(s) WOcloC6 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# HOURS OF OPERATION: Mon. u- uTue. lr oWed. oL dThu. u-io Fri_�atAb!,u' osun.r�- TYPE OF ESTABLISHMENT /,� FEE (check onlvl RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ---- ----- -----------------CYE31----------------------------------------------------I" .. - .. .. . .. . ....--1= 11135P ---------- RESTAURANT NO less than 25 seats 25-99 seats more than 99 seats =$200 - ..............---------------------------......----------------------......----------..... BED/BREAKFAST YES NO------------------------------------------------------------------------------------$100 -----....----- ---------------------------------------------------- - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES N $50 ALL NON-PROFIT(such as church kitchens) YES O $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signat6e�� - Date Social Security or Federal Identification Number ---------------------------------------------------------------------------------- --- -/-------------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date 7y7 (o j`�l� CITY OF SALEM B(MD OF HEALTH ' EstablishmentNamei�/h��h/7,f � Y ��_ Date: _ ��0 Page: of Item Code C-Critical Item DESCRIPTION-OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY ,4 /t Yr< 1 n513POt7U'► 1AP Al/vGv/l /.tP/'2 node 1 LL I >41U/o�i��7�ms rllP Y d),-) 5/i7/a� � a0192 ' have h(_an_ 1 I 7"G,,s �tzrG�l Jsh►n�n I� Sp-1 fa rP t�i�h t�Py l__)"Awd l)f' 1 pea-Hh I 1 —Th/2_f_lc woo , I I - _ I Discussion With Person in Charge: Corrective Action Required: I ❑ No I El fes i I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure t your food permit. ❑ Voluntary Disposal ❑ Other: t �-501.;4fC) PHFs teemed at Tentperaturee Violations Related to Fcodoorne NL^ess fntei ventions avid Ris4 I twcordmg to I:rw Cooled to Factors pteaas 1-22) (Cont.) ; .11`F/=t5'-F cti'itlun ; Homs. ' PROTECTION FROM CHEMICALS i +-5111.15 I Cooling Methods for r NF's i 19 PHF Hat and Cold Holdinc j 14 Food or Color Additives ;-501.t6(8C,,Id FHP:;ivlainnnned at or below 3-202.12 Additive,'' ( J j 590.00-4(F) -4!=/45" F. 3-302.(4 Prnv.ction Go; i!nanDrotrod Additive'" ;-SOL 16(0} Hut PHFs Maintained at or above 115 Poisonous of Toxic Substances 1-10!.I I Ideon run lnfotmauc:n-C)-igin:t: ! 3 501 16(A) Roasts Held at or above 1;0"F. I Ccntainet::" ! 21) ! Time as a Public Health Control i 7-102.11 Common lame-`r4'urk:n^ Containers' , i 7-_UI.I 1 Scnarati:m-Stom,r," I 1 3-501 111 Timc as a Public Health Control* i I 1 Rrcl-i 7-ZI 1540.004(11! ; Varian:c Requirement ; (}2. aion-Presents and Uae'f 7-202.12 Conditions o't;sc' I 17-203 It T„+n Conta ncr,- Prol-.:hi;;ons, I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sm»t:zees,Criteria-Chemie.:i POPULATIONS(HSP) 7-204.12 Che I!Cak for`A'a3h,rtf- Produce,Criteria" 'I 3-801 U(A) U11pastetn'ize.1 Pre-packaged Juices seal t3eeetati'es with Warnin) I abcls* 204.14 ( Dnviny Agents.Criteria'" I � - 2(I5.!i i ! ?-801.II(P) IilseofPastcnrizedEu2s" 7- I Incidemai F.n x1 Cvn:act,Lubritarrts' - i 3-801.11f D) I Raw or Partially Cooked AntmA Food and 11=206 11 ( Resuicted Use Pe,ticides.C'r#ter,::'' I ! 7 at- �.12 Rodent Bmt hadI ; Raw Secd Jprvuts Not Set vett. wts" . 13-801.11(0) ( Unopen::d "urd Package Not Re-served. " 7-2,76.13 Track:n}: Powders,Pct Control ano Monitonep` CONSUMER ADVISORY TIME TEMPERATURE CONTROi..S 22 3 603 11 Consuact Advisory Posted tis Consuniptiv i of Animal}-hods"that arc Raw.Undcrrooked or 15 Prager Cooking 7'em,Pera;uses for ! Not Otherwise Procet,wct to Eliminate PHFs -even,',.woe }f :- F G t P3tItOQ.:nS." i-401.11 A(l)(2) , 1€ 155`.155. r,. Lues- 1n:mediatz Jercice !45'F15:.ec` 3-3ti2 13 Pas,eunzed Fagg,Substitute lige Raw Stell 3-101.1 I(,%)(2) Cufnminutc:<r ash,M,-ats&Game Le""LL Animals- 155°F !5 sec 3-401.11(B)(i,(2) Pork and Bccf Rost - 130-'F 121min* ! SPECIAL REQUIREMENTS 3-401.11(AN2; R;+tires-hr .Led Mcats-155'F !5 i 540.(109(0)-(D) Violations of Section :i•-0.009(A)-(D) in sec. catering, mobile food• temporary and 3401 !1(A)(3) Pouim WilJ dame. Stuffed PHFe, residential kitchen operations should he Stetting Contanung Fish, :Cleat- dehitcd tinder the appropriate sections bahry,n Ratites-16e°P 15 sec. alcove it related to ttxxlbornt ilhiese 401.1 I;(')(3' 'Ahoie-muscle.friiactF„- � •ef Steaks ;ntenrntions and rt,L faclors. (Jibs.r 590,009 violations relatim- n,good reta;! 3-401.1? Rnw Animal Foode Cooked in a practice,should be debited under#29 - - TvI:crowave I65"F I Special Requiremcnts. 3-401.1](A)t1)(h) Afl OCier PHFs- 145-F 15 see. 117 Reheating for Hot Holding I VIOLATIONS R2LATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHF, ui5`,'15 sec. ° (Items 23-30) 3 40?A I(B) Micro wave- 165`' F 2 b4rnwe Standin;t ( Ctural and nwi-serosal vadauov.J, nhich, do not relair it,file Timet' j foodborne illness inreivenlams and riskJdrtors listed above ave be, ;-403.1 If,C; Comrnzrcially Pmee:sed RTE Food- i .Jou�rJ Jt the fnlJnn-Ing<ertions of the Food Code and 105 C:lfll !40"`r' ( 59(1.000. 3-403.!1(F, Fceniaining Cnnhced Portions of Beef' I Item Good Retail Practices FC I, 590000---! Rrasis" 23. Management and Personne! FC-2 .003 24. Fa,d and Foal Protection FC-3 004 ! 18 Proper Coming of PHFs 129 cavwrnent and Utensils FC-4005( . 3-501 14(A) Cooling Cooked PHFs from !40`F to '6. 'Nater,Plumb!nq and w'nste FC-5 006 J 70'F Rlihin 2 Hours and Frond 70'F '27 Physical Facility FC-6 007 to 41`Ftc;5'F Within 4 Hours. " ! ! 26. ! Poisonous or Toxic materials FC --7 I .003 I 3-501.1a(t3) Cuolin,•PFIFs Mad: Front Ambient _29. Speaa;Requirements ,009 Tcn:pei are higredieim I 41"F/45`F; 30. Other ---_-- i A9thin ; !tutus'^ m-w.a:,-i mo •Denotdv critical nen:III,he f lend 1499 Fond('ode or 105 CPIR S"U 0-10. CITY OF SALEM BOARD OF HEALTH Z J Establishment Name: dlO✓/17VAIIS Date: ��G Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY /f 17/�dOJhS 1A Mt I /,f /a/1G lAr-111 4""1 1 /U , V, el�e e, nr� I I IA 1 r. .r (u CF(t wt c+� e "�� S Pif. - all (3Yt tGi rn /CIG I ,�d✓- �-„+,-,S �� v.S��L(� �,1 1�-c ,I,L ln.tn�i� c� ct.v��' v,��Io� . I I ��- G� �o�. � �o� -vt�(,tN i�,., �--( 10� ��rn-✓t Sb.�-� �cS nu��1 � o� C`ovt CkA 0C_ �_->0 ss A la Le wa �C r C'an IM I vl rri AN 4ka-1 cwV.z ItA man 1 I ¢ ,-kk S'1rn v vv t rr. �-�/k )cAr 6 ✓.r� I,- � ��(�'[� G ✓2 G S G� In 6 e PK Dc7Sc_vX 1AAA U o )� Q� I,uvlCJ Pa_Si _ I a� C _ ✓N All avers I,, a 1ae' c U_aA,�e a,"C( ,,wt.' h-7-a f0 I • I �i � L.t�;1 ro-,�-. 1 .� �-U I Z , r,c�ua�f I ,, c 1 art I ��t C� �ti c< < r, I-�10(.�� K'.. r V r� L/ C--V4) A-(t 6 oG( Gl v d, oG�f� C (M stn I V 1.C/L S �D � C(t S�Gt✓�� Ypt d//A ;1ocAv( (tj la� 'tluu.t 1d1`�c)P�i�C1U� � v Discussion With Person in Charge: U Correctiv6 Action Required: I ❑ No I ❑ res have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion t violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that p g y p noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. — ❑ Voluntary Disposal ❑ Other: ?tfFs Rei,cived at T--ilivetatures Violations Rolatr.a to Foodburneilmess!nterven!iwisand Risk Acord ng to I:aw Cooled to Factors(items 1-9-1) (Cont.; 41'F;lT'FWithiii4Htsjrs. : I PROTECTION FROM CHEMICALS I =('1.'5 Coolimi Methods for Prfl=s 19 PMF Met and Cold Holding 14 Food in Color Additives 3-50 i.16(B) Cold PHFS Mmritained at or below 3-202�12 Add�%,s' -,-302 14 protvcl;u!� loom(r,"Apoo)%ed AildltiieO 59t'I 004(F) 4 t'!45�F' Poisonous ot,Toxic I;ubsum.ces 3-501,16i A) Hot PHF, at ir 81bo,c 1404', r 7-101.11 IdentiiyIn", 3-5ul 16(A) lku;Os,I-le'd at or above !30`F Conljincr�' Time as a Public Health Control 7-102.1 . C-n'w':oil Noun-Wraknig Coraain,.t," 3-'01. Time as a Public Rollin ConooP; 2o 1.!1 scr':IaLion-Stoiakd- 7 202,11 I"ertriction-PreL"Clice dill U'c" 7-202.12 Ccaidilionso!'Usc' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-201,11 1 oxt Contain,�o, -Proh:.rioons POPULATIONS(11SP) 7-204.11 S6;nrlzers,Criteria-Ct;ennr,0s` 7-201.12 ChernIcah;for Washim,Produce,Crilew, 21 1-801.11(A) 121ipasieurized Ptv-packaged Juices and 7-204.14 Dryiul,,Ascnts.Criteria": Revert.-es with Warnine 1,;ibob 7-205.1 i Incidental Foul Contact. Lohric!ints' - ' 3-sol 1](B) U'Ly�- )--pasteurizeelf-pes* 7-206.:l Restricted I Ne Pesticides. Crocq:� 3 SQ 1,11(1)) Raw or Paltiifly Cooked Airiniral BNO and Raw Seed Sprouts Not Se;-%ed. 7-206,12 R.Nient ball '�tvdorls- 7=_'[)6.13 Tracking Powders.Pv,i Control and 3-801.I I Xi Unopened Foixi Packagw Not Re-served. Monitorin"', CONSUMER ADVISO;RY TIME(TEMPERATURE CONTROLS 22 3 603 11 Consumer Advisory Posed for Con;anuption if 16 Proper Causing Temparr'Urres to., Animal Foods'lliat are Raw. Undercooked or Not Otherwise Processed to Eliminate PHFs 3-41.1 lkl)(2) 135'F 15 Svc. pw'hogcos.�-""' Flt�'!�s-lrornediaic Serv;cc 145Fl5secr 3-302.13 Pasteurised Fgg.s Substitute for Rai,,Shell 3-40C1.1 t(A)r2) Fags" owirinnned Fish, Moats&Game Ainmali;- 1 F I i se- � $PEC;AL REQUIREMENTS 3 401.1!(B)(l j(2) Pork and l3v-[PoaFt - I l0i'F !-'I rum* 590.0(9;A)-(])) Violations of Section 590.009(A)-(D) ill 3 401.11(A)(2) R:;rjtes. iniecte� Mv:rls- 155`1� 15 sec. catering, mobile food, ternporm-y and 3-401.11(.x!(3) Poultry.Wild Game,SrutT.d N IFs, i residential kitchen operations should be Stuff.n.,Cont,-.4t:w.Fish, Moat, del,iLed under the appropriate sccijqnc Poultry oi Ratites-165"t' I5 sec. above,if related to foodborne illness 3-101,1)(00) Wholc nitrscle, Intact Beef Siaks I irtorventions and risk factors. Other 1-1511F," 590.009 violations relating to good retail 1-4101.12 Rov, kninta!Foo js Corked in a practices should be debited under#26 -- Miuoyvav: 165"F"'. Special RvqL:ilcMCl1tS. 17 I 340!J ;(A)(!)1h) All Otfi,r PhF, 145"F 15 se"-. Reheating for list Holding VIOLATIONS Rr:LA TED To GOOD RETAIL PRACTICES 3-403.11(A)&(U) PHI-s 165'F l5scc. 47 (items 23-30) 3-403.1'(B1 MiLrOWro'c- 165'F 2 Nfinuic Siandina i cans ll and non-urinciel which do 11"t lelarp 1"the Time" foodborne ilhleSS hlt(`Illerdion;;v;drhtA jactors listed above, (an he 3-403.11(C) Gimrnvrciaiit Pimessed RTF Food- f"wid In lhefnIhmolg carbons qfiheFood Codc,nd 10i Cfl')? 14(i'F% -5110.000. 3.40? 11(E) r.e;iiajning Uroliced Portiriv,ol'13ccf I Item Good Retail Practices FC 590.000 Roist"t23. Manarremcm and Personnel FC 2 .003 Ig Proper Cooling of PHFs 24 Food and Foal Pro,,ecticn FC-3 .004 25. Equionnern and Utensils FC-4 .005 ?-501 14(,,\) Cocdiri2 Cooked PHFS froris 140"F it) --i6 - Water, Plumbinq and Waste Fr--5 .6-6& 70`! 1Vithin 21-four,and From 70°F 27. Physical Facility FC--C 007 to a]+/45`F Within-I Hovis. pir Poisonous or Tony Materials FC 7 .008 3-501 1403) Cooling,PHFs Made From Ambiellt i 29, Sp=cial Requiiements; rlog Temperature Ingredients,to 41`'r/45'rF 30, Other Within 4 llumrs" CITY OF SALEM 0-7 � BOARD OF HEALTH / �7 Establishment Name: L-ie0 >J6-, Date: C /� /a� Page: G of C_ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PR'NT CI PURL V hos, 111M,17 /u C(, r/l> S fi /r�P!/ fA 2YIllC! (j71 �3 liC ( /C /7�L/l . x! 7/7 rC14 /,1 V rx-y(� ' C, I ' . , �-,(f S � o D 0-CI e"C) 1r( (S 10 tIX- aaIV-1d f ('DIACR CAi( hies . .� ✓) �c n�IJV IiC h/111,r)-WA'.f !a2 lP12W/AI� r/� `�1� m.�s_,� � l�..o,. I �In �c�1 c.•�-� G�.ti(c{' �o�la�.� �'�a✓cF O — Ve - I Ire 6 ate. n ✓A�� / r��vPc. r�n� n� vld �� rcrn5 V1C)A,-r_dI ivy A"Ak<, t2nc�(t— /{ k kf t/ it ;ttir L' lJili I)e CIo(P 'Vo O(��' - _ v I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all Cl Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit.- �_�,� ❑ Voluntary Disposal ❑ Other: 141(:11 PHF,,Received.-'1'emptxatures Violations Related to v.-dharne illness Interventions and Risk Aceotdi ng to Iasr Cooled to i Factors(items 1-22) (Cont.) =i-I T i,i'F Within 4 Hours ' PROTECTION FROM CHEMICALS ? 501J5 5 Coolie. kledud<for HF'S � 14 I Food or Color Additives l9 PHP Hot and Cold Holding 3.207.12 1Jdi d vzs" 3-501.!6(N) (oldPHFsMaintamedatorbelov} - 1!'!459 F^ :_;02.14 ProtectiuI:]rorn Unappu,ed Ackidive:" 3-501.16(A Hot PHF,, Maintained at or above I,5 I Poisonous or Toxic Substances t4U'F. " 7-101.11 tderuiiping In iortna+ion-Ciirmal _ 3-501.16(A) Roasts Held at or above 1317F. Coivainer;' " ! 7-102,11 fomm��n:Name, N$nrking Contaireu'T ?� Time as a Public Health Control 3-501 19 Time as a Public Health Control* 7-'.OLi1 Szparation-St crave* , 7-202.1 1 Rcsniu:on-t'renence and t'.e'. 59011041 H? Variance Requirement 7-202.12 Condition;of Use' 7-203 ! ! T.,c;c Conta ners-Prchin:nous" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.1 ISai»tireis,Criteria-t'iiemic;is" POPULATIONS(HSP) 7-201 !2 Cir-niicals for.\lashme Produce.Criteria" ( 21 3-801 l I(H) Unpas+eurired Pie-packaged Julie;,and Beverages with Wavnine Lab 7-204.11 Diving Aeznt::.Criteria" ;-ROI 111 B) Use of Pasteurized Eggs* 7-205.11 lncidcn:ai Fuad C'nnte_'t.Lab:tennis'. 7 2-06.11 Restricted C<e Pesticides. Cr,wrr:•* ' E01.1 1(1)) Rau or Partially Cooked Almost 'Foov1 iuid ! Raw Seed Sprouts Not Served. + 7 706 12 Rodent Bali Stat(o*s' 1 3-g01.1 I(C) Unopened Food Package N"t Re-served. " 7-206,13 Tracking Powders,Pest Control and Monitorimi' CONSUMER ADVISORY TIMETPEMPF_RATURE CONTROLS 22 3-603.11 Con;nmer Advisory Potted for Consumption of Anhnal Fax)::'1'hat are Raw Undercooked(it15 Prager Cooking Temperatures for PHF,, Not Otherwise Processed to Eliminate i 34(1.IEA{1)(2) Eggs- 155`FtSSrc Pathogens.^ - Ei;_s-fmmediate Sc rice 145`"1 ss,:'' 3-302.13 Pasteunzcd Egg:,Substitute till Raw Shell '-401.11(A)(2) Comminuted Frh,Mcdif,&Garrie I Eegs' Anima!:- I;3"F i;sec, " J 3-401.1 t(Bi,i H2) Pork and Bool Roast- 130`F 1st mins' J SPECIAL REQUIREMENTS -, < 590.009(A (D) Violations of Section 590.009 A)- ?7 in 3-401.1 ((Au,J Rant;s. hijtru-d Meats - 1 ,5'F :5 ( ) t ) e; catering, mobile food, temporary and :-401.1 I(A)(3) Poultrq,N'ri:d name, Stuffed PIPs, residential kitchen operations should he ( ':offing Containing Fish, Meat, debited under the appropriate sections F":ulrry or Ratites-1659, IJ sec. ' above if related to foodborne illness 3-10111tC)(.3} Sv'hoie-ru;sde. intactFM'Stcaks I interventions and risk factors. Other >°F 590.009 violations relating to good retail 3-4ULL Raw Animal Fouls(7xtked in a ptacnces should be debited Under 7#29- hliiaowave I W P* Special RegUitements. 3401.11'AVM(b) All Other PHF;- 145'F 15 see. 17 j Reheating for Hot Holding v(OLATIONs R_LATER TO GOOD RETAIL PRACTICES j 3 403.1 VA)&(1)q 11HFs 165-F 15 sec. -' (items 23-30) 3-403.1 i(131 MiL rowave- 165'F 2 ktinaie gtandim; ( Critical and non-crit,at violations, which do not relate to the T;ntc" i loodhorne Hlnecv iutep,entians and riskjwtors listed above, can be 3-103.11(C) Coinnaacutlly Ptoceesed I2TE Food - lound it; theJol/mrrug .ie:.tioiv'of the Food Code and 105 C A4R 140`F I590.000. ----------------- 3-403.!I(E) Remam:n;z unc;iced Porrons of Reef I itoar Good Retail Ptactiees FC 590.000 Roasts* 1 23. Manarement and Personnel FC- 2 .003 18 Proper Cooling of PHF=_ 1 24. Food and Foci Protection FC--3 ,004 -- _ 25 Eauirancnt and Utensils FC-4 _005 _ f ;-50114i:U (poling Couiled PHFs from 140'-F to 26. Water,Plurrbinq and Waste FC -5 .006 '0'F Wahin 2 Hours and Fmra 70"F 27 Pnvsicai Facility FC-6 007 to 41'F!¢5"F W:,hin 4 Hours. ` 26. Poisonous or Toxic Materials FC-7 ; .008 3-501.:4(8) Coolie.,, PHF,,Made From Ambient 20. Soecial Ragwremente 1 .009 I Tempetanire 1w redients 1,,,11'17/45°F 30, Other Uvui;m" Hours# •..•,ro�,�a.�.ro�z do% *Dclote <o';Co!nem u:the:?dcral 199v Fwd ode or lu5, MR 590 Gait. I EA7 {i+a �.^ "1"t�„+ .rt�rr�'e, .'TE, .,ri:- -„ .*e, -n,- ^�a..,�r "_� I y z CommonAM wC_e�alth;otMassyacrhusetts �� shyµ 4-M y y a;�Wi Xda^ y �L� 'i+T '�,� :: "`^ � .j4"*kY•• ; +,�' z.:y,+'4}`R'r '�' F,'•+i%C*,¢�'' .� e+ #�"¢�t°'�a} �u'+s'� �� # a +��” +i.�ti�1f-`�'�'t:lty'Of Salem•. Aa � "�. � w � ao y� .{ vll -VI �-: "L •'1\ i \ `` 1 'AMY' YL t��. �„��'s"�h�- twi`.,w,6t�?K;Ffi"'t��•�r'.x`�.vivrk^w.'�' �"C § S`! 'ty.""F"�'±'ulxv.r''�'!`ro,�a+�-` w"a''✓`,1 $�y.9>��s�i>, '`\"t �d SALEM,MA 01970 Foo&Retail Establishment Permit DATE PRINTED: 05/02/2006 WHO'S PLACE OF BUSINESS IS: Giovanni's Pile Number stip-2005-0007 44 Jefferson Avenue Salem MA 01970 LOCATED AT: 0044 JEFFERSON AVENUE SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0465 May 2,2006 Dec 31,2006 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health 11iyver R1 , This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1 } CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH f a 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 W W W.SALEM.COM Kimberley Driscoll ,JOANNE SCOTT, MPH, RS, CHO Mayor HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT a% n v b, YV YV t \ TEL#1 7X 2(a =,1-U-s° ADDRESS OF ESTABLISHMENT 1 i 4t MAILING ADDRESS (if different) 7 7 OWNER'S NAMES NC 4-r-- �o y�T TEL#J/ T 3 2S&,3 ADDRESS ? o tit v AL 9-6 Y ' 4 2. CITY C O STATE V-tv-S S ZIP Ot y T CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON S'r&v�E V-Q vv', HOME TEL# '?b'( S�3' SSS j HOURS OF OPERATION: Mon. lo_IJTue.i (o Wed. o- Thu. o-ro Fri.(o�lcSat. o- o Sun. it- TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 - ...................................... ... RESTAURANT XES NO less than 25 seats =$100 259 lea 0 more than 99 seats =$200 BED/BREAKFAST ... ....--N�--------------------- ------. ........................................$ YES100 ------------------------------------------------------------------- ------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. 14 bo o Signature Date Social Security or Federal Identification Number ----------------------------------------------------------------------------- ------------- Revised 11/03/05 FOODAP2.adm Check#&Date -2'7 g& S � Q I 29'-6' I I 15'-6' I 2 0 N 6'-0• L-OF� O o n pp ' — Y-00 12'-10" ' fSllmu xn�ln To�muuMme 21eh__--- —_— -- ALL WALL wTEMAL TO BE FRP PANEL AM TO MING c Q ALL MING TO 9E ACT W 4%6 UGHTS FWRM ILL Bh4B0ARO IO BE _TUE___ " I a i GRILL/FRYER i Nil— I _ FFFI I .moo .. .111E 7-5. 17-0' 6-24' I FRONT COUNTER N UNIT 1 1590 SF RESTAURANT 24 PEOPLE SEATING p 3Y-0'I i G I III'II} I 1I,1 I FFF i ALLUMN SIT I ALUMINUM STOIEFRMT � AWIUNII9 SfOW"T I I 1 H I I 26'x2' I io If _ I I 0 S 26'10• 2'-00. ��pdq✓In F �` fq 2 CITY OF SALEM BOARD OF HEALTH Name of Establishment: Giovanni's Address: 44 Jefferson Ave Owner(s): Steve Konis Phone: 978-744-3222 Date: May 1, 2006 The proposed owners of this establishment presented a Floor Plan for review in accordance with the State Food Code. FLOOR PLAN Hand sinks are located in the middle and rear prep areas. The front counter personnel are within 12 feet of the middle sink. Hand sinks are for handwashing only. There must be wall hung soap and paper towel dispensers at each hand sink. A food prep sink is available for washing vegetables, etc. A mop sink is used. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. MENU/FOOD PREP All food must be purchased from a wholesaler licensed by the State. All food must be held at 41'F or lower, or 140°F or higher, at all times. Therefore, meatballs should be at 140 before being held hot. Salad display items, such as vegetables, must be cold prior to being held cold in the salad unit. Food may not be added to containers in salad 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. CERTIFICATION There must be a Certified Food Manager working at this establishment full time. When a CFM is not onsite there must be a Person-in-Charge (PIC) who is fully trained in sanitation techniques and has a thorough understanding of the operation. There must be a person on site at all times trained in choke saving. UNDERCOOKED FOODS -q,here mus n asterisk and a on the arding---� undercooke.foods A)o orlclevCm"d rrnd�, Ole- ala EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station and for the patrons' tables. 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 3rd bay of the 3-bay sink and spray bottles and/or wiping 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. Spray bottles and wiping pails must be clearly marked 11sanitizer". Outside area of premises, including the dumpster area, must be kept clean and sanitary. The appiicationlZ as submitted. Please call one week prior to opening to schedule an opening inspection. joann e Scott Date Health Agent Steve Konis Date Owner CITY OF SALEM, MASSACHUSETTS o ; BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT January 26, 2006 Tony Hantzopoulos Giovanni's Roast Beef& Pizza 44 Jefferson Avenue Salem, MA 01970 Dear Tony Hantzopoulos: You are currently operating your Food Establishment, Giovanni's Roast Beef& Pizza located at 10 Jefferson Avenue, without a Food Permit. This is in violation of the State Food Code, 105 CMR 590.000, section 8-301.11. In order to receive a 2006 Food Permit, you must: • Pay outstanding tax bills, if any • Pay outstanding tickets from the Board of Health • Pay for your 2006 Permit • Submit a completed 2006 Food Permit Application You are hereby ordered to obtain a 2006 Food Establishment Permit forthwith. Failure to do so by Monday, February 6, 2006, will result in a Board of Health Order to cease all food operations at your establishment immediately. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. An attorney may represent you. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Sincerely, Joanne Scot Health Agent CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH y 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 _ FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Giovanni's Roast Beef& Pizza Address of Establishment: 44 Jefferson Avenue Owner's Name: Tony Hantzopoulos Restrictions: Application Date: 1/3/2005 Permit for Food Establishment 253-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALF-Mg MASSACHU \V1 BOARD BOARD OF HEALTH gj 120 WASHINGTON STREET, 4TH FLOo DEC 3-0 2004 SALEM, MA 01970 TEL. 978-741-1800 CITY OF SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTA LII�S1HMENT NAME OF ESTABLISHMENTC�/kO-G r, -k� 2 -F/�/r?TEL UVJ # ?VY-01 AP ADDRESS OF ESTABLISHMENT Lr/7 J PIScN 'Are ' MAILING ADDRESS /(if different) �J OWNER'S NAME ' lU`✓Yy %/�il/7/TZ��cc�!�d TEL(�& 7 ( d— x ADDRESS CITY STATE CERTIFIED FOOD MANAGER'S NAME(S) c,v o, Gi 19 iS CERTIFICATE#(s)46 O(-0 t(c)� 3/ (required in an establishment where potentially hazardous /food is prepared.) �+ 1 EMERGENCY RESPONSE PERSON �WnI�U�'��/�%/ G�� HOME TEL, %�/ HOURS OF OPERATION: Mon/0-10 Tue.&ILWed/G d Thu.016 Fri. )U-iUSaV(A/d Sun./O %() TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT CES NO �53,6� less than 25 seats = 100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES 00 $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YESO $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as churchk•'tchens;- YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best kno all state tax returns and paid all stat taxes require under the law. /`2,ZS�� f o' 7 7j 1 , - Signature Date Social Security or Federal Identification Number ---------------------------- ---- i�-'1 Revised 11/03/03 FOODAP2 a d m Check#&Date -�J71,]�/J1 �o7r11P 67 q / oO ` Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 0 Floor Division ofVood and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name / n Date Type of Operation(s), Tyne of Inspection Food Service ❑ Routine Address ry� Risk l ❑ RetailPrRe-ins ection Level r El Residential Kitchen /'Previous Inspection Telephone � G_ �, !(� �//� / I El Mobile Date: I-(p -O� niS `1 f ❑ Temporary ❑ Pre-operation Owner 'I /) /)Il 1'I iU L,- 1- _71 by-) U� ` HACCP Y/N El Caterer ❑ Suspect Illness I ! Person in Charge(PIC) 90 p Time EJ Bed&Breakfast El General Complaint � In: ❑ HACCP Inspector/i l)//)y))-)X Out: Permit No. ❑Other Each violatiori checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection, ❑20.Time As a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations ✓"25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 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: S5 aoc 'Ins eCtOr)6Si tdre: Print: V ruP N TU X / PIC's Signature: i7i �72�a�l, Print: I Page of�Yages v! /�/ IN Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) y PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT K Cross-cuntam!naiian ( 590.003(A) Assignment of ResponsibiliL}" 3-302.11(2)(1) Raw Aminal Foods Separ and fiooi i90.003(B 1 Demonstration of Knowledge" Cookod and RTE Food!,': 2-103.11 Person in charge--duties ( Contamination from Raw rngredents 3-302.11(A)(2) Raw animal Foods S:rpnrated from Each EMPLOYEE HEALTH Otho' 2 it)0.003((,) Responsibility of the person in charge to I Contamination frim,the Frm,7onme,ot require reporting by.rnxl empluvees and i 13-302 1 l(.A) Food Pi utection" applicants* I 3-302-15 tVashtgc Fr6Ls anti Vegetables 590 003(F) Responsibility Of A Food Employee Or An i3-304-11 Food Contact wuh Equipment and Applicant To Repots To TFie Person In Utensils Charge* Contamination tram the consumer 540.003(G) Reporting by Person;n Chat"'" 3-306.14,k)(13) Returned Food and Reser i;c of Ford 3 590.003(D) Exclusions end Rostiwtions", D+sposition of Adulteraied o+ Contaminated 590.003tE) Removal of Exclusio,as and Restriction, Food 3-701.11 Distardmg or R corrurioning Unsafe FOOD FROM APPROVED SOURCE "Food: 41 Food rna Water From Regufaied Sources r 9 Food Contact Surfaces 590,004(A-13) C'rmpliame with hood Law* 4-501.111 Mantra Warewasbine-Hot Water 13-2U1. 12 Food in a hermetically Sealed Container" ( Sano zaWm"1'empeuatures* 3-20;.13 Fluid Milk and Milk Products' I 4-501 1 12 h4rchanic:l Warew'ashina Hut Water 1 3-202.13 Shcii Eegs'^ Sanitization Tomparalure?"I 4-501.114 Chemical Sanitization-temp Fi, 13-203.14 likgs and R1ilk Product::. Pstewizcd"` I concentration and hardnesct, I ) 3 202 16 Ice aMide From Potable Dnnk o,Water" 5-101.11 thinking Water from an Approved Sworns ( � -t-6U1 111.4) Equipment Foul Contact Surfaces and tltenciis Clean' 590.006 A) Bottled Drink;og Water! I 4-602 11 Cl.anin b=Free uency of Ei a *+rtcnt Fond- S90,006(H) Water Sleets Standards in 31(1 CAIR 22 0" l She!Nish and Fish From an L)Ce Approved ro ( Contact Surfaces and litensils' Fah and Recrc.atianall} Caught Molluscani 4-'702.1 i Frequene}of Sanitization of Utensils and iI F<xs9 Contact Snrt:u:cs M"fquit.mert* Shellfish': 4-703,11 Methods of Samtraliun --hlol water,+nd 3-201.15 Molluscan Shcllfsh&oro NSSt'L1 +sted iCheml..d'' Sources' I I to I Proper,Adequate Handwashing Game and Wild Mushrooms Approved ay 2-301 11 C1e:m Condiunn-- Hands and Arne," 1 + Reguistoty Author,'ty 3 202 15 Shellstovl< Idzntifi ation Present" 12-301.12 Cleamn_Pvoxdurr-' 1590-004(0) Wild Mu.hnwms' ?30:.1d iyltca to Wash` i 3-201.17 Game Amntasx` I '=1 Good Hygienic Prs�icea ,5 Receiving/Condition 2-x401.11 Ealing Drinking ir. Using Tub,xorj 3=_'0211 PRFs Rccc:red at Proper Temperatures* ( 2-4U .a 2 Discharge; Front the Eyc.s.Nose and 3-20_'.15 Package hlteta-ity* i4h:oth' 3-(0;.1( Food Safe and Unadulterated ,. 13-301 12 Prev miw_,,C mamma:ion When Tasting,. 1 TagstRecords:Shellstock ( li. Prevention of Contamination from Hands i 3-202.1,xI Shellstockld nUfication` I 590.001(E) PreventingConratmnatim?ton] 3-203.12 Shellstock lcientificatinn Nt.turiained" ( F,mptHandu'rash uash TagstRecords: Fish Products ( 13 Facilities j 3-402.1 I Par'ssite Decuuction' Conven;entty;coined and AccesslWo 3-402.12 Recor&,Creation and Retent+nn* I I 203.11 Numbers and Capaciues 590 004(); Labeling of Ingredients' I 15-204.11 Location and Plsccmo::tx' p i Conformance with Approved Procedures I ( 5-205 11 P,a'rsibility,f)pemoon and ',Maintenance /HACCP Plans I Supplied web Snap and Hand Dryi�g 3-502.1 i Specialized ftrxesc'ing b4edawls;' ;avice-s ( h-301.11 Handwashins Ciennsen Availability 3-502.12 Reduced oxyeen paekag,ng,cruel m' ' 0-!03.12 G.:nlbrnanee',vith Approved Procedure,,' 6-301.13 hand Drv;ng rror.su:n ''iknoie,enucal imp a)Tire fi o,a! I ti99?+u+d"ode or 105 CNIR 50++.000 CITY OF SALEM /' BOARD OF HEALTH Establishment Name: ( ll h V/1 Vl 1/1( C K/? )"J --;af ( 10il-,;17/ - Date: Page: of Item Code C-Critical ItemDESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 1 No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I a-i v-)e, 0+7/11 /� n/ -F7-.-( I �D /7')nn ,��Ya✓�!/ / moi,rar �^l''� /sj /�) i✓�Pl? n _ Crn /iiih c I � _ )p-7ylnGQ/rrry /J��//rn�//ii ia, /sf /�7� 'ter/ ��al�14 I l>oI�TPT� )fYaOr"�oar/•�/ t!- �///S?�>�d7�dP?/ / /Y QPd n/�7 4) /-'t'n �/ L/ cy/�*_n/3OI' I ✓✓>n�C'lhl0. i_ rvm/n/� S/ c�C/�J �_.//no,v -�v ..�1'._ m�l�� l��Jl-><X I -11 l//fry/o�J/IviS �i fa/111�� ham . I i/ { I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yee 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. _ jr— G�_ ❑ Voluntary Disposal ❑ Other: j ti: _50! !?;C) PHFs Rzcetved at Temperatures Violations Related to Foodborna Illness interventions and Pis& Awnrdine t„Law Cnoled to Factors(items 7-22) (Cont.) 411'r45`F ttirthin 4 Hours. r PRorEcrloN FROM CHEMICALS I 3-,50l 15 Coolow Methods for i'HbS j 114 Food or Co!cr Additives 19 PHF Hot and Cold Holding 3-50 i.16'B I Cold P1-IFv Ylamtanted at or beiow 3-202.12 Addinw,.t 590 Welt F) 41'451 F" 3-302.14 Prot�dtun troth Unaertru ed ride:,tr:-s• -I I 3-i01.f h(,A) [lot PHFs Maintained at or above IS Poisonous or Tame&ibsta:,ces 140'F " 7-101.11 identifying htfbr;,;;non-Original ( 3-501 16(:1; kua:a, Held at or above 1:0'P. Cu:uainera* , - I7-102.i I Common Name-Working l 21) Time as a Public Health Control C:•:ttainets' ! 3 5!)1 19 Timm ah a Public Health Conuolf 7-201.11 Sepaiatiun -Ctoraec^. 7-20111 1L.sffrosen ictiou- Pce•---id590.004(11) V,:fiance Requirement :d Pse" ' 7-202.12 Condrhnns of U,e" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203 11 lw.ic Container: -i fohibftinns4 I POPULATIONS(HSP) 7-204.11 Nanrtize'r,,Criteria- Cherlirals' I 7-204.12 I Chemical,for Washm?Pro;!ttce,Criteria" I 21 1-301.11(A) ilnpaaeurrzed Pre-pack-wed Juice;and j 7-204.14 Drting A.ge::fs.Criteria' I 6ecentges with W,uning l.abe!s4. ,S , j 13-801 A I(B) Use of Pasteurized Egon^ 7-205.11 C_.1 t ncidental Food Contaet.Lubncams° ( 3-801.1 I(P) Raw or Partially Cooked Annual Food and 7-20o.I I Rc.:ti Lied Uv, Pestiailes.Critena^ Raw Seed Sprouts Not Served. " 7-206.12 Rodent Batt Stations' 13-8i1 L t 1(C) Unopened Food Package Ivor Re-served. ' I 7-206.i 3 Tr,ekurg Powder ll,Pest t onirn!. and -- - -. Munitcrito, j CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603,! 1 Consumer Advisory Potted for Consumption of Animal Foods shat are Raw,Under-Looked or lfi i Prooer Cooking Temperatures for ( PHFs Not Otlm mse Promi Processed to Eliminate 3-401.11A(Ij(2) Fggs- ?Si�FI)Set. j Pathooena.* `rnn..2 ;i.ru,n Eggr:-humaliate Sety-ice 14,i`Pl5"a j 3 301.13 Pasteurized Eggs Substitute for Raw Shell 3-40i.11(A)(2) Cntmmnmted Fish, Mcuis/!!tame I Egos.` Anitnals- ;5J'F 15 sc c. " j 3-401.11(6)(1)(2) fe)}k and 3ecf Roast- 130"F 121 raiii* SPECfAL REQUIREMENTS 3-401 I I(A)(_) Rnotes. injected Lfmnh --155-F 15 590 009(A)-(D) Violations of Section 590.009(Al-(D)in sec.- catering, mobile food, temporary and. 3-401.17(Ai!3) Pnultry,b4"ilei.:ame,Stutfcd PHFs, re5id rtial kitchen operations should he Stuffing C--,wl:mnmg Fish,Aleat, debited under the appropriate sectwns Rotdtry or Ratites-165'F LU src. " ( above if related to loodborne illness 3-401.1 i(C)(3) )Whole-mn,cle, Intact Beef S'Ieaks interventions and risk factors. Other 145°F' 590.009 violations telatmg to gond retail 3 101 12 Rau .Animal Fol uls Cooked in ! practices should he debited under 6'29- R3,cny,vave 16J"F* Special Requirements. 3401.11(A)(I)(1h) All other PHF.,-- 145°FIS sec. * j 117 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.111A)cxJ)) PHF" 165'F I5 sec. r (Items 23-30) 3-403.11(6) hticrfrw_wve- 105' F 2 Mumte Standing I t:ritiarl and non-rrih,al vmlotron,,, which do not ielare ro the _ 'i into"' foodborne iGnrsi inter ventrms Lind;isl,factors leafed obove, can he 3-403.i 1(C) Commzr_ially Ptccessed RPE Food- I found rr the fidlou-iagg.set eons of the Food Code and 105 C;Lik !4u'F j 590.000. 3-403.11(E) Rentatning Unsliced Parioas of Reef ItemGood Retail Practices FC ( 595.060----i Poll its IF 23. I Manat enient and Personnel FC-2 .003 _ 24. Food and Food Protection FC - 3 1 004 j j 18 I Proper Cooling of PHFs j 25 Equalment and Utensils FC-4 605 j 3-501.14(A) Conhng Cooked PHFs from 140'-F to 26 Water,Plumbino.and Waste FC-5 00_5 - --- 70'l,Within 2 Hours and Prom 70°f' 127, Physical Facility FC,--R 007--_---� I to 41'F14S'F Within»Homs. ' 23. Poisonous or Toxic Materials FC 7 03 3-501.14(13) Cnolin;_=P1Ifli,Made FrranAtubi ent j 29. SocialPeotnrements 1003 j Temperanuefogredient,to41"F/45`F 1 30. Other j Pei ii ! " qq n.1lot:.,' i L)erwlvs critical item m the t:deral PAP lu d C""L or 105 CMR V90 o00. Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4" Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name ) / (Dit� J Type of Ooeration(1 Type of Inspection ^,ni 1_1f 1 in , .Cn r l C'L Food Service IV Routine Addresls V y(� r l �l l . Risk ❑ Retail Re-inspection - P �� Level ❑ Residential Kitchen Previous Inspection Telephone (' ❑ Mobile Date: Owner / ❑ Temporary ElPre-operation 1;JtJ47Z PYv i/OS HACCP Y/N I El Caterer E] Suspect Illness Person iri C64ige(PIC)' Y Time - ❑ Bed& Breakfast ❑ General Complaint I El HACCP Inspector/ - o Permit No. ElO herr L�,r,nna I out: Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities•. EMPLOYEE HEALTH E] 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE ❑ 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) a ❑ 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 R3-'19. Hot and Cold Holding EJ/8. Separation/Segregation/Protection ❑20.Time As a Public Health Control Ld` 9. Food Contact Surfaces Cleaning and Sanitizing (j) REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate'Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good'Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventionsn/ immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): / G 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 ofC 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 4. Food and Food Protection (FC-3)(590 004) 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 (a 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590 007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590 009) within 10 days of receipt of this order. 0. Other DATE OF RE-INSPECTION: S 5901nsPxfFo,m6-14 tlac 1 - 1/3 aft r Print: 1 1P1\ WIsTSignature: �--�� I Print, / � - -� I Page I of Pages l Violations Related to Foodborne Illness r Interventions and Risk Factors(items 1-22) _ PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-conkrmihanrn 1 ( 590003(A) I Asvgntnent of Resp„nsibility* ! 3-+02.1 I(A?t l) Raw Animal Poodn Separnad from 00.003(17) 1 Demoashation of Kriowledge' ( Cooked and IZTE Binds' I 2-103.11 Persvn in charge- uuties ( Cootarnln9ton from Ran,lm7rodients 3-302.11(Al(2) Raw Animal Fotxi,Separated from Each EMPLOYEE HEALTH O,h,w` ' 2 390.003(C) Responsibility of the person in ch•u^_r.to Covtaminat,on from the Environment require otporting by food enmloyees and 3-302.11 iA) Faorl Protection" applicant;' 3-3()2.15 VNasht.te Fruits and Vegetables 590 003(F) Responsibility Of A Foix!Employee Or Art ( 3-304.11 Food Contact with Equipment and Applicant To Repo- i! To the Person. j Jtensi Ls* Chatne,,, Co::tannnahon from the Consumer 590.003(G) Reporting by Pcroon in Chargc" i 3-;06.14(Ak B) Returned Food and Rcscivice of Food" 3 590003(t)) Exclusions and Rest;tiaions;: Disposftion of Aaulterated o.-Contam!nated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding in RCLOnditi6mntt 1,45Efe FOOD F IOM APPROVED SOURCE Food," 1 4 i Food and Water From Regulated Sources ; 9 Food Contact Surfaces 590.004(A-B) Connolmoce with Ft,od Law'r 4-SOL I l l Manua? Warewashing-Hof Water 3-201 12 Fond in a Hermetically Sealed Container" Snniri'r.ation Tcmpecrhr[es* 3-'01 13 Fluid Milk and Milk Products* 4-50i 112 A echaniwl WarcwaAiina Ilot Water 3-2()2.13 Shed E2gc* Satntization Iemperewres' }202.14 Effgs and Mill. Products.Pasteurized" � 14501 114 Chemical Sanitization-romp.. pH, .:oncrntration and haidnea.c. ' 1 5-1"A.16 4c Made From Prizm a AppoL• SNste° 4-601.t 1(A) ECluipmem Rood C:entact Surfaoa and 5-101.I t Drinking D iter trim an Appr:nrd System* I CI 590.006(A) Bottled Drinking -1-502.11 Cleaning nin eaaning Clean"Frequency of r.yuipmer.: Food- 540.006(B) Watei Meets Standards in 310 CMR 22 0- Conta_r Surfaces and I}icnsilt"' ShelNish and Fish From an Approved Source I 7 4- 02.11( Frcquenvy nl Sanaieallvn of thensils and 3 201.14 Fish and Recreationally Caught Molluscan I Food Contact Suri;tcrs of i3quipmen+." SheII fishx ?-70.3 11 Methods ,f Sanuizat,un-- ;Sot Wat,r and ! 3-20 1.15 Molluscan Shellfish from NSSP Listed i ChemictdT Snurces's 10 Proper,Adequate Handwashing Game and Wild Mvshroomc Approved by I ?-301.11 C'lron Co,^.ui tion--H.mds'Aad Arms' Regulatory Authority 3202.18 She!isto.k Identification Present°` 2 30 1.12 Cleaning Procedure" 590.004(C) Wild Mu;hnwms" >-'3D 1.14 R'brn to Wast* 3-201.17 Game Annuals" ( I l I Good Hygienic Practices 5 deceiving/Condition :'.-a0i.IIEati::g, DrinkingofUsingTobacco- � 1-702.11 Pl-1F�Rccerveu at , 2--01.12 Discharges From the Eye:s,muse and}mper'Pemperauues°° � 3-202.15 Packaee Intem tv I Mouth" .1^_ Preventm,Contamnraion When Tastin 3-101.11 Food Sale and Dnadulrerated 3-301 ` � g%'. 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands z-20'<,18 Shetlswck ldeN dicatinn° 590.0044 E) Presenting Cuntannnation from 3-2413.12 Shellstock Identification Maintamtd' Empioveev" Tags/Records:Fish Products 13 ' Handwash Facilities 3-402.1 I Parasite Destruction* ! i Convexently Located and f,ccossible f 3402.12 Records.Creation and Retention" ( 5.203,t I Numbers and C:apacnin" 59(00411, Labeling of Ingredients' ( ( 5-204.11 Location and Placernent' ( J 05,11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures ! IHACCP Plans I Supplied with Soap and Pand Drwr,g ' 3-x02,1 t Specialized Proces:,im,Methodsi- Oevc'es ' '.('2.12 Reduced oxygen packaging,criteria' ^-301.1 I Handwasnng Cle,mser.Availahifity j 6-301 11 Land Diving Provisi R"103.12 Conformance with.Aopioved Procederes" on Den:ae:sn,�.a nen,o the I':dcra! 1999 1°rx:d ndz or 105 CNIIR i^0.4100 R CITY OF SALEM D O /� BO RF HEALTH Establishment Name:61,9 an � S ,W as4 �� `f �� Z� Date: Page: � of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified .s PLEASE PRINT CLEARLY I I I �nnf �rv,n`alPe� ( 1 Kt-), res' hP//rr .c rrd -fir,--G7/ hares. ,(fn , Yo G)C S�rPcC I I (n ortuL e -blI-le_ rj re '1R /'on15_-7i/7p.e �Arrf7rr)ing hlvach Add i its' it z I ✓ 9 G Pl) ' ha17kz/r� 47P4 N761 reol&t�V . t l 4'-A7) HPh1-ic . J I � � (?T ( uhti ha��m_P. 0n�ars-ar-er( { �cl. / q G 4arn n f/nr-f- u>Mn/a haar;,l < tblW l a Sn�rPd psvr�zr�� nr `-�/ola'V . J - �Y9 e. - -Wpa-fhaffL hard -�elyW o4 //2 °F ��a /ls ute�e rP -7,�jf®r ). he hid Q,/ a -1-em p / 4-10o dl,., /,?A, 11 K " e1 -hl'9c hl9d wake Owl?e,P `lt.eW blgn7hIAJ Discussion With Person in Charge: Corrective Action Required: I ❑ No J I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. _ .- r J �- ❑ Voluntary Disposal ❑ Other: I t I PHFs Recrived at Temperatures -. Violations Related to Foodborne illness Interventions and Rts.A Acc cidir. to Iaw Crxllcd 10 Factors(items 1.22) (Cont) ! =1!"F145"-i=A-(thin d Hours. PROTECTION FROM, CHEMIM I 3 M.15 ( ck ohne Methuus for i'til-s 14 Fcoo or Color Additives 19 ' PBF Hot and Cold Holding 3-202.12 Additives r 1 3-SOL IG(6) Cold PH7's Maintained in or below 13-302 Id Protection (rc+n, UnaPProvcd Addihve„„ H14(F) -I'/45'F" 3-`01,16(A) Hot PHFs Maintained ut or chow � 15 � Poisonous or Toxic Substances j i 'F 7-101.11 ldentityvrclnfor-lauon-OngI40 inal 3-50i,!((A) kvd!ts datorabon'c )30'F. Containers'" 7-102.11 Comttaun Narnc--1�nil ink Cott!a:neWs 20 ; lime as a Public Health Control 7-201,11 Sopa:a!ion-Ctor.:ac'° 3-501.19 1 T m. ,a::a Pubtic health Con'rolx „ - 590.004(Pi ( V:Ir*i,-r:ccRequirentent 72Restriction-Presence acrd Lse* - - 7-201 t 2 Cunditions of Use' 7-20111 Toxic Container,-Prohibitions" � REOU1REh--LENTS FOR HIGHLY SUSCEPTIBLE : 7-204.11 Sar.trizer's,Criteria - POPULATIONS(HSP) z 21 '3-EoL! !(A) I L'neof,euri&dF7e-padkaged,hticcsand 7-203.12 Cheraticals for hashing Prum,ce.C.titcria' ' Bove;.,yes w:dl N':uninz S.rbels^. 7-205.1-1 Dryden talents.Criteria" 3-80;.1 f(P) Us-of k'estcurized Ecus' 7-205.11 incidental Food Contact. Lubne!mts- 7-206 I1 Restricted Use Pestiudec. Cnrerwa ?-8Dl.1 li l?t Raw or Panialh Couk.d ArninA Frsd and - i 7-2RAW Seed fiprauts Noi Sened• 'F (16.12 Roden: Bait Stations' ! 3-501.1 I(C) I In•;penEd Rood Packa;9t Not Re sanrd. " 7-M6 13 1'racking Pi-Adcrs.Yes;Control and Monitorito, CONSUMER ADVISORY TIMErrEMPERATURE CONTROLS 22 3-603.1 1 Consurtrer Advisory Posted lire Con.+uniption of Animal Foods 1'hat arc kaw. Undercooked(it- PHFs r PHFs 16 Proper Caaaing Temperatures for AnimalNnt Otherwi se Pr.:cessed to Eliminate _3-lol.1MIT,(2) Figos- 155-r15Set. Pathog:its.* Egos-hnnrediate Service 1457l5secr 3-302.13 Pasieurozed FS>> Substitute for Raw Shell + EY s t,b' 3-401.t 1(A)(2) Comminuted Fish,A4cae: F Ganic fi ` AniTtijk- 155'F 15 sec. 3-401.11(13)(I)(2) Pork and Beet Roast- 13(1`F 121 min' SPECIAL REGiU?REMENTS 590.n04tr11-(I)) - 3-401.1 t(A)(2) Rattus, Injected Meals-155'17 15 Violations of lection 5'70.0091 A) (D)in sec * catering mobile,food, temporar✓and 3-401.1 I(A)(3) Prvltry.Wild Game, Stuffed PHFs, reeldentaal kitchen uperatioas should he Sturaug Cont%;nling Fish, s4eat, debited under the appropriate sections Poultr:or Ratites-165'17 15 see A, above if related to foodhnrne illness 3401.11'(0(3) \','hole-nurccle. Intact Leet Steaks interventions and rids factors. Other 1a5P 590.009 violaf:ons relating to good retail 3-401.12 Raw Aniolal Foods Cooled in a ,n actiee[.should be debited under#29- Mic,ona:•e 165'F* Special RequircruclIM 3401AI(A)(1)(b) Ml OtherPIIFs- 145 F 15 sec. 17 Reheating for Hot Hording VIOLATIONS R. LATED TO GOOD RETAIL PRACTICES 3-4011 I(A)&(D) PHFs 165'F 15 sec * (Items;23-301 3-403 I I(B) Micrlwace- 105' F 2 Minute Sta,udin, ! Criurai and non-c ri6cai orotatiuns, ithich do not reinre to the Tome" focelhurae illness inter ventioea and risk Jw iors lined above, ,an be 3-1:03.111 C) Commerc,aliy'r`rocessed RTF Food- i awed in the j)flowin- sections of the Food Code and/fLS Ct/N 140rW 5 e0.onr. 3403.1 I(E) Rcnrainitry Unsl:ced Portions of Bref I Item Good Retai(Praetices FC 580.000 R,,asts" 23 Nlananoment and Personne! FC-2 003 18 Proper Cooling of PHFs 1 24. Foo,'and Fwd P rxoct!on FC-3 004 ! o, 25. Fgmpmect and Utensils FC--4 .005 _ ;-50 1.I4(A) Coolnn�Cooked PHFs from 140"F to 26 NateF,P!umbinq and Waste FC -3 , .00S � 70'F Within 2 Homo: and From 70-1 27 Physical FacritY FC-6 I OC; f to 41`17/457 Within 4 Hours. Poisonous w Toxic FP:aterirls FC- 7 .008 3-501.14(6) Cooling;PHi's Made Fn.ni.Ambient ( 29 Saec!al Roottiremems Oou I 'remperatute Ingredients to 41"F/45rF 30 Other Within 4lluur.' •or,",.-,o.:a., Dr:nm.v cnhca,km:u:hr Irdernl 1'199 rood;'ado o,105 CMR 5'io rlti0. i C. ; CITY OF SALEM 1 /BOARp. OF HEALTH Establishment Name: ( //>�/2f�12! S )l��/ Of /,L/ Date: (�lL " Page: v of Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION !Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY soo%n�CL -O/x)/?Pe o--,Acv' Lol-vio rpnsh7x-rha,,� 1 Is�.do, U) IQ1041. I I P,/Jiz/e-P L I l 1�6me /v,7rAL)e P� z��l >4fl {a'�1 �n sta ge be Cl ZX_ an 111( 0)M/)l(2 curd m� �a' i orn�q�/U Ch i GalreiP. (k ? p d 7 huc Le4 -iv.coVre" lea d be �W'r�YD h OOA' un 4 �r.i.rz 4nl . -7 ori �Aa L( nAa 7b&C/2 a 7�__6, rel&6pl sd Afe ✓res - �ni�e f �z�k had �� rr/nfiar, o-< „d cLbv/s- �h�/vDAhlz� X"C? G Srn . a)mi hrds eI)Spd 1',e /�rt�l�,m <f1 arm a7s S' i�ed�S R 01 _� j - 4-i1i�6A AOar4. a/ _cihK W dS qe"ledl CUq_1Z(19q . Lomas G l'rrrn frt�R had �rruw,l)/a.7ii /) t' �vd drzbHs' %ha�u�hl - -mi rn wave, floods opheorl (lea.",12 I 4 I t A; .; Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or sus ension/revocation of E) Embargo El Emergency closure your food permit. t �--� ❑ Voluntary Disposal ❑ Other: 4 F � a 3-50l.:VC) PHF, Recereed at I�emperatures Violations Related to Foodborne Olness interventions add RiO Aceordinv%tU Iaw Cooled to Factors(items 1.22) (Cont.) 41`F/45'-Within d Hours. ' PROTECTION FROM CHEMICALS 15 Co-•+i:nr AI t1�ids for PHFs 114 Food or Color Additives 19 PHF Hot and Cold Holding Additioe: ( 3-501.itr(H) (-old PHF,N1nmtain,d at(it helou 11-202.12 590.00^:F; 4-:.145°F* 3-302.I11 Prowctionfront l;aapprm-ed Additives" ( I ,;_50;.16(A) H.itPHFs Maintiateda:orabove IS Poisonous or Toxic Substances 7-101.11 Idenutvwe lr form-!i n::-Ot iginal ; + '+Ol.l niA+ Containers" - Roasts Held at or ab,Ac 130'T. 0 Time as a Public Health Control 7-10.2._1 : Qnnnam Name-working Container<'% 2 I ? =1',1 19 Tiu;e as at Public HealthConh'ui* � 7-201.i t Ser.aration--Storzwa: I - 7-202,1 t Restriction-Presence and13'}0.00d(H) Vinane,Rcgnirement 7-202.1? CordroomaufU;e" 7-'_'03.1I Toxic Containcis.-Proio,ninonS4 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 I Sanitizzn,Criteria -Chemical.r POPULATIONS(HSP) 3-Yo 1.1 l(4 Lup;+;tettrtze,i Prv-packaged fit ces and j 7-'.04.12 ( Chemicals for Wnshme Produce,Criteria* I � 7-201.14 I Dry:np.lgenis,Criteria' I Peveutees with Warnme labels" 3-80!.!1(B) Use of Pmtemized h,tlsT 1 7-205.11 I Incidental Food Contact.Lubricants* 3-30 i.1 (D} Raw or Partially Co,ked Atmuai F'cxd and 'l-206,11 I Renincird Use Foeticides.Criteria's Raw Jced Sprouts!No"Ser++zd. ` '.-206.12. i Rodent Bait S-,6,,ns" I ;-901.1 l,'C') Unopened Food Packaae Not Re-sen'ed " 7-206.13 Tracking Powders, Pest Comrol and - - Monixrir.' CONSUMER ADVISORY TIME(TEMPERQTURE CONTROLS 22 3-503.11 Consumer.Advisory Posted for C'omuniption of .tfi Proper Cooking Temperatures for Animal Fonds That are Rau-.Underco,lked oi PHFs Not C+tNcrlr;sr Proccse+i to Eliminate PathV;'ena '' 3-4u1.11A(Ix21 F~Y`- 1553TI5see. E- gt -Immediate Service 145`F15sec' 3-302.13 Psteuir ed Egg,Substitute for Raw Shell 3-401.1 i(A)(2- Cotnnunnted Fish,Meats &Game F,izzs* Animals- I5YF I-, aec. ` 3-101.11(B)-,1)(2) Pork and Beef Reasi - 130"F 121 min* I SPECIAL REQUIREMENTS 3-401.11(A)(2) Routes,Injected Meats-- 155`F 15 590.00e)(A -t D) Violations of Section 590.009(A141)) in sec. .. catering, mobile fe:,d,tear,not ary and 3401.11(A) 3) Poultiv,Wild Game SrufteJ PHES, rc aden!ial kitchen eperntions should be StufllneCaniaining Fish, Meal, debited a:der the appro if sections Poultry or Ratitcs-165'17 15 sec. I above if related to foodborne illness 3-401.11(0)(3) Whole-muscle. inract BeetSteaks interve+ntior"s and risk far!ors. tither 145°F.: 590.009 violations relaLinv to rood retail 3-401.1? Rate Animal Fo;,ds Cooked in a 'oiacllces should be debited under #29- Nficrtmave 165017* Special Requirements. 3401A I(A)(Oah) All Other PHF;- 145rF 115 see. 17 Reheating for Hot Holding ( VIOLATIONS RvLATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(P,) PHFs 165-F 15 se:. * I (Itetv`,23-30) 3-403 111 B) N51u'owave- 165' P 2 Ninlra(r Standine Crittral and non-rrhwat viula7unr iehwh do not relate to flip Tiuner` I foodborne illness i:;u"rvenriorxs and risk:?,ours iisled above, ran be 3-403.11(0) Cuinmcrciaily Pra:e<szd RTL Fend - i four:u'tr; d; /L1G,�,ing seainns q1 Uro Fend('ode and 105ChfK i4(`F"' 590.0w. 3-403.1 ltfi) Remaining Unsiiced Portions of Heel' Item Good Retail Practices FC 1590.000__ Porion" i 23. ldanagerant and Personnel FC -2 .003 Ig Proper Cooling of PHFs 24 Foal and Food Protection FC-3 11004 25. Equipment and Utensils FC-4 005 3.5;+1.141.1) Cooling Cooked PHFs front I JO F to 126, Water, aq,mbhc and`,ti'aete FL'--5 I 006 70'P Within 2 Hours c nel Grum 701'F 27. PhVsi-al Facildy FC--6 007 --to 41'FAYF Within 4 Homs. "" 2_fl Poisorimn or Taxic Mate^naI? -7 .003 i 3:501.14(B) Cnolimg PI 117a Mad,- Flour Ambient 29 Special Reguirerrelft i o09 _-- -' Tenq,ewfureIngredients1: to4l`F/45` t.30. Gtf:er i - ---- � Denote:cru+cal nem in the 6•deral 1909 BmJ Code r3 1'!5 CRIR 090 600. CITY OF SALEM BOARD OF HEALTH _ _ + / A_ Date: (0 U Page: ofEstablishment Name If Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY y' ' 'c� Del Re-t?ICA -moo �i2''h(-)H 4-Pnr io v,t�/hs'rf �,SSn�by �E i llfl� O� 0O /-I Y 1Dzt in -nirpn(iols ti I7 ` ✓ti S— - 4arnQ_ ,-,t+ Inr/C1 00-fAt)m1 )inf- ►on /-I f�vc±- Ao_b0s -I- 'C\r(PA ' I ✓P� G - S'Qrti'lst, � �r,.l -f h� �a w ('h Il'.l�on ��fr��Pt�l /�t P.�� Dt�a �Ctct • - ,` I 12aW--r��.�-I-s 1-a �e S`tnmcE Srixtr�r6-1.�� f�vrv� Qty 1^Prrc-l�� -�v �a-� >,cls A-b 9rerrer\+ rrns- oonf-ato1n -han X iRe,-,4 12eUm3 1 �ovYteln s - !�o V►r�ka�ons Fib �rnotns - w��ssir,q i�rstle � �Pr2 hnPc 2 - V-P' lase Ir niz i(d h.e `A)d p)ychose 2 &,-)6215 fvoe Lack- z�reDQ�a Gvi�/`�qr/vim_. € -- k (fif1L. J2,Pa LVMdct/S la Lea/ t`dearer7YlV_�,_ aYtlti'' 77u oAUX- {oYmoi/ Q r P � ✓�1r�v1elt�X.?C�nlvi0'I ''• FX1Pym l nalvt n (A i - Ava Jab(a _i-r)<jX('_taV . eqO I W, (-14,w Qua) F fD I I 'I�t�l~(��"Cj�=-a-fl(�=� `�7tve�' -•�'- - -�",�e �-t-° Itae. maLln-trAln.2cl v.cu�i,<,l� J :WT, 1-tt)Y) 1 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree-to correct all ❑ voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of t en -five dollars r-saspen�ocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: r i , S%I.;4P::; ?HFI i:ece;ced ar"1'enip�,atmos ' �, I Violations Related to Foodborne L'fness;rrterventimrs and RlakAccording to Law Cooled to Factors(Items 1-22) (Cont.) 41 Fi45'F Wtddi 4 FO,ns. I ';SOI.(` Cooling Medsodl for PROTECTION FROM CHEMICALS I i4 Food or Color Add4vni:; 119 PHF Hot and Cold Holding b)(B} Cold PFIF's Maintained at or below 3-203.12 Additkes* 590.004(F) 3-302.14 Protection front Unapornted Addin Fes^ ,. I j 3-501.16(4) 1-1ot PHF. Nlaattauted at or above 115 Poisonous or ,oxic Substances I 40 F 7-101.1 I Identifying intormanon --CA-;g:nal ( 3-501.16rA) Roasts Field at or nb:we 130"P. " Containers'" 7-102.1120 Name -Working Containers' 20 Time as a Public Health Control I -i(il 19 fume at a Public Health Connoi 7-30!.11 S.. --Storage° I ( 7-202 11 Rertiction-Presence and 1 ke'^ . 590.004(14) Variance Requirement 1 7-20;'.12 I Conditions ni Use' 7-203.11 I Toxic Container,--Ptnbihiti:ms' j REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2()4.11 I Sanit;zers,Criteria --Chemi,ats` POPULATIONS(HSP) 7-304.12 I Chemicals for%VashincProduce,Crit,riz"' 71 8-501 Il(A) UnpastemazedPre-pac'.kageaJuice;and B,veun�es with`v\'ranine I:i`vels* 7-201.14 Diving Agents.Criteria: I ! 3-80111(9) U:e(,IPatteuri2edE_ps^ 7-205.11 incidental FtHxi Comact.Lnbucaoiti'. 7-'_06.11 Restricted Ilse Pesticides.Cnitena"" 13-bli'..i i(D} Raw or Partially Cc of S v ed.it Food and Rate Sced Surou!s tint Ser,rd. _ 7-206.12 Rodent Bahi dors.Prst Conn,of and s" 7-206.13 Tracking Powders, 13-90 11(0) Unopencrl Food Package Not Re-served t%lnnitotinp` CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603 11 Consumer Advisory Pu;aed for Coo,uniption of Animal Foods Tiait are Rate. undercooked or 16 1 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs I 3-401.11A(1)(2) ( Egg,- 195`F I5 Sec. patho�Tat,.M 'S F 3-302.13 Pasteurized Fggs 6ubstinite for Raw Shell Eggs-Innnedia.c.,,nir•e 1,..`P i Ssec 3-401.11(A)(2) Comntinubad Fish, Mews'i"Game i Eg.v,` Auiutak- 155'F 15 sec. ` 3-40LI 1(-4)k 1)(2) Pork and Bect'Reast - 130 F 121 nent I SPECIAL REOUIREMENTS 590.009(.',)-(D) Violations of Section 590 009(A ID 3-401.1(IAN.-) Ratner. Tnicctedbica;�- 155'F IS )- ) to sec. ' catering. mobile foal,temporary and 3-401.11(,%)(3) Poultry,Wild Gamc, muffed PHFs, residential kitchen operations shtn;ld be Stuffing Containing Fish.Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. . above if related to foodborne illness 3-:ol.1[(call I b%'t;ole muse`:,,Litact Becf Steaks interventions and risk factors. Other i 045`F" 590.OG9 violations relaitag to good retail 3-401.i'2 Ravi Animal Foods Cooked in a practices should be debited under fl29- Nlm owace 165`1'+ Special Requirements. 17 I 3-401.1 i(A)(l nb) Ail Other PHF.:- 14i`F 1` sec * I Reheating for Hot Holding VIOLATIONS Rt.LATED TO GOOD RETAIL PRACTICES j 3-403.11(%)&(D) PHFs 165°F IS sec. ' I l items 23-30) 3-403.11(B) Mictowaee- 165'F 2,N1 amte Standing Ctiticai and non-crit%cul vmiao,ms, thigh tin riot re!are to the Time" foodhornc i!btec, interv,;nimna mrd risk Ja(tor't listed above, (an he 3-403.11(C) Comtncrtially Processed RTF btx,d- I fmind,rn;heiolloivot,q see.-!inns of the Food Code and 163 C:LIR 140'F- .`9QI,00 3-403,11(F i Rentm:nng Unsliced i'urtions of P,ecF I I item Good Retail Practices FC s907 rx)o I Roasts 23. Management and Porsannel FC-2 .003 18 Proper Cooling of PHFs I 24, Foos and: coli Protscfion FC - 3 004 25Egwpmeni and Utensils FC-4 005 3-501.14(Ai Cooling Cooked PHFs From 140°F to j 26--- -Water, Plumhinq ant",Alaete PC-.5 005 70°F W 't ithin 2 Hours and From N , 27 PhVsica[Facility FC-6 OOi to 41"Fr45"F Within 4 Hours. "' 28 Poisonous or Toxic Miiterial3 FC-7 .003 _J 3-501 11:13} Coulinr PHFs Pelade Front Ambient 1 29 Sooaal Requirements i 009 Trmprialllrc Ingredients to 41'F/45--F i 30, Other Within 4 Hourx* 'Uunu:es crai'M item a,!rye 6.4aal 19,tu Food Cade a 10'.t;n1R.a9n 000 l Y 0044 JEFFERSON AVENUE Giovanni's Roast Beef & Pizza City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 744-9111 Non-compliance with: Not Done Owner: . - Anti-Choking PASS ❑ Tony Hantzopoulos Tobacco PASS ❑ PIC: Tony Hantzopolous FOOD PROTECTION MANAGEMENT Not Done Inspector: - - PIC Assigned/Knowledgeable/Duties PASS ❑d RED Janet Dionne EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑� RED 9/1/2005 A(�_I�vl Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level: • FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASS RED BHP-2005-0379 Receiving/Condition PASS ❑ RED Status: Tags/Records/Accuracy of Ingredient Statements PASSd❑ RED Open Conformance with Approved Procedures/HACCP PASS �/❑ RED #of Critical Violations: Plans 4 PROTECTION FROM CONTAMINATION Not Done Time IN. Time OUT. Separation/Segregation/Protection PASSd❑ RED Notes: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical d❑ RED /cutting boards stained and scored. 261: resurface or replace. Proper Adequate Handwashing PASS RRED Urgency Description(s): - Good Hygienic Practices PASS ❑Q RED BLUE: Violations Related to Good - Prevention of Contamination from Hands PASS ❑d RED Retail Practices (Critical Handwash Facilities FAIL ❑d RED t"/nt hand sink and restrooms papertowles violations must be corrected need to be placed in papertowel immediately or within 10 dispensers. days)(Non-critical violations GeoTMSO 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 06,2005 ) Page I of J 0044 JEFFERSON AVENUE Giovanni's Roast Beef& Pizza must be corrected immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) Approved Food or Color Additives PASS ❑d RED RED: Violations Related to Toxic Chemicals FAIL RED 1,-Pint stored on bottom shelf in back Foodborne Illness Interventions storage area. relocate all toxic chemicals and so not store in food storage areas. and Risk Factors (Require TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done Immediate corrective action) Cooking Temperatures PASS RED Reheating PASS ❑J RED Cooling PASS RED Hot and Cold Holding FAIL RED . meatballs at time of inspection being held at 112`f, meatballs and all other potentially hazardous foods to be held at temperature of 140`f as mandated. Time As a Public Health Control PASS ❑J RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS ❑/ RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS RED GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 06,2005 ) Page 2 Of J 0044 JEFFERSON AVENUE Giovanni's Roast Beef & Pizza Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE -to d stored on floor in walkin and in back prep area all food to be kept at least 6-8 inch s off floor. e following units had some uncovered food 'at time of inspection J lad unit ✓true refrigerator ✓'vue freezer /walkin and other products throughout establishment All food in storage must be covered at all limes VAayo being held at room temp all PHF To be held at 41'f or below as mandated. Equipment and Utensils FAIL Critical ❑ BLUE sanitizing solution not at proper ppm at time of inspection.solution to be maintained at proper strength of 100-200 ppm. anibzing spray bottles to be labeled. provide sanitizing solution at each work station. unitizing log not being maintained log to be maintained daily. true freezer on prep line and delfield freezer at temp of 20°f at time of inspection.freezers to be maintained at 0°f or below as mandated.service units to ensure proper temp in needed. `^ ]_. ,��tCJ�-� n opener had accumulation of food �C--o & U\J debris.thoroughly clean and sanitize. knife in knife rack had accumulation of food 1 0 debris.thoroughly clean and sanitize utensils before placing in knifearack. arack.k. Ll,,),b /relocate thermometer in walkin near door I '[QL for accurate reading. ,/Irhite freezer missing thermometer. provide n� np3l,k '\n„�r 4b visible accurate thermometer maintained at GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. T YV Y ( Rev. Sep 06,2005 ) Page 3 of 0044 JEFFERSON AVENUE Giovanni's Roast Beef & Pizza 0"f or below as mandated. ,e0ca cola fridge unit had accumulation of ✓mold on fan and shelves. general cleaning of unit needed. ,/true freezer needs general cleaning �sils used for veegie prep stored VVV incorrectly provide cleaned and sanitized container for storage. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Critical ❑ BLUE , back screen door has gaps seal all openings to exterior to prevent entrance of rodents and insects provide sweeps. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE 22065 food permit not posted. post permit GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 06,2005 ) Page 4 of :w 0044 JEFFERSON AVENUE Giovanni's Roast Beef & Pizza City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE REINSPECTION Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 744-9111 Non-compliance with: Done Owner Anti-Choking PASS ❑ Tony Hantiopoulic Tobacco PASS ❑ PIC: Tony Hantzopolous FOOD PROTECTION MANAGEMENT Done Inspector: _ PIC Assigned/Knowledgeable/Duties PASS RED Janet Dionne EMPLOYEE HEALTH Done Date Inspected, Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑J RED 9/8/2005 Personnel with Infections Restricted/Excluded PASS RED Risk Level: FOOD FROM APPROVED SOURCE Done Permit Number: Food and Water from Approved Source PASS RED BHP-2005-0379 Receiving/Condition PASS ❑J RED Status: Tags/Records/Accuracy of Ingredient Statements PASS RED PARTIAL COMPLY Conformance with Approved Procedures/HACCP PASS ❑J RED #of Critical Violations:.- Plans 1 PROTECTION FROM CONTAMINATION Done Time IN: Time OUT Separation/Segregation/Protection PASSd❑ RED Notes: Food Contact Surfaces Cleaning and Sanitizing PASS ./❑ RED 279. Proper Adequate Handwashing PASS RED Urgency Description(s): Good Hygienic Practices PASS ❑d RED BLUE: Violations Related to Good Prevention of Contamination from Hands PASS ❑d RED Retail Practices (Critical Handwash Facilities FAIL Criticald❑ RED front hand sink had boxes placed infront of violations must be corrected it. handsink to be unobstructed and clutter immediately or within 10 free to promote and ensure proper days)(Non-critical violations handwahing practices. GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 13,2005 ) Pave I of 0044 JEFFERSON AVENUE Giovanni's Roast Beef& Pizza must be corrected immediately PROTECTION FROM CHEMICALS Done or Within 90 days) Approved Food or Color Additives PASS ❑d RED RED' Violations Related to Toxic Chemicals PASS ❑d RED Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Done and Risk Factors (Require Cooking Temperatures PASS ❑d RED immediate corrective action) Reheating PASS RED Cooling PASS ❑d RED Hot and Cold Holding PASS ❑d RED Time As a Public Health Control PASSd❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done Food and Food Preparation for HSP PASSd❑ RED CONSUMER ADVISORY Done Posting of Consumer Advisories PASS RED GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 13,2005 ) Page 2 of 0044 JEFFERSON AVENUE Giovanni's Roast Beef & Pizza Violations Related to Good Retail Practices (Blue Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils FAIL Critical ❑ BLUE true freezer had temperature of 42'f at time of inspection. unit is holding food at refrigerator temperature of 41°f.contents not to be refrozen unit must be serviced to maintain temperature of 0°f or below as mandated. delfield freezer had temperature of 20'f. unit to be serviced to maintain proper temperature of 0`f or below as mandated. knife in knife rack had accumulation of food debris thoroughly scour, clean and sanitize utensils to remove all buildup before placing in knife rack. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL ❑ BLUE back screen door missing door sweeps to seal gaps to exterior provide door sweeps and seal all gaps to exterior to prevent entrance of rodents and insects. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE all other violations cited in the 9-1-05 report have been corrected.Thank you. GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 13,2005 ) Page 3 of CITY OF SALEM, MASSACHUSETTS t BOARD OF HEALTH y 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741.1800 ia FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Giovanni's Roast Beef& Pizza Address of Establishment: 44 Jefferson Avenue Owner's Name: Tony Hantzopoulos Restrictions: Application Date: 1116/2004 Permit for Food Establishment 262-04 Frozen Dessertslice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS �. BOARD OF HEALTH 2 • 120 WASHINGTON STREET, 4TH FLOOR ' SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO MAYOR--' HEALTH AGENT 2004 APPLICATION FOR PERMIT TOOPERATEA FOOD ESTABLISHMENT (� NAME OF ESTABLISHMEN-k.�I000:[lAu7 i1S I2-vGS�( heel TEL#' ADDRESS OF ESTABLISHMENT 7 Y )A4e� ,-, A e MAILING ADDRESS �(if -different) / OWNER'S NAME ///O� I/ �J�lv7T� CPUvI TEL#�74) 7 VO ADDRESS `?T CITY--;,C , _ STATE' ZIP G' / ci -2 U CERTIFIED FOOD MANAGER'S NAME(S7)a1c L,,--4 CERTIF1CA"I"E#(s)A(5 ccoo L(Uctl) (required in an establishment where potentially hazardous food is prepared.) p EMERGENCY RESPONSE PERSON C(vJ77Z ?OJ6S S HOME TEL�)s) 0 J`3 HOURS OF OPERATION: Mon!O"/0 Tue.L/ ' Wed./Gyo Thu.X�/O Fri 10-0-1Sat.' n�x un. /O/6 TYPE OF ESTABLISHMENT /' FEE check only RETAIL STORE YES NO a 0� less than 1000sq.ft. =$ 50 a((j 1000-10,000sq.ft. more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief ave filed all stat$tax returns and paid all state taxes re uir d under the law. U2Z- �S�i natur Date Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------------------------------------------ Revised11/03/03 FOODAP2.adm Check#&Date �( P�O�R'TANT MESSAGE ) FPSR e )4—,n��v" DATF //O— ��—O � A.M. TIME P.M. M OF PHONE AREA CODE NUMBER EXTENSION O FAX O MOPi1 F AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL I WILL FAX TO YOU ME AGE �V SIGNED FORM 4009 MADE IN U S A NOTES 6prbT ..._..._�._.. ..�. F r' f ..x '�_ t �Y-�. �. 1 CITY OF SALEM BOARD OF HEALTH 4 Establishment Name Date: �� "Z 9- U7 Page: C of Item Code c-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION I Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY „Y I ��.cad -m /�t /- rrn/�c�c /I)A'f /0' /7 1,14 nl�P CLs`>/la (-)A- /ncla�c�7al I � r� F "hr d hp fold ` � i2U� lt)mt �e �i� ofi-il CZt,rh /s., • I - �la�s �� /�ir�ra l�o� i�tiQ�, h��rr�l�u� r�adu �n�r,-F -�u�° - C�lrn s h) 1:;e ✓.vi)n"I j LOA o_n /n loh4xr- ' IaH-) JoY . rPcdu /361Y _ 1 %ate_ m ny 6-0 n ¢ 1 ;� i slz• _��nl�.i� I i Discussion With Person in Charge: Corrective Action Required: Ll No I L] Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P L3 Re-inspection Scheduled L) Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fin sof twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �'� �s�� ❑ Voluntary Disposal ❑ Other: h_ 10, PH FS Rc, rued,t'lemperatn", t4olations Related to roodbotne Illness Interventions and Risk According to Law Cooled to Factors(Iterns,1-22) (Cont.) 4 1^,F/45 F 4 Hours. PROTECTION FROM CHEMICALS C"cilinc Methods ior PFLFs 14 Food or Color Additives 19 'HF Hot and Coid Holding 3-202.1.2 Additives' 3-50: fi(P-) Cold PHFMmirualucd at or below -4-V12,14 Protection from I inapproNed Addiri�es� 590.00?:F) 4! 11 f 15 Poisonous or Toxic Subs!arucps 3-5 0 i.I 6(A) I I or PH F.M:,i stained at or above 7-101.11 I(Ittia I I yl ri�Inf"I'l 11,111 on-Ou'a na I 140T. " 1 1 3-501.1!.(A) Ponsts Heid at or above 130,017 Containers" I rate art a Punuc Health Control 7-102.11 Conarion Nam. -Working Coritainer<* 7-201.11 Separation-Suvaae- 3-501-1() T41yr-ds,: Public Health Contiol* 7-202.11 Restriction-Presence and U,;e' 590.1104-,H) Variane Requirement 7-202.12 Conditions of I j-* 7-203 11 Toxic'Contaifir+--Prohibitions." j REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 S-initizeii,'criteri"'.-clicynicals* POPULATIONS(HSP) 7-204.12 Chenu-mli, tor Vivastung Produce, Criicrio' 21 1-801.1!(A) Unp:isteunzW Pre-packaged Juices oo,j Beve,alles with V,,.trnoi� Labels Di ying ALents.Cri i ei ra" 3-SO 1,11(P) Use of Pasteur ized fii!Qs4 7-205.1 I hiciderned F(tod(-'Clnuirm Lubricants, 3-'801.11(D) Rao Partially Oxiked Aminal Food and 7-206.11 Rc,,u icied Use Pe;tioide,;.Cfacriir, Raw Seed Sprouts Not S:rued. *' I 7-201) 12 Rodent Bou Ciarions- 3-SO 1.11 iC) Unop,tied Food Packagc Not Re served. 7-206.13 Tricking Powders,Pest Control and Monilorin— CONSUMER ADVISORY TIMErTEMPERATURE CONTROLS ?2 3-603 11 Consumer Adi r,oryl-'Osted lor Cunquription of 16 Proper Cooking Terviveratures for Animal Kxtdii'llial nic Raw.Undetcoolied of Not Otfi�rviise Processed to Pluninate PHFs 3-401.1 .,-k,-1)(2) Egg(- I I S-F i 5 St,. EggF- hurnediate Service 145'F!5sce" 3-302.1", Pasteurized Eeg�Substitute for Raw Shell 3-401.11(,)(21 Comminuted Fish,Meat,& Gaine Eggs` Animals- 155T 15 sec. s 3-401.11(11)(11(21 Pork and Beel Roast- i!O'F 121 run)* SPECIAL REQUIREMENTS 3-401.11(A)(2) Raines, Injected Mcati,- 155°F 15 1 5905:09(A) (D) Violations of Section 590.009(AMD) in see, ate-rij)'C. mobile firiod, temporary and 3-101.1 I(A)(3) Poultry,Wild Game, Stuffed PHFS, residentiai kitchen operations s11-.),.dd be Stuffing Cont:iinin.g Fish, Meat, 0ehited under the appropriate sectiones Poultirvoi Ratites-165`F 15 sec. ^ above it related to foodborne Alum 3--401.1!(C)t3 i Intact Beef Steaks inierventionsand risk factors, Other 14517 5901.009 vio!a!ions rotating to good retail 3-401.12 Raw Annual Fools Ctx)lied i. a j)rJLllCCS should be debited outlet #29- Miciowjve 1650F I Special Requirements. 3401,11(A)(I)(b) All Other P[IFF - 145"F 15 sce. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD REI AIL PRACTICES 3-403AI(A)&(1)) P14Fs 1650F Li sec. '; I (Items 23-30) 34(l3.11(B) I Micioxvive- 165'17 2 Minute Slandin',, Critical and:7r,i-critoal violariom, olfich do om )-elate to the Tinic' foo,"llorne dln-,sx inter i,eprrions and;,is4 lo(iors iisted above, con he foll!ldo?the 5 01R 1-403.11(C Commercially Processed RTE Food- j follow;nesecrions of the fi'ood and jo 590.000, 3-403.11(E; Remaining Unsliced Purdons of Beef I lton% Good Retail Practices rc 5.90.000 Roasts"' I 23. Nlanacloment and Personnel FC 2 003 18 Proper Cooling of PHFs I 24, Foci and rood Protection FC-3 1 004 25 Equipment and Utensils FC-4 005 3-501.14(A) Cooling Cooked PFFs from 140T it, 1 26 Watw-, Plumbing and WFaste C--5 .006 70'F Within 2 Hour,and From 70'F 1 27 Physical Facil:!y FC-C .007 to-11"F,145'F Within 4 Hours. t 1 28. Posonous ot Toxic klat-r:als FC-7 .008 3-501.141 B) Coillii)21 P41-is Made rrom Ambient 29 Screcitai Requirements 00-0 Tenipciantre Ingredients n-141'F/45'F 30, Oilier Within 4 Hours* I:Itlf rd(2 o' Denol,s cot ical ociT,it)the federal 1999 Food(',)tie or 100 CNI 59f 1000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Hem Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I I I - 1 I 1 I 1 1 I 1 I I I 1 1 I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: I ffil 14(1) PHFs Received et-lempernures Violations Related to Foodborne thiness Interventions and Risk According Ic Linc Cooled to Factors(items 1.22) (Cont.) 51'Fi-15`1 Within 3 Hours. ` i 1501,15 Coining Alelliod..for PI-IF's PROTECTION FROM CHEMICALS I Ig PHF Hot and Cold Holding 114 I Food or Color Additives ;-501.16B) Cold PfiFs'Maintained at or below, 3-202.12 Additives* )9(t004(F) .11:'4;''F- 3-302 14 Protection front Unapprm-ed Addittve> 15 Poisonous or Toxic Substances 13-507 INA) Hot PHF:Maintained at or abuzz 7-101.11 Idennfcang Infoarcrocn-Oniginal I 14WF. ' Cottainers„ 3-501 INA) Roasts Held at or above 130'F. 7-102 11 C ouunnn Name-Working Containers, I 120 Time as a Public 14ealth Control � 1 3-501.19 Tfere av a Public Health Control* 7-'_(11.11 Separation-Storage'` 7-2U...I I Restriction-Presence avid 1)Fr" 1590004/H) Variance Rruwrement I 17-202.1 1 onns of Use 7-203 11 TxicC jtchihitu SREQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 SLInfleS,CFiMD-Chcui�als* POPULATIONS(HSP) 7-20--1.12 Cheuncals for Washing Produce.Criteria' I 21 l 1 s'01.11(A) I:npnsteunzcd Pre Packaged luicec and 7-204.1.1 Diving Agents.Criteria' Hevera^es unh Rarnin;I.tbclsT 3-801.i 1(B) Use of Pasteurized Eggs` I 7-205.11 Incidental Food Contact.LuLucants ( 3-80;,11(D) Raw ur Partially Conked A;nuwI Fraxl and 1 7 205,11 i Rvmricted Use Pesticides.Criteria* - Raw Seed Sprouts No"Scruc•d. 7-206.12 Rodent Bait Stations e 13-801.1 UC) Unopened Food Packanr Not Re-served. 7-1Ub.13 "t7vcking Powders,Pest Control and i Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 --603.11 Consumer Advisory Posted for Consumption of 16 ( Proper Cooking Temperatures for mime) Fexmds"That are Raw,Unctcrcooked of PHFs No, Othtrwisr Processed to Eliminate 3-101.11A(U(2) Eggs- 155•F 15 Sec. f'uthugens.T-n•ova v;:z�ar Eggs-humediate Service I 15"F15se& j 3-302.13 P.:ste-u azed Eggs Substitute fon Raw Shell 3-401.11(A)(2) Cotntnlnlited Fish, Meats<k Game Fags' Animals 1557 Is sec. ' SPECIAL REQUIREMENTS 13-401.11(B)(1)(2) Park and Beef Roast- 1-'WF 121 min* I 5vO.U(}9t:U-i D) Violalious of Section 590.001)(A)-(D) in 3-101.11(A)(2)-- - Rn IteS, Injected Meats- 155"F• 15 sec, v catering mobile too([,temporary and 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should he Shilling Containing Fish, A4eat, ( debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-40:.1)(C)(3) Whole-nuscle,htact Bent Steaks interveobons and risk ]actors. Other 145°F* 590.0109 violations relating to good retail 3-401.12 Raw Aninrni F:,ods Ciaoked in a practices should be debited under tf29- Microwave 165`F* Special Requirements. 3-401.11(AI(7)(b) All CNher PHFs-- 141 'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS R_LATED TO GOOD RETAIL PRACTICES ;-403.11(A)&-D) PHFs 165'T 15 sec. ' i (Items 23.30) 3-403,11(B) 'Microwave- 165`F 2 Minute Standing Gzti al and non-crilir.al ciohutun,c. pinch do not mare to fire Time" lundberne iilnere otter venlions ,I'd I isk fartore liocd obove, can be i 3-403.11(C) Comtncrually Processed R 1•E Food- found s:the fallowing sen ictis of the Feud Code and 105 C'AiR 140"F" 590.000. 3-403.1 1(F t Rem unmg Unsliced Portions of Meet I Item Good Retail Practices FC 590.000 Roasts' 23 Management and Personnel FC -2 .003 Proper Cooling of PHFs 24. Food and Food Ptulection FC-3 004 25 EquitI and Utensils rC-4 �. 005__----� 3-50LId(A) Coulmg m Cooked PHFs from 140'F to ( 26 Watei.Pluoinq and Waste 1'C-5 006 70'F Within 2 Hours and From 70'F 27. Physical Faclity FC-6 ; .007 J to 41`F(45"F Within 4 Homs. x � 128. Poisonous or Toxic Materials FC-7 .008 3-5o1.14(B) Cooling PliFs Made From.Ambteut t 29. Special Rei,temerts 009 I Temperature Ingredients to-11017145'F 30. Oiher -( Within 4l four:' ,""" "•' "a,: -Denotes critical item in the Inderal 1999.Food i gide or 105('NIIt 5r+tr 00(), 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 I 1 I I I 1 I 1 ' I � 1 I � 1 I 1 I I + Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance -❑ Employee Restriction/ 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. LIVoluntary Disposal ❑ Other: It • � i .5_,) 74(:1 E't-1 F-,Receive:: at Ternrerature, Violations Related to Foodborne Illness interventions and Risk Acaorri:nv i o 1-,w Co.,Ied it, JI Factors(items 1-22) (Cont.) »PFMJ'F Wid-an 4 Hours. " PROTECTION FROM CHEMICALS C'll.15 C00itr Methuds for PHFs 19 PHF Hot and Cold Holding 14 Food or Color Atlditives 3-50i.:wis) Cold PHF:.Mai ntain= 3-2O7 12 Additivee-> � I cd at at below 590 Chi4(F) 41"145°Fx 3.302 14 Poisono n from Unapproved Actdihvrs _;-501.10lA) Hol PHFs Maintained at or above lj Poisonous or Toxic Substances 14017. ` 7-101.1: IdenBrying lnfiruenion--Origiml i Couamer,;' ! 5 1.16(A; Roasts field a, or.:bu,e 1 30"F. 20 Time as a Public Health Control 7-102.11 Common V:ae,e-W�,>shine,Conta,cr-c" -_O1.I 1 Sep iratior,-Sturave" 3-501.19 Tia-;e as a Public Heal+CortioP 7202.t1 Restriction-Pieecnce and Use' =it}09041H) Veri:mce Requirement 7-202.12 Cnnduutns of Usv" 7-203.11 'toxic Contain r.--Prnl,ihiti,ms' REOUIREMENTS FOR HIGHLY SUSCEPTIBLE I 7-2�1 tt S:utitizer;,CriterCriteria POPULATIONS(HSP ) ' 121 3-SUI"1 i(A) l-i oasteunzed Pre-packaged lakes and 7-204.12 Chemicals for Weshutc Produce,Cntrria" , 7-204.14 Drying.�ents.Criteria' � i Beverages with Warning L,aheln* 3-RC'.1 !(B) Use of Pacteutized f✓.,es" 7-205.11 Incidental Food Contact, Lubricants' -- -- 7-200.11 Restricted Use Pesticides,Criteria' 3-80:.i 1(D) Rate ur Partially Cooped.-Animal Forxl and -206.12 Rodent tint Stauons* Raw Seed SProt11s Nut Serv<d. 3-801.11!Cl Unoncned Prxtd Package tint Re;;rn•ed. " 1 7-206 13 Tricking Powders. Pest Control and i Monitoring* j CONSUMER ADVISORY TIMEJTEMPERATURE CONTROLS 22 3-603.11 Consurper Adviaory Posted f,)r Consumption of Animal Fonds'That arc Raw,Under.00ked of 16 Proper Cooking Temperatures for ; Nct Otheiwise Processed to Eliminate I �• crt,e+.,,,.:.wee 3-401.11A(U(2) Egg- 155"F 15 Sec. a,hogens.. Eggs- hinnediatc Service 145'1715ec* --302.13 S'asteunzcd Eggs Subsutute for Raw Shell 3-401.11 iA)(2) Comminuted}isly Nh;ate&Gane Ez-s Animals- 155'F 15 tie,. ' ( 3 40i l i(B)(1)(2) Park and Bed Roast - 130'17 121 REQUIREMENTS 737 :n,n* � 3-401.1 t(A)(2) R.nacs, hrjrted Meats- l55'F IS 590.009A-(D) Vola*a s ec S ection 590.009(A)-(D) in i sec, - catering, mobile food,terrpnrary and 3-401.11(1)(3) Poultry, Nkiid Gam:,Smt''ed PHFs remdential kita,cn operations Otonid be Stuffing Containing Fish,Meat, debited under the anptonriate sections Poultry ur Ratite,-165T 15 sec. * above if related to loodborne illness 3-401.11(C)(3) Whole-nmscie, Intact Beet Steaks ,ttterventions and risk tactors. Other 145`F" 59�.{N)9 violations relating to food retail 3-401 12 ( Raw Awmid Foods Cooked in a ( practices should be debited under 1129- I Microwave I65`F x Special Requirements 3 401.1 i(A)(1)(b) All Other PHFs- 145"14 i 5 sec. 17 Reheating for Hot Holding V IUL.ATIOMS RZLA TED TO GOOD RETAIL PRACTICES 3-403.1 i(A)lt(D) PHFs 165'r- 13 sec.`" {hetes 23-30) 3-403.11(B) I R9icuxravc_ 165°F 2 M,mue Standing Criucal and+:u„-critic u[vmlurams. +ihich do not eelate to the Time' hx,dboeee dL+ess inte'rsenlion.c and,-W jarrors ii,ted above, can be 3-403.11(C) Cominenially Processed RTE Food- (otnrd ire eho fuflom wg cerr,,nS Of lite Foal Clue and 105 CL1R {40'F" 59171)00 3-403.11(E) Rrmaininp,Unsliced Puaion;of Beef - Item Good Retail Practices FC 590.060 Roast-," 23. I Manatiement and Perscnnei FG -2 003 18 Proper Cooling of PHFs 24. I Food and Food Pro;eccon FC--3 004 nq EPu,Pma;a and Utensiis FC-4 .005 3-501 14(,c) Cooling Cooked PHFs from 140'F lu - r• - Vdater,Plumb!nq and Waste v�-S 005 --� "t0"F\'vithm 2 Hours and From 701, 11.7, Physical Faciiily K:--fi .GGT w 4["F14.;'F Within 4 Hours. " 128 Poisonous or Tonc IAaleriais FC.-7 .008 _;-501 Id,B) Coni in..PHFs Made Frr.m Ambient ! ( 29 Special Requir<^^meets 009 Tempelcure lneredientsto 11`17145"F ( 30 Other --- Within 4 H+gtrc` Ucnotas amend nem;u:hc le,ierd 19c)v Poi vl I ode or 105 C'MIR 59(1000, Massachusetts Department of Public Health Salem Board S Health M 120 Washington Street,A'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax (978) 745-0343 NameDaJe Jj Type of ODeration(sli Tvpe of Inspection AALIANOVorr- /I/7•l14 I baa' IS/ mood Service Lw7 fi u ine AddressRisk [3Retail ❑ Re-inspection "q .rIF/Iy.CG S,A, ,LmLevel ❑ Residential Kitchen Previous Inspection Telephone ( I*i ❑ Mobile Date: '-7N44- 911 f ❑ Temporary ❑Pre-operation Owner I HACCP YIN ❑ Caterer ❑ Suspect Illness �N.`� NAf/+ra�PnuGos Person in Charge(PIC) STime I ❑ Bed&Breakfast El Complaint ttMs In: ❑ HACCP inspector f1Aj11 rxA�M.;- Out: Permit No. El Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors. Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE TIMIETEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling PROTECTION FROM CONTAMINATION ❑ 19.Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20,Time As a Public Health Control VFood Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11.Good Hygienic Practices ❑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 t immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): t 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 x by a Board of Health member or its agent constitutes an 23. Management and Personnel FFC-2)(590.003) order of the Board of Health. Failure to correct violations 24 Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of �,2,�E„i' Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food t Y& Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590A07) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.o08) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s sswsxnto�s�a.noL Inspector's Signature: n _; / t/_ Jam_ Print: -T,4 -A�g� PIC's Signature: /"''l i��'��7--I-Print: ( Page of t4ages Violations Related to Foodborne Illness Interventions and Risk Factors(Items i-22) PROTECi!ON FROM CONTAMINATION FOOD PROTECTION MANAGEMENT ( !i ! Cro;s-uxrtaminatron � Assignment of Respon>tbiluls" i 3-3(1'2'.1 UA)(i) Ra,,.Anima! goods Scp�rn:ed fcotn 590.0TgB) Demonstri::On ui Rnolrledge* Cooked and RTL F:xxls- i 2-IU) 11 Person in charge -duties j j ComUniinatron Item Raw!ngreaents 3-302.11;,k)(2) Raw.Anims3Foorl%Separated front Eath EMPLO"EE HEALTH 0:hct 2 -M0.001tc) Responsibility of the person in charsa to j Contamination from the Erwaonment require repotting by f(Y.)d employee;and j 3-362.i t(A) Foo" Protectionr j applicautts* j 3-30115 W ashmg Fruits at:d Vegetables 590.01)3(F) Responsibility 01 A Food Employee Or An 3-504.11 Food Cunt:ct with lr,luipment and Applicant To Repoa To The Person In I Utereiis: Charge* j Confaminatior:from rhe Consumer i 590.003(G) Reporting by Person in Charge' j j 3-306.1-VA)lB) Reuu'n;d Food and Resei i ice(it Fooll"` j J 590.003(0) E�alusionsaud Restrictions' ( Disposition ofAduiterated or Contamtnared 590.003(F.) Removal of Exclusions and Restriction., ( Foro i-701.11 Discarding or Reconditioning-Unsafe FOOD F 30M APPROVED SOURCE Fool 4 Food and Water Rom Regulated Sources i i 9 Food Contact Surfaces 590.004(rr-B) Cumplomo: with Food Law* ( 4-:SOi.III Vi;_Auld 'A;�::cwasfing-HorWater ( 3-201.12 rood in a Ilennrticallyr Sealed Contsiner`" Sanitizatiull retupciaotres : ! 4-501 112 Mechanic:: W'arewashim.- Hot 'Vater 3-'_0:.13 fluid Milk and Milk Products* Sanitvatiun"(eutperatuu c" j 3-202.13 Sheri EcgsT 3-202.1 k F,egs and D4ilk Prodi;em Par.k'unzcd;` ( 4-501.111 Chemical Sanitization-temp„pH, ij 3 _(2.16 Ice Macte From Potable Drinkingng Water' ( 14-i01.;; A} Eaqnuicirp:rneot Food Contact Sur"faces anJ 5-101.11 DtinkinG'Water from anapproved System" ' Uten,tisCl au- j 590.00fit A". Bottled Drinking Water" 4-602.11 Cleaning Frequency of Y.,quipmanr Food- 590 006(B) Nater h Standards r, CMR 22 R'r ( Contact Surfaces and Ptcnsils° Snelttish anandd,9sh Froin an Apprppr oved Souroe j 4-702.1' Frayueucy of Saul nzahKmt of Uten::iis and ! 3-21((.14 Fish and Recreationalh Caught Mollusenn I Food Contact Snri:ices of k?4uipment�" SheI1L,h j -1-703.11 ;42ethodsafS::nrtiz;aiur,- Hot`r\'atcr.x:tJ � 3-201.15 Molluscan Shellfish holt NSSP Listed C'hemic,d* sources" ( 4 Game and Wild ivtushrooms Approved by j 10 Proper,Ade nate Handwashing Re_giWon✓Author;ty ( 12-301,11 Clem CondiQdoe--Hands .:rtd Arms" j j 3?02.15 Shellstuck Identification Present" ( x'01 12 Cleaning,Pnxedill j j 590 0040 Wild Mri hoioms` 2-301.14 W-1ren in Wash"' 3-201,l7 Game Anunsls'. j i '<I Good liygienic Practices i 5 Receiving/Condition I '-=401 11 Faring,Dnnkmg of List na Tobacco i 3202 11 PliFs Rc:,etved at Proper Temperatnre;: 2-40 L 12 Dsetc;rces Pruni the 6yrs. S'os. and 3-2011i Package tntegity', I i Mouth* i-101.11 Fon 3-301.!"_ Preventing Contamination When Tasting' Ford Safe unit C:nadulternted'� ( r j t 1 agslRecords:Shellstock ' ( 12 Prevention of Contamination from Hands j3-2{12.13 Shellst+,ck ldctnification ' j 590.004(E) Presenting Contamination from i i-21)3,12 Shell6tock Identification Maintamed" I Ernphwae.' I TagslRecords: Fish Products j t-; Handwash Facilities j 3-402.11 Pmnsite Destruction` Convenienthy i.oceted and Hccess%cio j 3-402.12 Records.Creation and Retention' s-''_U3 11 Lo noon and Ca,clue t'* l j 590,0:}4(,l; Labeling of Ingredients' i 5 205.11 Accessi and Placement° 7 ( Conformance with Approved Procedures 15-205.1} ,4caessibiiit)',Operation and t2aintenattee i IHACCP Plans SoppErd with Sonp and hand Drying 3-51:2.11 Specialized Pttxessing Methods` i Devices i ri-301 11 Hand 3-50_'.12 Rcdnr"eci:,xvilen packaging.criteria -4(11.11-4(11.11 hand Dr\'in" ( Dnein g Cleanser Aaailnhilit\ i i $103.17 Conformance with Approved Procedures" g Ao\isiun j `Denik"tnuc,l o,mt in the Iide:al 1404 Fa qd C,,&ur 105 Cb112 t96 000 CITY OF SALEM BOARD OF HEALTH Establishment Name: 6:10ranrwf� r /frtE.4 Date: 444-ya Page: 2 of 2— Item Hem Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY ,✓ �� " r.�� tbto� SYeff.Vo 1W t3uzi4o Ms/ tv BS A/Nfi � o,rv' i4111� ahv✓A( .Jd( (eJCe/NQ AW stjr_-rAe4 . I 1 i A IZ sf®Ir_£o ,a- /.2V a.r ve' A , Q /�,cA4,f_-3 n F� CZd � - 1 I 2S dJc r M/ c A , "&4Q os CLAA WfW& A/fn rANrnEJNG- I I X 0 r /�C _ Accu,F.o#_6E F"Id&.#--pt.,r,n.>E'�b Pl'wic a vt /h 9 _ - Sbti+s vr►r� Gutrf tr/F /Su,4ND Tc cis D rt ti(A t f i!twv-� IP /cbrtilLfhli� cow I � A5:A , r. 1 rd Ar r0V14 114 14,( i-n rf,- MPr I i✓S,4tf,6, ZfrJrr ,�c.sa�r � Discussion With Person in Charge: Corrective Action Required: ( ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension � comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: A -- r 3-50: :-(C) ' PHFS R.eerved ,tl'Temperatures Violations Related to Foodborne illness Interventions and Risk i Acecrring to L-ov Cooled to Factors(items 1,T) (Cont.) i 4I`F/45=F 1,Yitt:vi PROTECTION FROM CHEMICALS 3-5 .l? Coelia Metltnds i•r PH F+ .9 1 FHF Hot and Ccle Holdrng 14 Food or Color Additives 3.;i0 i.16(B) Cohl PI IFs Marmatned at of helow 3 20' 1'- Additive;* 590.( 4Pf45" F' +04)f^) 3 -402-14 Protection Rota Uraoptoved Additives0 I 1590A U�)A) Hot PHFs Maintained at or above 15 Poisonous or Toxic substances 7-I0L I I Identifying hdornemmn-Original 14047. * ! Containers` Roasts Held at or above 13 0`F 'r 7-102,11 Common Nante -Wor kiny Contain--c,' ( 90 Time as a Public Health Control 201.11 ScPatation--Storage" 3-501 Ay 1 Time as a P ibhc'rteaith Control* 7-202,11 Restnetion-Present..and t:se' 0041H) r 99)) I b•arlanc:.Requirement 7-202.12 ( C„nddion•.of l��se' 7-103.11 "toxic C'ontaiuer,--Piohibitions" REOCIREMENTS FOR HIGHLY SUSCEPTIBLE Cd 7-� .i1 � Senitizets.Catena -Che POKM ATiONS(HSP) ll 7-204.12. Cheicals for Wash;m,Pr:�ducn.Culeua 21 341'01.1 ITA) Unpa,t:unr:ed Pre-pachaoed Juices and I k I3eceraces :;.t'r, ?Varinnt:L;abels° 7-204.14 Diving)amts.Criteria' ]ItBi Use of F'asteu:ized�'rzl*;" 7-_05,11 Reittem a1' FooIlse Contact.Lubntriol i 13-y,OI 11(1)) Ra;v of Patua'.ty Coekeu Animal Food and 7206 11 Restricted Use Pesticrdes.Cru-triol 1 Kava Seer;J xouts N,:t Served. .r-206.12 Roucnt Ban Statlerts' ! 3-;X()1.11(C) ( Un.',nened Fond Package Not Re-served. " ;'-206.13 'tracking Powders. Pest Control and i hioni[orim" CONSUMER ADVISORY 22 3 603.11 Consumer Advisory Posted tar Con.umption of TiMEfTEMPERATURE CONTROLS Ant:-,tal Foods'Fhat,vc Rao.Undercooked of 16 ! Proper Cooking Temperatures for � PHFs INA OtiterwiseP;otersedtrfEii!mnate 3-40!.1 iA(U(2) Eggs- 153"F 15 See. P`tw",us." _ Etttt>-untnediate;Se 145"P15sec '�-310.13 P�steunzed Fags Suhsnmte lot Raw Shell 3-401.11'A 1(2) Comminuted Fish. Meats&Game r-',c•as Animals- 155"F I S Sec. it > 401.11(E3)'(I)t2) Pr,rt and Beef Roast - 130'17 IZl n;ir, SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats- 155F 15 590.0OWA)-(D) violations of Section 590.009(A)-(D) in sec.: catering, mobile fochl, temporary and 3-40L1 i(A)(3) Poultry,?vr'ilI Game. Smit"!""Fs, residential kitcl+cn operations should be Stuffing C(ntaininl,Fish,Meat, debited❑)?;1cr d,e dppropriate sections Pnu;try or Ratites-165TF 15 se_. - atroce if routed to ioodboruc illness 3-401.1 hC)(;) Whole-muscle,intact Beat Steaks interventions and risk factors. Other 145"F* 5x0.009 violations relating to good retail 3-401.1_ 1{aw Animal F.,od,Ccx)ked in a 11ctcttce, should be debited under #29- Micr.,waxe 165`F' Speci,f: Requirenimts. 3=401ll(A)'i)(b) AII0tlicrPHFs- 145"F15sec, '' J7 Reheating for hot Holding I VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)f1(D) P41-s 165'F 15 sec. ° (ite)ric 23.30) .3-403.111 B) M;.,.rewrtie- 165' F)'4finute Standing Ca11117 aml,rrnrnilhA1 violatumc. Which do nnr relate to the Time" foodborne illness iraereeniiona and risk far tons listed above, can he 3-403,1 I(C) Commetaal ly Procewd RTfi Food- found in r§n julio+ring wrrimt,+g1'the Food Cede and 10.E 011? 140`14` 59610(;0. 3--103.1 it G) JR,ini nine Untheed Portio;of Reef Item Good F,efail Practices FC580.000 J Ruasis' I 23. Management and Per!ohne! FC-2 003 1X Proper Cooling of PHFs 24 Food and rood Protection FC-3 404 25. Equipment and Utensils FC--4 005 3-501.14(A) Cooling Cooke I PHFs front 140"P to : ?g 411atet,Plumbing and Waste FC-5 .00o 70:F Within 2 Flout.and Frnm 70T 27. Ph =;cal Facd¢'v r - y.. C-S 00.7 to 41'F/45"r'Within-' Hours. ` 1 28, Poisonous n:Toxic Nlatenai.•s FC - 7 .008 3-501.14(13) C olinf;PI-Ws Blade F-om.Ambfent 29, SPeaiai Fie+quirements A09 Tem(+eranfre hrgredicnts to 41'F/,15-T: 30 Oiher Within,I ltcmrs:` Dei,,;tr:;.•rn+.al item m tht fed:aal 999 Fou:;Cwde or 1f4(1,1R"90;j00 ( IMPORTANT MESSAGE ) FOR DATF 7 TIM5/11-1)'s —ml� M OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOEIII G AREA CODE NUYBER TIME TO CALL TELEPHONED v PLEASE CALL I !. CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU I !, MESSAGE D SIGNED ��/ /� FORM 4009 V ��■��YYY777... FORE IN U.S.A.' ll// J I a NOTES I I Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,41h Floor Division of Food and Drugs, Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax,(978) 745-0343 i Name a T _e of Ooerationfsl, Tv/ of Insoection �..� inrxj A)[c �'nAcr /�avFq ��Za DL /D Iffj Food Service E] Routine Address" rsk ❑ Retail ❑ Re-inspection ru . Tt GrC7' Sm ��dv I Lev I ❑ Residential Kitchen Previous Inspection. Telephone ❑ Mobile Date6-/7'� f /ate l 7��- �, Owner ' HACCP YM ❑ Temporary E] Pre-operation /Irv^/V. I1f14 fi7d All)112,S I I ❑ Caterer ❑ Suspect Illness S Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint -1?WNf i4,4A„^2 Oz.nrN I In: ❑ HACCP Inspector /I /-o - ntor ,✓. i.SYtf�s I Out: Permit No. E]Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMErTEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding 71/8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR c Health. 590.000/federal Food Code. This report, signed below, when c N P 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an „ 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-a)(sso.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food v 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (Fc-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 59 lnsp aFcm 14 Eoc I sp c[or' r e: Print: 7PIC s Sighaturer� Print:7 Page of 2Pages r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FRO1'A CONTAMINATION FOOD PROTECTION MANAGEMENT g Cross-cot trmtnatron I ( 590.003tA) Assignment of Responsibility" ( 3-302.1 UA$1) Rau Animal Fo,uis Separated from 590.003A(B) Demonstration of Knowledge" Cooked and h`7"c Food;,. . b I03 11 I'�:rson in charge-duties I Contamination from Raw ing:edonts j 3-30111(A)(2i Raw animal Fowls Separated from Each EMPLO"EE HEALTH ( Other^ I ,. ! 2 `4U.UO3(C> Responsibility of the person ,n charge t Centam,irabpn nom tha Envirorment r qune reporting b) foot employees and j 3-302.1 I(A) Food Prnfecbon, applicants` j 3-302.19 Washine Fou!-<and Vegetables 590 0103(F) Rcsponsibllitr Ol'A Foot Employee Or An I 1-304 11 Food Contac with Equiprnent and Applicant To Report Te the Person Lt ( Uten:.std" Cor.;amioatio;r r-rctn the Consumer 590.003(C) Reporting by Person in Chaise* j 3-30(04(A Hli)l Rebored Food and Reset vice of Fuld^ ( 3 590003(D) EXdusioneand Rest:4dons' Dispusi5nnofAduiteratedofContaminated 590.00316) Removal of Exclusions.i nl Pestrictio i• I Food 3-701.i i Dis-_arbors or Reconditiunin unsafe FOOD FROM APPROVED SOURCE Food' .4 ( ! Food and Water Frcm ReuuWed Seucoes 19 Food Contact Sur faces - 5t�U , -4-501.11 i btanuii Watew,;shine, Hot Water i ( _ .t,(.=1(.4-B) I Cnmp!t.mrc with Fund Law! � uantres` j 3-701.12 Food in a Hermetically Sealeri Container' Sanii;zation 1:•mp' ( 3-2 Fluid Mil',and A1ttk o rocucKr 4-501.112 Mechmusal W,sew0,mg-Hui Water Sxmtlz.:an i 3-202.13 I Shell6cesc n'tem cr.,tures' 14-50! lid Chemical Saniozahon-temp.,pH, ?4U?.I4 kegs and A!ilk Products.Pasteurized' i concentration and hwduegs. 3-202.16 Ice Dade From Potable Drtnkie_Waller* 5-101.11 Drinking, Water from at:approved System„ I 4-01 (7i A) Equipment et Food Contact Surfaces and Utcnsas Clear,' 390.006(A) Bottled Drinking Water ( 14-602.!5 CleenmgFrequencyofEquipment Food- 590.006(H) Wader Meets Stendards in 310 CbIK 22 0'" N I Cenct Suri:rcce and Uten,ils* j Shellfish and Fist?Froman Approved Source ( 4-702 11 Ftcyoeucy of Sanitization of Uten i(s and Shellfish!'-301.14 and Recrr,nianally Caught Molluscan I Fond Contact Surfaces of Gquipment* heli 4-703.11 M-Thuds of Samtizauon -I tot l"Dater and I 3-2UL1:5 Molluscan Shellfish from NSSP Listed I Chanical' Sources* Game and Mid Mushrooms Aparoved by j I`t Proper,Adequate Handwashing Repulatcr I,Authority 12-30Lll Clean-Condition--FS.:.iia and Anus j .i-'02.18 Shellswrk Identift cation Present" I 2-=07.1? CA•anmg Procedure' Wild M,rdurNitbs* j 2-3u1,14 Wien to WssW 3-201.i 7 Cattle Animals" j j If Gocc Hygienic Practices j c RrceivinglCondition j 2-401.1 i Eating. Drinking•,i Using Tobacco- 3-202.11 PI-!Fs Rcce,ecd at I'ropei Tetnperaoares'. i 2-IM 12 Discharges Brom the Eye;.Noae and j 3-202.15 Packaeeinteuity* Month` 3-101.i 1 Fond Safe umI Unadulterated* ( 3-301.12 Preventuie Contamination When Tasting* ( 6 Tags Records: nidal ei a j 12 Prevention of Contamination from Hands j 5-202.18 Sheildnekldent:ncation' ' S900"t4(Ei F're,cntingComammationfirom 3-203.12 Shellstock Identification Maurained, Einplogees* Tags/Records: Fish Products t 13 Handwash Facilities Conver,)ently Lccated:;tta Accessih'c j j 3-40211 Parasite Destruction, 102 12 Records.Creation and Retention' ( 5'03.11 Nutnbers and Capacitie ! 590.00.1(!) Le'aetingofingredients' , ( 5-204113 Lcca,ionand Kiccment S-21,5.11 Acccss;odity, Onerdtirn and NT.;mt::iI 7 : Conformance with Approved Procedures I i - Sup;;,4ad wrtn Snap and Mand Drying iHACCP Plans Deoalto 3-502,11 SpeciaLnd Processing tYkthods" Reduced ozy>en packaging, ( {;-301J I H:mdwashlne Cleanset..icaii.,baty 3-50'_.12 :.' packaging.enter j S-103.1'2 Conformance with Approved Procedures.. j 6-3UI 12 Hacd DrNing Fr.,eision ?c aoa_,c:':enl item in:he fe,±ernl i'i')y Pnud{'o•'e cr His Cbl it Stn iptlr,.. r CITY OF SALEM BOARD OF HEALTH Establishment Name: s /Y'e7st APpF V R�'2 '7- Date: /' oL 0 "04 Page: °� of Z Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 1 No. Reference R—Red ItemVerified PLEASE PRINT CLEARLY ZG, — urswh �i �P ri�i,vsecF� C�rt� c t�/2 P� �ti�S/C7e DDLnrt /SOT Y� — r1�.r',r��..re✓v �t�Pvii°c l�.Chi�q,S�.ui-/i2rr✓9 I !S� .�iiPP�i 7/,Se�_ /rP/4pL C.Q'Y/P ��l..'4/l�rixir+''l.�L �%�i/�9 Ly � rh P C•'�PP r�� 2,,�:/P I s I +/'�ec�.�'fiFi�� ,fJ/rfed /✓�/el/2✓r fpr�i � I v ff%ti.Uu45//rir� I I �/YJ��visa l4 �•� I • .�"#j OrP/�.�✓ !G .Pr1 r` Gin.+7 —nI vPC �G �/Gr.e/�dR If.SP,7X�/ f7SS r�f' DR ?I,IeW Si`c e= �G i I Yom'°tea: I I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have-read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p L3 Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that , noncompliance may result in daily fines of twenty-five dollars or suspensionMevocation of ❑ Embargo ❑ Emergency Closure your food permit. 1 ❑ Voluntary Disposal ❑ Other: 3-501 14(0 PHFs Rgicivedat'rempernhires 1 Violations Related to Foodborne illness Interventions and Riski Accor•<ling to 1.1"r Cooled to Factors(Items 1.22) (Cont.) 4I'I'/45'F Within 4 H<nus. PROTECTION FROM CHEMICALS 3-501.!,5 Cw)lhrg Methods for PFirs 19 PHF Hot and Cold Holding 14 Food or Color Additives ( 1 3-501.16(8) Cold PRFs Maintained at or below 3-202.12 Additites` 50U•0;)4(F) 41`/45'F 3-302.14 Protection fruru Unappiw ed Additives', 13-501.16iAi Hot PHFs Maintained at ur above j 15 Poisonous or Toxic Substances ( I - 7-101.11 Identiii'ing lntbrmation-Onginal ' 140'F. ' 3-501 I6tA) Roa,ts Held of of ahme 130''F, ' Containers' ( 10 Time as a Public Health Controi 7-102,1 1 1 Common Name Working-('en tamers* 7-201.11 Separation-Stnraee^` � 3-501 I Time as a Public Health Control;' 7-202.11 Reariction-Presenccand I%;e:` 590.004(11) VarianceReyunement 7-202.12 Conditions of Use, I { 7-203J 1 Toxic Contdinars-Prohibttiona" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 7-104.11 Swini2ers.Cn!eria-Chemical,; j 21 3-801.1 ttAi Unpasteuriz d Pre-packaged hiices and 7-2tl-1.12 Chruueels for Washme}roduce;Criteria I B-%vnwe, with W,irninn Lahe!s" 7-204.14 Dt}ing Agents.Criteria" ; 801.11(6) Use of Pasteur!>ed Eg a. 7-2(}5.1 1 Incidentai Food Contact, Lubricants" j 7 3-S01 I I(D) Raw of Partially Cooked Anima) Food and i -206.11 Restricted Use Pesticides,Criteria' I Raw Seed Sprouts Not Served. - 7-?0(i.12 Rodent Bait Stations' 3-S(11.11(C) Unopened R.xrd Pac4:aee Not Re-sen'ed. " 7-206.13 Tiackiq,Powders,Pest Control and 14onitorinv' CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3'603.if C'onsunrs Aehisoty Posted for Consumption of 16 I Proper Cooking Temperatures for Animal Foods that are Raw.Undereonked or PHFs Not Otherwise Processed to Eliminate 3-40I.IIA(1)(2) F,e+rs- 155"F 15 Sec. Pathogens.a. `ne,'vc ".= L'-s- Immediate Service 1d.5"Fl Ssec` 3-302.13 Pasteiinzed E-f+gt. Substitute for Rav;Shell Fogs ! 3-407.1 i(A)12) Comminuted Fish. Meats k Game I Anunals- 155'F 15 sec. ' SPECIAL REQUIREMENTS 3-401.11(13)(1)('_) Porl:and Beef Roast- 13WF 121 rnin' 1 3-401.II(A)(2) Ratites injectrdMcats- 155`'FIS 590 009(A)-(I)) Violations of Section 590.000(A)-(D) in Sec ; catering, mobile foal, telnporary and 3-401.1l(A)(3) Poultry. Wild Game, Stuffed PHF,. residential kitchen operations should he ^cl,iicd under the an iatc sections Stuffing Conhumng Nish,b1eaC, I � - -prno`, r! Puirltry or Ratites-165'F 15 sic, - above if related to foodborne illness ` 3-401.1 l(C)(3) Whole-muscle.Intact Beef Steals interventions and risk factors. Othei 145"F" 590.009 violations relating to goat retail 3-401.12 Raw Annual Feuds C(x)ked in a practices should be debited under#2c)- Miciowave 165`F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs 145°F 15 see. 17 Reheating for Hot Holding VIOLATIONS RrLATED TO GOOD RETAIL PRACTICES 3-103 11(A)&(D) PIIFs 165'F 15 sec. (Items 23-30) 340) Hill)B) Microwave- 165' F2 Minute Standim, i Critical and non-crairal violations, which do not relate to the 75nte" i fnndhornc Illness inien•entions and risk(actors lister!above, can he 3-403.11(C) Commercially Processed RTE Food- 1 found i„ the following seo tions of the Food Code and 105 CAIR 140-F" 590.00(. 3-403.1 ItE) Remaining Lnsliced Portions of Beef Item Good Retail Practices i FC 59ti000 1 Roasts'' I 23. Management ano Personnel I FC-2 .003 18 Proper Cooling of PRFs I 24. Food and Food P!oteciion FC-3 .004 ! 25. Equipment and Utensils FC--a ,005 3-5U1.14(A) CoxrlingCnokcdPHFs lionl4(1"F to j 26, Walet,Piumbinct and Waste ! FC-5 .006 70"F'Wid!in 2 Hours:uta Front 70'F 27 Physical Facudy FC-6 007 to 41"F/45'1-Within 4 Hours * 28. Poisonous or Toxic Materials FC-7 .008 i 3-50I.14(B) ONAing PHFs Made From.Ambient j 29, Special Requirements .009 _ Temperature Ingredients to 4PF/45'F 30 Other Within 4 Hours. Deni,le,erilwal item in the federal 1999 Fond Code n! 105 CMR;90.000. COURT DOCKET NO. CITATION NO. CITY IO SALEM FD �} ©90 `-� VIOLATION NOTICE 1' J. ,71J NAME(LAST,FIRST,INITIAL) r-7otJ-v�eS N57 1"h'E'F' 1 lei::.z!Z STREETADDRESS CITVrrOWN STATE ZIP =Pl v rFt Ale LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNERS NAME(LAST,FIRST,INITIAL) }/rin�7zo/�vv1�5 . TG's✓uytiirr,Le STREETADDRESS l - CITY/TOWN STATE ZIP ,/c/ zfT&FFe.wsfrt 11"'e- REGISTRATION NO. STATE I EXP DATE I MAKE/TYPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL ❑AM NmRY ❑PMS'F El EJYENO LOCATION OF VIOLATION ENFORCING DEPT pa7.�ct yr OFFENSE CHAP. SECT. FINES A rrriLt,,,ep 7fO C,SYtalAl 14C2. Baeqo� f <s� ��, OFFICER I.D NO TOTAL �^ G FINE $ ✓'/'.Y.'FLSc rI�S DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR )� -7�y1 �/ p�' ❑ IN HAND X '(/�///Cl:.�[.{tiv'�'�/w ❑ BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL AT DOCKET NO. 0 TAXION No CITY OF SALEM p VIOLATION NOTICED ra: E(LAST,FIRST,INMAL) 1 il CD CrIYrFOWN STATE 23P C13 <37) e &71eld2711t(019 N `l LICENSE NO U P.DATE DATE OF BIRTH I ci L) OWNER'S NAME(LAST,FIRST,INITIAL)U) z CC rzo 7P 1v v y /f//('O 7 STREETAID DRESS CRY/TOWN STATE ZIP , 2ti 0 REGISTRATION NO. STATE EXP.DATE MAKE/TYPE I YEAR ICOLOR DATE OF VIOLATION TIME Ll AM JDATECITATIONW71EN Mw'A ES1 oy! --o 4/ 0 Fm _ONO LOGATION OF VIOLATION rn O u. LTi OFFENSE Lau" FINE$ U T'm 0 A fa) 6 E13 0 13 ROL 0 n 0 OFFICER LD.NO. TA s 00 ITFOINELI DUE tll4asnrAls- OFFICER CERTIFIES COPY GIVEN TO VIOLATOR Er IN HAND �x BY MAIL Q DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY 0) r11 aORDER OR BY CHECK MADE PAYABLE TO: 74 CITY CITY HALLCLERK 93 WASHINGTON STREET 0 0 P SALEM,MA 01970 t chTEL.(5N)746-9595 X 251 03 'FHEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON zREVERSE,CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE o(pa 5 PAYMENT IN THE AMOUNT OF OZ4 . 0 z cc 0 Er CASE# T z 0 SIGNATURE 0 I * '0 .I V, ER SIDE FOR FURTHER INFORMATION SEE OTHER Y-.,-,.ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL W > 2 o CITY OF SALEM, MASSACHUSETTS vQ' BOARD OF HEALTH 3 s • 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT January 15, 2004 Tony & Nicole Hantzopoulos Giovanni's Roast Beef & Pizza 44 Jefferson Avenue Salem, MA 01970 Dear Mr. Hantzopoulos: In November the Salem Board of Health sent you an application for your 2004 Food Permit. Included in that mailing was a cover letter stating that you were required to return the application by December 4, 2003. In addition, on January 5, 2004, you were sent a ticket for not returning the application. To date we have not received your application, application fee, or ticket fine. You are operating your establishment without a permit in violation of the State Sanitary Code Chapter X: Minimum Sanitation Standards for Food Establishments, 105 CMR 590.000, Section 8- 301 .11 . Therefore, you are ordered to close your establishment on Friday. January 16. 2004 if the above mentioned application, fee, and fine, are not received. in this office by 7 PM. today. January 15, 2004. Sincerely yours, R oanne Scott Health Agent JS Hand delivered by Inspector & regular mail i-IMPORTANT MESSAGE ) FOR DATE � TIME Minh� _� `'� ��`Ir�1 1l32✓�� S PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBII F AREA CODE NUMBER TIME TO CALL TELEPHONE❑ .,. , , „„...................,.,............_._� PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL- / I WILL FAX TO YOU MESSAGE ids 6LI0.-bZQ 1.:�:._ (� o SIGNED FO d 4009 `0 IN IJ.S. /ao-off �nq oet ZY- � Als / t. 1� w +i I+ F� i F CITY OF SALEM _ BOARD OF HEALTH Establishment Name -71 1)-Vd n l,?l Date: -aU � Page: of 3 Item Code C-Critical-item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date # No. Reference R—Red Item I ,Verified 9 PLEASE PRINT CLEARLY ^� vf'`�^ss�n1 �m /� /'�n�.r�/D��lf ✓v,��iis�l/ �,-� -//,�i/�iUl�� h��/�l,//r/�1//l/.� J I ` n roapo/P -fDuhoh or, reuol/ 01 6J l t0! ,> 1,tic i. tiM - 1 I C F-an IM k�;I-Po Jc /-Yl - irlLt OR 0 W M 2 1 4-nlixrt Trnsporfaf /�� vt1 ` I 1 � I r : I ' I j - � Vr 11-O�IYI�L 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: L A -J0!.!4,.( PHFs P.ece.ved::Tenrpermucs Violations Related to Foodborne Illness Interventions and Risk Aaotdi ng to Iary Cooled it) tactors(items 1-22) (Cont.) 41`F/=45'17 Within 4 Hunts, I 3-50 i5 Coohn_,\-T::thuds for PHFs PROTECTION FROM CHEMICALS 11 Food or Color Additives i9 PHF Hut and Cold Holding ( PRFs:Maintained at o: below ? 5p( I!i(13i Chid 13-202.12 Additives'" 5910.004(F) 41';'.}5'F'` 3-302.14 Protectwn frnm UnaP oved Addnn'es* ( L K 16(A, Iioi ;HF;IdainWmed at or above IS Poisonous or Toxic Substances I 3 �"" 110'17'. 1-10t.11 klenitf}111glntarn:ancm-O:nginai i Container.," j3-5U!.!6(;i) Roasts Held atnrabovel3U'F .' ! 2(; j 'tare as a aub3:c Health C.ontro! 7-IO2.11 Common iVacoc - \'orkmp,Coo?ainzrs' 501 iP T;mc as,: Public Health Cunt!;r!" 7 '_'07,11 etvatio -Stou:f•e` ( I =i9U.fdidl Hl V:triunce Rcgnircio�jit 7-20-7,11 Reshiction --Yresenc< and Use I 7-202.12 Conditions )t sc* 7-203,11 i'oxie Containon-Pwfoho::tna' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE j 7 204.11 Sanitizer,,Criteri,, --Chemicals* I POPULATIONS(HSP) 7-^_O1.I2 Chemicals of `h"wslnnc Produ.�e,Criteria" I 121 ?-ROI.i'(-S) LoPasteunzed Por pael.aged Juices wad 7-204.1.4Di vmg Agents,Criteria' Bevrrazes with W arnin.�Labels` 7-205.13 Incidental Food Contact.Luhnrmrc+ 13-RC;.E!(TS) Use ofPaatenutedE�I 7-206.1! I 13-PO!.I till) Raw of Patnally Cooked Animal Food and Restricted Use Pesticides.Criterm° Raw Scd Spn,uss Not Served. 'A j : 7-206.12 Rmlent Ban Stations` I 3-801.11;Ci t 7nnpencd Fcui Paek.:ge Not Re served. " 7-206.13 "Tracking Pawdvrs,Peat Ccnnrof and i Rlumturin;,'r j CONSUMER ADVISORY 22 13-60 11 1 Com nsnet Ad,,isoq P:!sted for Cow uirption of TIME(TEARPERATUP,E CONTROLS lninuil Fno s'1',-t arc x.ne' Undeicooled of 16Praper Caoking Temp.=aturos tar I 1 Not Chhcre ise Processed to Eliminate PHF., 3-401 IIA(I12) Eggs- 15?`'FI5 Sec. i I Yathq; ns.` Hateshnnudiate Service !=45"FiSsec* 3-301.1; Pasteur;?ed R�s,. Substitute for Raw Shell I - I 3-401.11(A)(21 Comminuted Fi.,h,Alcats&G:unc HRca* , Animals - 155'17 15 sec. " 3-401.11(B)(1)(2) Pork and BeefRoist- !30`F121min* SPECIALIIEQUIREMENTS 3-401.1I(A)(2) Ratites,;nicetooNI.ata--155'1715 590 0091 A) iD) Violsous of Section 590.004(x'.)-(D) in sec, t catering, tnobnle�tood, ternpornry and 3-401.11tik)(3) Poultry,WildG::me,Sn 'cd I'1-IFs, remdent:al kitchen operations should be Siufting Comairir.-Fish,Meat, dented under t:":e o,npropriate sections P,-,ultrp or Ratite,-165°F 15 see. ° shove if rcka-_d to foodborne:illus; 401 1J(C)t:) Whole-nm•„le,Intact Beef Steaks interventions and risk f:!ctors. Other 145`17; 590.009 violations relating to guod retiil 401.12 Raw Animal Fouls Cooked in a practices should h-,(lebited under 1129- ! Micno+nave !{i5`F ' Special Pequicetnenis. 3-10).1i(A)(I)(b) All Other F'HFs - 145`F f5 sec. 17 ( Reheating for Hot Holding j 4I;OLAT/DNS R FLA TED TO GOOD RETAIL PRACTICES ! 3-403.1:(A)ACU1 11EF. 1651P15,,,c. (Itent523-30) -1-403.11(B) Mictowave- 165'F 2 Minnie Standin;= Cufe ad and non-drina:l viuGmnno l:hich do n.ri relate to the 1 Time'' f:odbonn,dL,ess wrer:,ent%;na and risk in<tors listed obore. can be 3-103.11(0) Commo."mIN Pox essed RTE Fool- found in rte follow 6f�,serosas of the Fond Cade and 105(.':Ill: 140'F- 5e0-000. 3-403.11(7,) Remaining t inshced YOrt10i15 of Ree` IItem Good Retail Practices FC =80,000 Roasts' ! 29. Management and Pe,sonnel FC--2 .003 It; Proper Gaoling of PHFs 24 Food are Ford Protection FC--3 .004 5 Eq,_:vn enI and Utensils FC-4 .005 3-501 14(;1) gwling•Cooked PHF, teem 140'Ir io ( 26. Wat.--:r Plumbing and West, FC-5 .Oob 70'17 Wohin 2 Hours and Front 70'17 I ?hvsical Facility F0-6 007 I to 41"F/45'F Within 4 How., ' --- - - -----) 2s:, Poisorcus ur"luxe,MaterialrC - 7 .008 '.-SOi.!4(Iit CoolingYtlFsP,4adcFramAnrbrent ( 25 ` pc-cialReumrrments 009 T,niretature Ingredients to 41`F145`F ( 30 Othe: -----_ Within 4 I inur:: penaes crmal i,em m are Irdcr:d 1990 Fo.v1('„dr a 105 IPiR',Qo too. IMPORTANT MESSAGE ) , FO a YLQ . DA,/" ` � Ol - / TIM tV� mr rnn .rl a E. OF PHONE AREA CODE NUMBER EXTENSION O FAX O MOBU F AREA CODE NUMBER TIME TO CALL TELEPHONED (i PLEASE CALL CAME TO SEE YOU II WILL CALL AGAIN WANTS RETURNED SEE YOU S U- W L FAX TO YOU MES GE I s DY in LE UJ P.l'a Il Y) �___ SIGNNEDEED � 0PS. F MADDDDDDE AMIN 40IJ0A PAP CITY OF SALEM ' + %� BOARD OF HEALTH Establishment Name:!_�in�2�7AJ S I�OCts7�f�v� /�/�z'7 Date: a- �� S� Page: of Item Code C-critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I n n.l mr eg- /i/»f�/Ol.r Jt' /?n i7, 0A Y /i��f, 4A ///ivrd-e 172 At-(I- l/il-e h/r ) aa'Leer J o /) / _ - // I'lAaA h0_11d(r11e'7 /ALL/i l<.a E I P?a(li -,17J s. `_ A/wn / 4/lik' hl'd V66 4 I l phi r l /a�Z PO Tia. YVnllcl/24 -A Ae 7(-I2 a/C - G/n�as ya o'/ /)// //V . 1 � �. , . P.�v/l hrx� 'ci�✓� �2 vn�c�� i / �'�r�l��e2 ,4 Y�/A? D� iJj CJ�G�ioY1 - ball(I' _L;U b,7e)e' A/) Q()b -� -h,4e- -A hind /,u/1 Ch 1`,04 4wrt�.2 10,fs )h vvxua' and 1 has rornauPd hnhn� CirH� fi e �� inzo �� /mac ( iAl - ,i Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: � 3->O; "C' PHFs Ke.etved at Temi,,:lanaes Violations Related to Foodborne Illness Interventions and Risil According tr l.aW Cnol.td to Factors(items 1-2.2) (Cont.) 41`FA5'r.!1'ithin 4 Hour;. 1 PROTECTION FROM CHEMICALS ?`•t)1 15 Cootin, vfeti:ids for PHFs r HF Hot and Cold Holding • 114 ( Food or Color Additives ' t9 I 1 .3 2Cq.12 Additives" 1 3-5W.16(B) �o!d P1 IFs Mai mailed It or below 590 o04(,F) -11 115° f'^ 1 3-302.14 Protect:un i;-oat Unappro,-eo Additives 1.5 Poisonous or Toxic Substances =-501.16,A) Het PHFs Maintained at or above 7-101.11 ldrnnitme Information Onginai I 3-ji21,16(A) Roasts Held at oraoo%e 130"F �ontat:en" ora• I ; 20 Time as a Public Health Control ( 7-102,11 Corn Narae -Wn�kin�Containers" 3-50 1 L 9 Time a:.a Public Health C'ortroP' 1 7-_i1L11 Sep,:ration- .S'!orcke^` ( r 7-202.11 Restriction-Presence and Use 59WI04(H) VrrianCe k0oUrrcntcer 7-202.12 Conchtions,6 Uscl i 7-203. 1 Toxic Containers-Prohibition:,+, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Saninzets,Critena--Chemicals- I POPULATIONS(HSP) 7-2(4.12 C'hemi•-als for W'ashuio Produce,Cr.crier"' 1 21 1 3-501 II(A) U po-4curiz d Pre-packaged lakes and I Eeve;a)_es with Warnin_labels" 7-204.14 Drtiing Asents.Criteria' - j 3-SUI.i'(PJ ilsrofYastearizedE;ces'" 7-205.11 hlcidcntul Fold Contact.Lubacann- 13-801.i I!D) Raw or Partially Cunked,Animal RYA and -06. 711 Restricted Use Pesticides.Catena Raw-Seed SPrxas Not Ser,ed. 17-206.12 Rodent Ban S:aOvas" I I I H(C) Unupelied Food Package Not Rc-s„rved. j 7 206 13 backing Powders Pest Cnntrnl and bloninni,'g CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS ?2 3-60.3 11 Consumc,-Ad+tarry Pomed for Consumption of :'Simnel Fowls 1hat are Raw.Undercooked or 1( Proper Conking 7emperainres for Noi Otherwise Pmc;sled n,F:!hmnate " PHFs 3-401.11 A(1 t(2) -- Fgg,- 155'F 15 See, ,_;02.13 k'a;teurired E Substitute for Raw Shelf Legs-hnmedirec Serrvicr 1.15Fi 5sec' gV€ -401.1 I(Al(2) Com:mnuled Fish, Meats X:Dante I Eggs Animal,- 153'F 15 sec, * I SPECIAL REQUIREMENTS3-401.11(8)(1)(2) Park and Reef Roast - 130P 121 mit:* 3-401.1I(A)(?l Rallies. Injected bleats- 155'F15 590.000(A)-(D) Violah,msofSection 590.009(A)-(1))in eaicrine. mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Gamc,Stuffed PHFs, residential Kitchen operations should be S!nffing Contaiuio«Fish,Meat, debited :ander the appropriate sections Poultry of Ratites 165`P 15 see. i above if related to foodborne !(mess 3-401.114')(3) 4Vhgk-awscie,intact Bee,Steaks intervention.and risk factor. Other 145oF* 590.0119 vielatiuns relating it)Good retail J X01.12 Rai& Annual Fonds Cooked in a practices should be debited under.R"9- Microwave 165"F* Special Requirements. ?-401.1 1(A) i)(h) All Other PHFs-- 145'F 15 see 117 Reheating for Hot Holding VIOLATIONS R iLATED TO GOOD RETAIL PRACTICES ; 40?.II(.A)k4tD) PHFs 165-T 15 sec. * ( (Relate 23-30) 3=03.11142) Micn acne- 165` i'2 Minute Staladitrs I t..r$ic<,i mrd eon-rriticu?vin;4r;u,r+s, which do,rot relate in tire Ti me ,irodborne diners isle rrenhon;;unci risk(ur tors lfs!td ubnre can be, 3-403.11(C) C'nnunerci;tlly Prixessed RTE Food- I ,found in the Jollmrin,g.sertrona o(!hg Food Code and 1615 CAP? I 14WF* 500.000 3403-11(F.) Remaining.Uncliced Portiomef Reef i Item Good Retail Procrices FC 530.040---1 Roasts' 3. _ Manarm eant and Pzrs `3 cn�el FC-2 .00 15 Proper Cooling of PHFs I -'4 Food and Fond Prote;bon FO- 3 004 25 Euuiumrnt aro Utensils FG-4 .005 ?'Ol 14(A) Cvolura Cooked Pfll s from IdU`'F to 2g, Violet,PluntLire and Waste FC-,-5 .006 i 70'F Within 2 Hour:,and Prom 7WF 1 27, Fao:;ity F"-6 007_ to 417/457 Within 4 Hour:;. ' 1 29. Poisonous or Toric Materials =C-7 .008 _ 3-501.141 8) C;mding PFIPs Made Front,Ambient I 124 Soec cal Requirement; 009 I Temperature fugredieuts toil TV45'17 1 30, Other Within 4Ilnurr 'Denotes caned Item it,Ou lateral 0119 Food('ode m 105 CN1R 50110(1 4 0044 JEFFERSON AVENUE Giovanni's City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 744-9111 PIC Assigned/Knowledgeable/Duties PASS ❑Q RED Owner: Non-compliance with: Steve & Katezina Konis Anti-Choking PASS PIC: Carole Madore Tobacco PASS Inspector: Janet Dionne EMPLOYEE HEALTH Date Inspected: Correct By. Reporting of Diseases by Food Employee and PIC PASS RED 5/2/2006 Personnel with Infections Restricted/Excluded PASS ❑Q RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS Q RED BHP-2006-0401 Receiving/Condition PASS Q RED Status: Open Tags/Records/Accuracy of Ingredient Statements PASS ❑/ RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS Q RED 4 Time IN Time OUT Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 03,2006 ) Page 1 of Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS ❑d RED Foodborne Illness Interventions and Risk Factors(Require Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED immediate corrective action) Proper Adequate Handwashing PASS RED Good Hygienic Practices FAIL Critical 0 RED �ments:employee was observed eating at front prep line at time of inspection.All employees to eat in designated areas to prevent contamination of food. Prevention of Contamination from Hands PASS 0 RED Handwash Facilites FAIL Critical ❑0 RED mments:There was no soap at back handsink at time of inspection.Owner to provide soap at hand sinkls at all times to promote and ensure for proper handwashing. PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS ❑J RED Toxic Chemicals PASS ❑% RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑J RED Reheating PASS ❑d RED Cooling PASS RED Hot and Cold Holding PASS ❑d RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Posting of Consumer Advisories PASS ❑d RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 03,2006 ) Page 2 of _ J Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE menu:there was some uncovered food in walkin.All food in storage must be covered. Equipment and Utensils FAIL Non-Critical BLUE Comments:Walkin fan covers had accumulation of dust and grime.thoroughly clean fan covers. Shelves in walkin had accumulation of dust and grime.thoroughly clean and sanitize to remove grime buildup. Water, Plumbing and Waste PASS BLUE ,Physical Facility FAIL Critical BLUE Comments:There were stained ceiling tiles observed throughout establishment. Find source of leaks and provide invoices of work to the board of health for our records.After leaks are corrected,ceiling tiles to be repaired or replaced. ,_�nt hand sink obstructed by boxes at time of inspection.Sink to be free from obstruction and easily accessible to ensure proper handwashing. grill hood needs cleaning.clean hood. crack entry stairs are cracked and chipping.repair or replace stairs. cracked light cover in back seating area.replace light fixture cover. ✓AC Vents had some accumulation of mold and mildew and grime.thoroughly clean vents. Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes FAIL BLUE —_Comments:There was old units/equipment outside in back area of establishment. please remove or dispose of properly. GENERAL COMMENTS: 597:This inspection was conducted for as a change of ownership inspection. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 03,2006 ) Page 3 of - Item Status Violation Critical Urgency R ! Mn ! t City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 03,2006 ) Page 4 of 0044 JEFFERSON AVENUE Giovanni's City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-9111 Food Contact Surfaci5s'Cleaning and Sanitizing FAIL RED Owner: ,-Comment:There was no sanitizer on food prep line at time of inspection. Sanitizer was made at inspection which read too strong. Steve & Katezina Konis Sanitizer to be rewadily available at all work stations with proper concentration. PIC: I Jason Gentry Inspector: John Gehan Date Inspected:Correct By: 11/29/2006 Risk Level: i Permit Number: BHP-2006-0465 Status: Open #of Critical Violations: I 2 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 ) Page I of r Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require /Comment:Walk in refrigerator has uncovered foods.All foods must be covered. immediate corrective action) /Th a are personal drinks being stored where food prep takes place. All personal items must be stored in designated employee areas. Equipment and Utensils FAIL BLUE ./Comment:True unit behind grill requires general cleaning. ,,:,,�rne unit missing thermometer. Provide visible and accurate thermometer. Sandwich unit requires general cleaning. a microwave requires general cleaning. (B/cP ack slicer requires general cleaning. „mean opener requires general cleaning. No sanitizing log available at time of inspection. Log to be maintained daily. �AeP- t-0r correctly. Mop to be stored so that it is hung and allowed to air dry. el gril requires thorough cleaning. ,,wMfe'freezer on food prep line requires thorough cleaning. vsame unit has.no visible thermometer. Provide visible and accurate thermometer. PhyXFay FAIL BLUE ere are many water stained ceiling tiles on food prep line. find source of leak and repair. Owner to fax over invoice to BOH from company who completed new roof. GENERAL COMMENTS: ✓Owner to fax over past three months of extermination reports to BOH. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 ) Page 2 of Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 ) Page 3 of Massachusetts Department of Public,Hdealth Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem MA-0.1.97.0= 523 FOOD ESTABLISHMENT INSPECTION REPORT <Tel. (978) 741-180�Fax(978) 745-0343 % Date T o_e of Ooeration(sI Tyge of Insoaction Name n� /�� J f ) P t A /P( u� �-1 a_'' I Food Service f�Routine Address (1 _ n n11�n3iS/M /1 �`/l�i�// Risk Retail f❑ Re-inspection �ae-K M.v I ,r Level ❑ Residential Kitchen Previous Inspection Telephone U � '144:0 ( i t ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑ Pre-operation El I c ElCaterer El Suspect Illness Person in Charge(PIC) rt�^n n n Time El Bed&Breakfast El General Complaint �s ( Y/ ! !� In; El HACCP Inspector c )rn�A_d, l�Im�t�'� Out: Permit No. ❑Other Each violation checked requires an exp n4 ion 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) p 590.009(F)/Ja action as determined by the Board of Health. FOOD_PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands V-t1N/ OR 1. PIC Assigned/Knowledgeable/Duties El 2. Reporting of Disease O 13. HandPROTECTION Fsh Facilities EMPLOYEE HEALTH .. ( PROTECTION FROM CHEMICALS Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals LFOODFROM-APPROVEDSOURCE "_ _;,) �-- ....,...- ❑ MPERATURE CONTROLS(Potentially Hazardous Foods) 4. Food and Water from Approved Source I TIMEFE ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures V� ❑ 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 t REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP): 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices I-CONSUMER ADVISORY G22. 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 gCN by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2)590.0 4)) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-4)(590..005) cited in this report may result in suspension or revocation of Q25. Equipment and Utensils (Fc-4)(59.0..0.05) 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 d 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 5901Llpe o 14,E Inspector's Signature: Print: }, ' I PIC's Signature: �� Print: �� Page o&Pages a-A.(� ho J s h� R IP Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 3-302.11(A)m Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients { 2-103.11 Person in charge--duties 3-302.11(A)(2) Raw Anined Foods Separated from Each Other' EMPLOYEE HEALTH J 2 590903(C) Responsibility of the person in charge to 3-302.1 Food P Contamination from the Environment 302.11{A1 Fuod Protection'" require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants* 13-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Fad Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 590.003(6) Reporting by Person in Charge* ( 3-306.14 A)(B) Returned Food and ed orCof Food* ' 3 590.003(D) Exclusions and Restrictions* ( Disposition ofAdukeracatedoontaminated Food f 590.003(F) Removal of Exclusions and Restrictions 3,-701,11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE rew* { 4 IFood and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-5{)1.11 I Manual Warewashing-Hot Water { 3-201.12 Food ma Hermetically Scaled Container' Sanitization Temperatures* I : { 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water { 3-202.13 Shell Eggs* Svtitization Temperatures" { 3-202.14 I Eggs and Milk Products.Pasteurized* 14-5{11.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* _ concentration and hardness. 5-101.11 Drinking Water from an Approved System- ( 4-601A I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean" Water Meets Standards 590.006(B) GMR�_,� 14-602.11 Cleaning Frequency of Equipment Food- I ppr Contact Surfaces and Utensils* } Shellfish and Fsh Fromm an,Apprnved Source e ! 14-70' 11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Rea'oatioaaliy Caught Molluscan Fad Contact Surfaces of E_uuipment* Shellfish" 4-703.11 ( Methods of Sanitization-Hot Water and 3=201.15 Molluscan Shellfish fram NSSP Listed 11 ChemreliP Sources" ) 10 Proper,Adequate Handwashing � Game and WiM Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* f 3-202.18 Sheltstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms` 2-301.14 When to Wash* 3-201.17 name Animals* { 11 Good Hygienic Practices $ Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 12-401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity' Mouth* 3-111.1 i 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 E 13 Handwash Facilities 3-402.11 ParasiteDostruetion' � Conveniently Located and Accessible � 3-402.12 Records.Creation and Retention* ! 5-203.11 Numbers and Capacities* 590.0()4(1) ( Labeling of Ingredients' � � 5-204.11 Location and Placement* { 7 ' Conformance with Approved Procedures 15-205.11 Accessibility,Operation and Maintenance /HACCP Plans I Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods' ( Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision f *Demes critical nem in the feder.J 1999 Pond Cade a 105 Cn4R 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: i/I f I n An AA i,✓J Date: '� - I Q - Page: of 3 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date. No. Reference R-Red Item / oA✓ P.VI '�� PLEASE PRINT CLEARLY Verified 5= ( � FA,,J-,e0. Int ^_jf� /� /�' CitC� I i7t ` Y �lQA nn. . . it A7/ � II/tv G/U' I✓� �1 A A $i rr �,nro_V eA I )n,A 1 0 A .-)A pMA'/ nl n l � ��/ . �Y)o fR�I.E�/1 — I/ lU l,0, A 17_)IOr I DW 1 �v-�-�/�n i i� � AJ ( �1�C; (VA ,�( ~ 0 0 A(\ rp..a1A, 7) G,;, 1) t� �_14, C.I, V01101-1 .n Q 10Yn-/� I ) Al11 .l_ J ,�- .rod (° �Jrvt rl �'Y 3'�xf�dl/IP/ C�� n '✓`1 fl/lel/ �1 Qw�i, /1.2�/y /nom i-.)/I� C. .o,rn T. a i.-'( J�,1 'W(.!�/J/ I 6 6A I Discussion With Person in Charge: Corrective Action Required: ❑ No 01—ye-8 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 EYRe-inspection Scheduled ❑ Emergency Suspension I with all mandates of the Mass/Federal Food Code. I understand thatI jP noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of LllEm ra go ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: S � 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'P/45`F Within 4 Hours. PROTECTION FROM CHEMICALS 0 3-541.15 Ccwline Methods for PHFs { 14 Food or Calor Additives d 19 PHF Not and Cold Holding 3-50L 16(B) Cold PIIFs Mamm med at or below 3-202.12 Additives* 590.004(F) 41°145'F* 3-342.14 Protection from 1?navproved Adtiltives'Y 3-50 L I ft(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances * 7-101.11 Identifying Information-Original 140 . 3-541.16(A) Roasts Held at or above 130'F. Containers* - j 20 Time as a Public Hewitt,Control 7-102.11 Common Name-Working Containers* ! f f 3-501.19 Time acaPublic menfltContrtat* 7-201.11 Separation-Storage* 590.064(H) Variance Requirement p 7-202.11 Restriction-Presence and Use* ent j 7-242.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* ( POPULATIONS{HSP} 7-204,11 Sanitizers.Criteria-Chemicals* i 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-2(4.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.1ItB) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(1)) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sperms Not Served-* 7-206.12 Rodent Bait Stations* 3-801.11(0) Unopened Food Package Not Re-served. " 7-206.13 Tracking Powders,Pest Control and Monitoring'^ CONSUMER ADVISORY TIMEIFEMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of i 16 I Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or Not Otherwise Pressed to Eliminate Ps Pathos ns.* Processed ,,,xnf 3-401.IIA(1)(2) Egggs- 1S5`F 15 Sec. Eggs-Immediate Service 145°Fl5sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats R Game Eggs' Animals-155°F 15 sec. 3.401.11(Il)(Ii12) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 J 590.004(A)-(D) Violations of Section 590.009(A)-(D)in j sec.* i catering, mobile food,temporary and 3-401.1 I(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec, * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,lnw Beef Steaks interventions and risk factors. Other 145°F* 590,009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PIFs- 145'F 15 sec.$ 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3443AI(A)&(D) PHFs I65T 15 sec.x {I4ems23-30) 3-4E)3.11(B) Microwave- 265°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors luted above, can be 3-WA I(C) Commercially Processed RTE Food- fnand in the following.rection of the Food Code and 105 CMR 1400P* 590.000. 3-443.11(E) Remaining Unsticed Portions of Beef � I_item_ 1 Good Retail Practices 1 FC 690.000 i Roasts* ! 23. Management and Personnel '. FC-2 .00.3 1 yg Proper Cooling of PHFs i 1 24. i Food and Food Protection I FC-3 .O(A 1 25, I Equipment and Utensils 1 FC-4 .0705 3-501.14(A) Cooling Cooked Mir%from 140'F to 26, Water.Plumbing and Waste 1 FC-5 .006 700F Within 2 Hours and From 70°F 27. I Phvsical FaciRty FC--6 .007 I to 41`F/45'F Within 4 Hours. * 1 26. Poisonous or Talc Matenals FC-7 .008 i 3-501.14(B) Cooling PHFs Made From Ambient � 129. 1 Special Requirements .009 I Temperature Ingredients to 41°F145°F 30' 1 Other Within 4 Hours* "Dmotu critical)ram in the f deral M0 FocJ Cale or 105 C4n2 390.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: 214 J„) nn.q ,.A, , Date: SS-( -1—i Page: of 2, Item Code C—Critical itemDate No. Reference R-Red item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Verified PLEASE PRINT CLEARLY , I OL--4- /t 'V 1_ L--4- -i� )��Fit, o 1,A1VV1VVt PEI,_n - ( .G n/1 a 1x5- til_--m3'o COIL - /�/� e „./- Y)r,4(,01 _47/ �� n �� Y� / 1 d.Li �/ � ) �,A /U�Q�M ew� V U/✓/ tQ 0y\ I � c ,a o� — �6 t\ — wo vno,Q. �x 1 e �, am 0'/V7u JL Pti Q I k EVAo_n -C .to ' �� I 6-Y 'It LMv A2' /`7 � LAAn_ e?',.0-01 d I >s r I-, nCoA ;A � � e . oma, (� npn -�,7t1MY/� � rL, �lannDrV� Discussion With Person in Charge: Corrective Action Required: I ❑ No I&3/Yes !, I have read this report, have had the opportunity to ask questions and agree to�correct all QjVoluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to p a/Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understain 1Ahat? 1 U' ,� noncompliance may result in daily fines of twenty-five dollars osspension/revocation of o Embargo ❑ Emergency Closure your food permit. t ❑ Voluntary Disposal ❑ Other: t �� 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne fitness lntemenilons and Risk According to Law Cooled to Factors(items 1-22) (Cont.) I -tl'F/45°F Within 4 Hou&. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives ` 19 PHF Hot and Cold Holding 1 3�OI.I6(B) Cold PHPs Maintained at or below 3-202.12 1 Additives o 3-302.14 Protection from Ur proved Addirives" 590.004{F) 'f45°F* bstances ;-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Su 7-101,11 Identifying Information-Original 140 F. 3-501.16(A) Roasts Held at or above 130'F, " Containers" 2® Time as a Public Health Control � 7-102.11 Cotmaton Name-Working Containers* 3 � 7-201.11 Separation-Storage* 3-501,14 Time as a Public Heald)Control* '� � _ 7-202.11 .Restriction-Presence and Use* ( 090.004(H) Variance Reduirement 7-202.12 Conditions of Use* REQUIREMENTSFOR HIGHLY SUSCEPTIBLEEPTiBLE 7-203.11 'Toxic Containers-Prohibitions* POPULATIONS(NSP) 7-204.11 Samtizers.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pte-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* 7-204.14 Drying Agents.Criteria* Beverages with Warning labels* 3-80L I I(S) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contam Lubricants* 3-801.11(D) flaw or Partially Cooked 1Sninral Food and 7-2V6.11 Restricted Use Pesticides,Criteria* Raw Seed Sproms:Not Served. * 7-206.12 Rodent Bait Stations* 13-801.11(C) Unocened Food Package Not Re-served. ' 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TiMEti EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of d6 Proper Cooking Temperatures for Anhnal Foods That are Rau-.Undercooked or PHFs Not OtherwistvPre cessed to Eliminate 3-401.IIA(1)(2) Eggs- 155'F 15 See. Patharens* Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.1I(A)(2) Comminuted Fish.Meats&frame Ems* Animals-155'F 15 sec." SPECIAL REQUIREMENTS 3-401.£I(B)(1)(21 Port:and Beef Roast-130'F121 min* 1 j 3-401.I1(A)(2) Ratites, Injected Meats- 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in } sec.* catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat. debited under the appropriate sections Paul"or Ratites-1-n- t5 sec, * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steals 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 k29- Microwave 165F* i Special Requirements. 3-401,1 I(A)(1)(b) All Other PHFs- 145°F 15 sec, E 17 Reheating for Hot Holding WOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. * (items 23-30) 3-403-11(B) Microwave-167°F 2 Mmnte Standing Critical mrd non-critical violations, which do not relate to the Time* foodbonte illness imerventions and risk,racrors listed above, can be 3-403,11(C) Commercially Processed RTE Foad- found in the following sections of the Fuod Gide and 105 CMR 140°F* 590.000. 3403AI(E) Remaining Unsliced Pordons of Beef i Item ; Good Retail Practices FC54A.UW I Roasts* ' 23.1 Management and Personnel ! FC-2 .003 I Proper Coolie of PHFs 1 24. i Food and Food Protection I FC-3 .004 I 1!Sg 1 25. 1 Equipment and Utensils i FC-4 .COS � 3-501.14(A) Cooling Cooked PHFs from 140`F to 2& ! Water.Plumbing and Waste PC-5 I ,W6 i 700F Within 2 Hours and From 70`F 27. 1 Phvaical Facility FC-6 .007 1 to 41'F/45'F Within 4 Hours.* i 28. ' Poisonous or Toxic Materials ! FC=7 .008 j 3-501.14(B) Cooling PHFs Made From Am hent 129. Special Requirements 008 1 Temperature Ingredients to 41°F/45'F 30, i Other i Within 4 Hours* 'D.c(,ta<critical iwm in the Laderal 1999 Fwd Code ww 105 C-SIR 590.000. -IM'4`b..ie',n�xa Mtiir4,ae' t -rA • . -'*'I* •:K•1ky:. .-"^�L,,:�"",w,'f��.+e.:d -�,, r'i e. �+. . ., .a a T Nfassachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4t" Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name-) Date T o€of Ooeration(sl Type 6f Insoection rJ i rl lJ�VI A 1 S R-�� {f 19 Food Service EKioutine Address 4 L4 �FD10P�S�� 7 P Risk 1 ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone qn � Mobile Date: - � u� - dill El Owner HACCP Y/N El Temporary El Pre-operation .7-% y W' on lI<; ❑ Caterer ❑ Suspect Illness Person in (PIC)Char g Time El Bed&Breakfast El General Complaint 9 ❑ HACCP Inspector t�� \n I Out:( �UxAXN Permit No. ❑ Other Each violation checked requires on exp anation 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)X/ 590.009(F) action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT a. � - ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH "PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded 15.Toxic Chemicals -FOOD FROM APPROVED SOURCE„ .TIME/TEMPERATURE CONTROLS Potential) Hazardous Feods ❑ 4. Food and Water from Approved Source (Potentially ) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION - ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)' ❑21. Food and Food Preparation for HSP VVV ❑ 10. Proper Adequate Handwashing E] 11. ADVISORY 11. Good Hygienic Practices [122. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board - and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 24. 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations v l 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 t 26. Water, Plumbing and Waste (Fc-s>(sso.00s> establishment operations. If aggrieved by this order, you O27. 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 S 5901nspoctFoim6-ILtlM'/�\l, 1 �.SYr7--�I-i"A-t,2.� �fl-OKorder. 30. Other DATE OF RE-INSPECTION:l_ 2U ,y�`. W � LV` Inspector's Signature: (` ) Print: Y•�,.� /IWIIA.•�N1`��/,�+�/J/•1pr/W�� //, _y`J'}�\�7/1 I C�.l PIC's Signature: i Print: Q)1��„ �', Y� I Page of3 Pages J 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* 3-302.1 I(A)(l) 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 Animal Foods Separated from Each EMPLOYEE HEALTH Other, 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 13-302.1 I(A) I Food Protection' f applicants* 3-302 15 Washimi Fruits and Vegetables 590.003(F) Responsibility Of A Fund Employee Or An 13-304.11 I Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590,G03(G) Reporting by Person in Charge* I 13-306.14(A)(B) Returned Food and Reservice of Food* 1 31 590.003(D) Exclusions and Restrictions* I I 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 I Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 14-501.11 l Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* - Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* _ __ __ Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 I Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Water from an Approved System' 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602,11 Cleaning Frequency of Equipment Food- I 590.006(B) Water Meets Standards in 310 CMR 22.0 ( 1 Contact Surfaces and Utensils* 1 Shefifish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish" I 14-703.11 I Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed ( Chemical* Sources* Game and Wild Mushrooms Approved by 10 I Proper,Adequate Handwashing Regulatory Authority I 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 ( Game Animals* 1 t Good Hygienic Practices g Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 ( PHFs Received at Proper Temperatures* 12401.12 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* 13 Handwash Facilities Tags/Records;Fish Products ( Conveniently Located and Accessible 3402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 15-205.11 Accessibility,Operation and Maintenance /HACCP PiansSupplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 ( Reduced oxygen packaging,criteria* 11 6-301.11 Handwashing Cleanser,Availability f 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision 'Denotes critical item in the Weral 1999 Food Cate or IUs CMR 590.000. _4 city. bV.,ADEM i nI BOARD OF HEALTH Establishment Name:X a/ TrUXA AVU Z„ > Date:�— �.(n—�_ �1 Page: c�2 of _ Item Code C-Critical Item i r _ DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date /" No. Reference R-Red Item ,J -y- Verifled � PLEASE PRINT CLEARLY `_LY\/tA"YL, ICA , 11.0, ► ,�� `t 1A)A 16, _�1 �" `�_ �t:' �At nim G XIFl� "1 /.V/ I V '/' - I��l)'7 LPr.. Y6 U.4 4-1. ::G F10Ctik� J _� �� /r)� � - ' ��)/1V t/Oil n.Cn ()/t.._.l! N_ '�!� �_�Va 4,Qil ,•,O.a t- 9,0 mR (An e_ 0, . n4 FGtP o^Aj (YP '-IAP_ �OA O.Aa.vt 1 � _/� �S . n /1 I� _ � . � � \ V t7")�'�" I�/1 - ` !AAAQ s�.I'AOP J ( s Q,'v1,c A t _ U i;a'-r'/ — A,)o r A r.,, � �nA�, _jW_c l o)-�-)kf) he r`>�� I ). f I ! ( (10/14) CP,11 J n,t/a Yi/v1i1 �Aj[nt_( 7 U ell �'il,rn.,l n).TV vbo Ar- -A(P' _9? ()L)rx L- ,( w"' ao '1 t Pn) r n'. IWAZ Discussion With Person in Charge: I Corrective Action equired: Ll No 1p, Y I have read this report, have had the opportunity to ask questions,and agree to correct all Voluntary Compliance ❑ Employee Restriction/ , Exclusion violations before the next inspection, to observe all conditiorls as-described, and to �6, Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that USC' 'JU 1 noncompliance may result in daily fines of twenty-five dollars or sus pen si_ on/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-54111 14(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk Auvi ding to LawCooled to Factors(Ifems 1-22) (Cont) 41'F/45`F Within 4 Hon's. PROTECTION FROM CHEMICALS 3-501 15 Coaling Methods for PHFs J 19 PHF Hot and Cold Holding 14 Food or Color Additives 13-501 }6(B) I Cold PHFs Maintained at or below 3-262.12 AdtLtives' 59011113(}-1 41`/45"I" 3-302,14 Protection from Unapproved Adddtve',' I - .. ..� r Poisonous or Toxic Substances 1 13-501 A A) ( lint Pi'll's Maintained at or above 15 ! 140'F (01.11 I Idenafymg infnmdlnm - ttug!n.d '+-5;N 15(.;1 I Roast,He(d at or above 130`9 ! Containers` � 17 1(P_.t l C_ou mot.Name �`t\ rte, ;,nr iner,' i 1 20 I 1 Time as a Public Health Control rinm as a Public health Control' ' ur --� � ',-2tF».1! kc>tticron-f'Jcunc:u;ai,•:* � ,--str't(�irHt .__ VvmcrRcgnfrenxnt j 7-2g1.i2 Condition,of Use" I 7-203 H 'Toxic Container, -Prohih,:iotio' REQUIREMENTS( FOR HIGHLY SUSCEPTIBLE 7-204.1 I I Jamlizets,C'nnru,-Chemic.,,¢^ I POPULATIONS(HSP) — >r > sE i-"t-�iti IitA, linpurr wit f`m-par.k:a:cdlouts:,nd 7-_,}}.L. � ('huuieals f?e Wa,h_in,pr,,d'r:z.Cntetia � ! "' 4 7-204.14 Ur,rnr Aetna.Cnte ut'^---- !3e.cra>e.with 1+'arnink I,ahei�,. 2U5 1 t Lt.id.:nt.+1 f-.,;xl t_ontact.F.uh::ean!s—� `Rt;: H(Rl 1'',e o' Fa.tewi.:rd Etip:` I . I '-,-S,t! ilri)i it.r.: orf,una{7'. G+tk:dAailnslF,x.tla1'd L >Ob:t I 2c.in�red f'sr Pe>n.:nte,, coteua" - -_ _-- — _--.---_ _ P S::•d>amnn. Not 5crvr,i. G:' 1 .rl:nd !-�,xki Pac:sCr 'tia! �'e-:;c.nc.; .itFl 13 •haAmg i'mu{et;, onttorin CONSUMER ADVISORY 't a4F1iEMPERATURE 9 OrdTROLS `1 22 itr= : It j t I'll nnwf .1 It et Pocl,d i.,r C'ont<an,nt+'n ui -. -- 3ttat,uc Rm, to i Proper for i ! ;u Cfthet^nse Pluxvser-d!",Flimorav PHFs ------'----- i .. I i-,d.torn:,.d Fs;g 1 tihs:itar•ka Rau'St"14 � t F,lzc-irifuwd; to '.e =tb_ I't5'Tl S:e.• R,s,{ .:c {>,; R ,.1 ; f- i;. -- cPFCIA.I. REOVIREMENTS aod i i .Itt:,l iiA}: ,) j Pnut,r•,,l',ild(i:u,n: Sla^'r.i PPG's --�- :;.it:r'uCai lh,:htn apetatiaas :?na;ld {zr Suffcta t'•,rrzo,n= ! ::;, '.!est, r.chd:•t' u:u=er tit: aiq>r,"prtx2'. �..:::utt, j i '";ui:', o: !:fa:+:-'E`; '+ �.�:. ..tT��; :' :�'I ray{ t,,_:`i':Sf}.:Tri. 'uf •� ' T rr,PirGaUID f.}t}, - ? tf.'Ht I,lrt .._. _.-' , r{; --t.,.� 600D PETAAIL (F',_;:.c_:FiC:,..` e 03,111 A)"'i t)_T Pili , 16s"i- ;AT)3 11lB} %Icn,I aw- I/:>' l ' 4hnn:,'S,andtm,; { Gr<::ze z' r o,r- ..rtr.,:, ::o• rt:..,,.. ,,;:ir tt e;t'•'.0 �,�t'tr +t... Tile 1 L)c.tr�q rftc i'ti+. . ....I .,q, ,•!,: "Aja,i Jt< j. ,,,f,+IPn (;.ti -403.i1t(:) C';mrns.'iaih },,t>,ec,,, Wt's- 1-,t ., .".l tf. .: -l+ x; , . . .<. ?4xrzl Cora a+.,%1",it'd;%i '40•l+` :-101 t 1(6 r Fetn:uninz,Ln wed trent Good Retail P,acttces FC So.PJG -' ' FC 1H Proper Cooling of PHFs ri" ''"d,:.>-xt F'_p,crpo=': _. FC - :' P5. t• ,t,^nir-n'.enr,t,ter_,s --- ------•_FC.-'' ;t.1 51,1 I IfA i Cwlinc Ctx, rd Pfii-c it-ri, 14),F ar - - '- -- - - - - - -� ' ) 4. ! + ?r,. ._ " '.,fir, -,4'n":mC` ef^ _.: I Of Within 21iuur<widFroin TIT _ _ ["tr: a___._ _.. --�_-:-FC_(;_-- �CC, -- 1 PWtNn-t Hours N Pu.>-a^_i r3.t„t��x:,.-tit;{ers's �I r"C -7 J 6pd-- 2 _ --- ----- it(H) i,K,liue PHF: A'tridr Frrot "1011mut � �-%°`_ ._3p,=i+a. R�4t.ir_.f�ri_�•._. `x� _ 3'rmi rraurce ht�red9rr.:= I,' ;1�!'i45 f� ; "+i; ' r,tac.: j lti'ithm 4 lt,nrr.' ., n,•„"tr,roots{tion ,nih,'I,dr,dI f CITY OF -SALEM p� BOARD OF HEALTH Establishment Name:8 _A/U71AA_n L.c1_ Date - -7�.t0—n q Page: of , Item Ccde C-Critical Item DESCRIPTION OF.VIOLATION/ PLAN OF CORRECTION Date No. ROerence R—Red Item a Verified PLEASE PRINT CLEARLY �I 7�� n.�G�FA `hrA IiA2i 0A Q_ � ArnA � . Olin- 004� I �:Ati1U ,a.- d rev c eel 11 CkilO O.t ail Pn v an�i,I R, (i nhwn-r !pn V> ��Y_L •'I �`JA l- 1/k,i �[jY�J_(�J/�/y't�� /�� r'\ , /'1., n.,FJ � �V JP '�7't,:J-Y • I v I A—J 0?�nA 010A . Q44/-\��I—� nA 7w __ - /n)n� J(�1�1�/� AN I I r t Discussion With Person in Charge: I Corrective Action Required: I ❑ No �e 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 2 U e,p* noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: l z E 3-5ol.id(C') PHFsReceivedatTemperatures Violations Related to Foodborne Illness Interventions and Risk According to Paw Cooled to Factors(!tents 1-22) (Cont.) ( 41°F/45'f`W effiin 4 Hours. * _ PROTECTION FROM CHEMICALS ' 3-50115 Cooling Method~for PHFs 14 � � food or Color Additives I � ]9 ( PHI Hot and Cold Holding 3-501.16(B) ( Cold PHFs Maintained at or below 3-202 12 I A(ditives" 590004(F) f 3-302.14 Protection from Unapproved AdddiveS, j 4('145`F^ t 13-�01.16!A) Hnt I HPS Maintained at or above Poisonous or Toxic Substances 1 I !40'F 7-((11.11 I Idcntifymg(ntn:mmon -Ung,nal i 3-501 , t 1 1:t-%) R„asts Held at or :,hove 130^1 , If Containers, - 1 ! Time as a Public Health Control 7-102 11 I Commonutmm�v tismr R'.�^kttrs'C,ou;nr,:•r+' � � 0 7-201.11 ! Sapat.tuon-5turape" 'rim, a.a Public Health Control' [2:102.11 _ Ite>iricGnrl-PJ,srncc.md{ .r" `-1 —.�'.t}i H j V r;arcr .ttomrt'nrenl i 7-202.1 —# C'andolon',of l kc" dl 7-103 tlTaxic C'onunnc - ProbiM:n+n,, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE -'_ 1POPULATIONS e:+r.a(tHczueSsrrPr)24.11 Janiowi,,.Critw-Chcmic:dS' 1, 7' henutaio-fvt Wathu •_nb ae ClittrVci dth Pr pnnc}.acLcadl.,JAusic` nS wa1 7-204 14f)r'an'+Accna Criteria' y{;; l - - (15.17 In:id:nt al F:xtl ("onta., I.ttb,1.:11111 S' Ili)t 3<, u or Pail'ai1'. Cog};;i! Animal Ftn,d and I T- 116,j I Re.itttldtt 1'>e Pe,tict,Fef. C11[er+:° I titi,rtad ._ No! %1lri ' PC,,Ci, i n. '1}vc l,n .£'+,'.t Jt•: }'...,C+stir.•' ,=ltd c `=--' - - ---_ _ �_..__.._� CONSUMEP ADVISORY o7 L TiME/TEMPERATURE CONTROLS ; 7e—i --`-----i Proper Cooking Ternpe,alwesfor '<:„+r"; i x•l. t'r,.t tet. 1't.,v, t:nticr.:>;*tett,:; i Press I �trt iltltrr. :v !'n�ess•',:; I:lu:urt.trc' 1 1 ., F +' huu,ttdr:ne err•Lc ! ;<`;'!5:e: `o�.i { I i',.::ern,:d !'gig..tit::arrnr ter K;+w Sliell , l= 2 l.nh, 5- i , ��->'�:�SQtiti..i Ua?(r7 : Haute• t,=ic.�'t: i.h.as - i7'+ c_i° �_ e _ RYa-at>t Y C, ; Eti Y:.I103)(1 ?t RCC __-- :n i � ftL, •, � F Yttir.O F„ tLJ},31. #th)t., ieHr}?.A3;,j 3t:L; i 4t11 1;,At,"tt !':ri)In t}ild CamC 5'itlteet}aRiF<. S :;:,'t;:'ei:al }.:tw}ten r<t',t.ttictns ;totttC S-i i j ('owio,iSSI_Fri n M z ,t 1 L";F"e;"v 4od1,I flu- an'l l,prlo!t. ',c'i ion, .. ;..�, =n i:; tt ,-. t . .,.. C':�� .... .. .v,. .. ..., !:, , . + Si t+y'. , + , :r _. Hot,,,r (--- .. 10L'--F, -. tA _ ( 3-itl5.ill,lit2<u; Plil 16`''t .c: t ;tteutti.:3-,4tit dG-{.l i!}tl _-- -- '•,7. ., Ir:^'(. , x!"tt::r St.tc,fird, u . ; ,-. ,,. , , .: ..t ..t: . rr.it eG:.rn; enta . Tint ( -..P.(ir, .. : . r•br4o,rt11 ,6t. . p ,. 4n Ly°1:•7(,1,..+ r, ,.+/r i,r ;_.jn3,1}tf'i C'rnt=:c<:::iniP, 74t„es�:i 2'7"t=}•-k` � ...:r:I i'r,j.;., ., •�;,;:....., ?t� 1'tr,r<t(rci;...,.d;r -,� d;n' 41,.P, 7(I:? f i?rrt::t,nng,L"r„i'trtf t>t.ctr„n.r>i'ti':rt 1 Ae,n rood Retu,l Prarficus - ----- �-�-_Ft---.- -{59L'OtXi. kna.`,, �' i:h,;na{7nmc ri a'a Peir.,,•,rr, I rC.. .? .__`_`___. , ' ! _''____.-`ax7.;,,d�t_V P:oice thoa FC-_3_ �(1()C_. ]S Proper Cooling of PHF5 - - --------- - -- _ _ . cga�l,n,?nt and L,iH'S•fg f r.' _ 4 dOD ( 5i!F Ia(A) f'txdlu+>Gw�,ri'PF{7=t (tont ! i(}<[ tr ,c _.. _ __ _._ _ - _ _ ._ n __ r_ Pu-%,”, v`!z:',^�- 7r t' Kuh,noFrom 7i" y ------- _FF jTf- -- -- - CC 5- G 6Cr F1nut -j _2•< __ __.vsanxt',er ,,t.,- 5ta[,-:'.1'° ___ .._,_=C- 7_ yUf.: r" 501.14(1(1 iroin+q('i11%1t Cdr I-Font Anthem •'-- Sp'�:'al Ficitgir•3trptr- _ _ -- --_ tX;;+- - Pcm},rarare :ueret!;cr,:"u' :7'4�'dS F� '!• ibex .r,I,.j-..�.J .r. a...,,vO.l:,•�,^u.t'r�:r.,r�.wt°''+^°^ M7e'�y-Y+Y• .v� .a + '"�`e�< .i.:1 1-<r' d.a Pr-k.`R'aa.1,..J +r� fli.1 i, .a r�r..i '�e � V J 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 F : Tel. (978) 741-1800 Fax (978) 745-0343 Name n Date Tyke of Okeration(s) Type of Inspection < ql(o(X I ®-Food Service [Routine Address _/i/I� [( �y� Risk ❑ Retail We-inspection wr\� flic Level ❑ Residential Kitchen Previous Inspection Telephone '7 �^ ❑ Mobile Date: 3 q74�! T 7 �� El Temporary ❑ Pre-opeion Owner ` / HACCP YM `) �VR K J S ❑ Caterer ❑Suspect Illness Person in Charge(PIC) r--� i ime I El Bad&Breakfast ElElGeneral Complaint HACCP Inspector - Permit No. ❑ Other 1 it s o r-, �A Out:y i-� Each violation checketl requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. "FOOD PROTECTION MANAGEMENT., _., ;1El12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El 13. Handwash Facilities EMPLOYEE HEALTH w „.. .. ' PROTECTION FROM CHEMICALS" ❑ 2. Reporting of Diseases by Food Employee and PIC „- • - ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded _ ❑ 15.Toxic Chemicals „FOOD FROM APPROVED SOURCE ... ❑ 4. Food and Water from Approved Source ; TIMEIrEMPERATURE CONTROLS(Potemielty Hazardous Foods)` ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION " " """ ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY sUSCEPnsLE POPULATIONS(HSp)_;'. ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices w ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection, immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. . 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-4)(590..0054)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-5)(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. h -- 30. Other DATE OF RE-INSPECTION: 1 5 59JMn,OFom 14 Doc 0 /)o \�, 1 1 'AV/g ✓ " Inspector's Signature: ^I' )(- Print: vC PIC's Signature: Print: rC�1� 1-eN7 (� _ PaSe oft Pages l/ Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION_MANAGEMENT { S Cross-contamination 1 590.003(A) { Assignment of Responsibility* j 3-302.11(A) 1) Raw Animal Foods Separated from 590.003(6) Demonstration of Knowledge'' { Cooked and RTE Foods* 2-103.11 Person in charge-duties { { Contamination from Raw ingredients { j 3-302 11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH I Other` 2 590.003(C) Responsibility of the person in charge to I ( Contamination from the Environment require reportirw by food employees and 3-302 1 t(A) Food Protection` applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.1 i Foal Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* I Coniannhation from the Consumer j 590 003(0) Reporting by Person in Charge" { 3-306.14(A)(B) Returned Food and Reservice of Foal* { { 3 590.003(D) I 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 Ford* 4 ( I Food and Water From Regulated Sources 9 Food Contact Surfaces { 590.00AI(A-B) { Compliance with Food law a j ( 4 501.i 11 Manual Warewashing-Hot Water- - --I 3-201.12 Food in a Hermetically Sealed Container* { Sanitization Teniperahres* 3-201.13 I Fluid Milk and Milk Products* { ( 4-501.1 L2 Mechanical W'arewashing-Hot Water { 3-202.13 Shell Eggs' { Sanitization Temperatures* { 3-202.14 Eggs and Milk Products.Pasteurized* { ( 4-501.114 Chemical Sanitization-temp.,pH, { 3-202.16 Ice Made From Potable Drinking Water- { concentration and hardness. j 4-601 A I(A) Equipment Foci Contact Surfaces and I { 5-101 11 Drinking Water from an Approved System" { J Utensils Clean* 590.006(A) Bottled Drinking Water* { 4-602.11 Cleaning Frequency of Equipment Fod- { 590.006(B) Water Meets Siandards in 310 CMR 22.0* { 9 Shellfish and Fish From an Approved Source j Contact Surfaces and Utensils" 1 4702.11 Frequency of Sanitization of Utensils and I 3-201.14 Fish and Recreationally Caught MoRusc'm Fad Contact Surfaces of Equipment* J Shellfish' 4-703.11 Mcthods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listcd ' ! Sources* Chemical* ! ( 10 Proper.Adequate Handwashing Game and Wild bfuAuthority oonrs Approved by 12-301.1 i Clean Condition-Hands and Arens" { Regulatory Authority { 3-202.18 Shellstock Identification Present* j ( 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* { 2-301.:4 When to Wash' 3-201.17 Game Animals* i 111 I Good Hygienic Practices { 5 Receiving/Condition { { 2-401.11 Eating,Drinking or Using Tobacco* { 3-202.11 PHFs Received at Proper Temperatures* { 1241)L 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* J { 6 { Togs/Records:Shellstock j { 12 j Prevention of Contamination from Hands { 3-202.18 Shellstock Identification * j 5'10.004(E) Preventing Contamination from { 3-203.12 Shellstock Identification Maintained'' { ( Emrployecs" l { Tags/Records:Fish Products { { 13 { Handwash Facilities 3-402-11 Parasite Destruction* j ( Conveniently located and Accessible j 3-402.12 Records,Creation and Retention:: i { 5-203.11 ( Numbers and Capacities* { 590.004(1} g g { { 5-204.1 l { Location and Placement* -- - Lobelin o41n Ingredients* j ry Conformance with Approved Procedures 5-205.11 { Accessibility_Operation and Maintenance { fHACCP Plans ( Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* ( Devices l 3-502.12 Reduced oxygen packaging;criteria* { 6-301.14 ! Hrmdwashmg Cleanser,Availability _ f { 8-103.12 Conformance with Approved Procedures- j { 6-301.12 ! Hand Drying Provision { 'Denotes uitical nein in the federal 1999 Pax]Cale of 105 CbiR 590.0W, i € CITY OF SALEM i BOARD OF HEALTH t l I Establishment Name: C Q1\fAA . c Date: Ll '16 /)CJ Page: ofrl` RemCode C-Critical ttem DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION . Date - t No. Reference R—Red Item Verified I PLEASE PRINT CLEARLY �� I�IVOI�Cy 3�P/' + 6, HA- 044 e 31'31 ',, c 41- So/laQwi�t ,_ t. Gr'131, CI GISJ Or } I f -�bcc _Qu &_!5 Un orijm 40/ i kUE w), I I { i i ` I r I 1 . I 1 f I Discussion With Person in Charge: Corrective Action Required: I Ll I Yes have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee Restriction/ I, violations before the next inspection, to observe all conditions as described, and to Emersion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: � i 0 Violations Related to Foodborne Iliness Interverdlome and Risk N. rdk,�to Lm, Coui,,d to Factors(Ihsrmf-22) (Cont) PROTECTION FROM CHEMICALS PHF Hot and Cold Holding j 14 Food or Color Additives I3 i 3-il)!AN-3) CoN P)iFs Maintain,([at,v balow 02 12 1 Addime,* 3-302 [1; E Piiiv^-ciioo trom J;aaqpr�,,cd kddiuyuN' 1� Poisonous or Toxic substances f4(jT' (01.1i IdellIffying ItIf"Ill'allor Oul"inn't Hold at or abole i VF, I conlaill--is, 2o Time as a Public Health Control I c0mvion Nam, ont tliler�,, i 3,5Gt.lr. llnlc as a PuMk.I le"llth(Ilnuot- 5U,)rIu4:H) Nlzirilmcc Rewitia wCat 77-202.11 R(�triclioll- 171"u'nc--and U�0, 7-210112 1 I Condition:-lit 1,rsol 7-20' 11 REOUIREMENTS FOR HIGHLY SUSCEPTIBLE i-204.)1 sarilli7el"Crilc,ie- (Iltulil:;1k, POPULATIONS(HSP) Uiipi,:tcunf�A Prc-l-jct,i�cd Juwcs wid QeS��,hjl %�arising7-204.12 Ch,:mluihs for NX it'hil 7204,14 Drvilw - geut; Cowfia, 3-s\Oi A 11 til 1 4�t�of PA,ickmzc'd L,)" 205,1hl,,-J&ujal I,vxl Conijm:-Lubi �,bu'i 111 L)I R,,w or Paroad, C'Ia,k--ki Animal Fo,Pj 4sid 7.2061 R,,,Ili,;,�A UwTe.,iuJeaR:t+x Sr id Not sci wd. 7-206.12 P(likmo Lent stjlll,,k.� 7 206 13 TI;wking PI,,V&r�,Pf�l i ;cA 3-e(il l)'CE Unoj�.,tio Pkx,d Packall� Not lic-�,ervcnl "'lonitoring- CONSUMER ADVISORY TIMErrEMPrRATURE CONTROLS 21 3 4A Cor,�umej 0�ij, F"mcd lor("at'slurption Of Ie Proper Conking Tempetalurss tor Underco,4.vd,oi PHFsNil�on-ite 3 101 11 k� F�lig- 155'F 15 So 1)(2) 1 jlathogml, ,�.-.:,..",:a I o��lqm, fen Fow shell i,5'Fl�,rc F,lf.S I 4 3-40 1.11 lA)k2) F",h, Nlcu,i&Gwilt i:szq" 1: 15 Se,. ' SPFC.IAL REOWREMENTS, -101.1I Pm), and B,�ei Roam - 130'l- 121 min' Viddlloli,,of Sk-ilon 3f in 4-"1.11(All 2) I'iiwl�jw, rp:kiL'fixid, temporaiv and ,-4WJltA)(:,) Poultry,Wild Gait«. Sailfed PHFN, ri,.mu-_,1i1izd W&.C!n op-Tatimi should be Swfiim,Cllrluminl,;Fish, Mull t t dehm,u un,tei the appropriate v:vnimis Foldir l",,j Kwite,-165 F 15 jbove if fokti:d lo f6i)dlhume Mors, 3-401 ilti7l,3, Alwle Imact Pref"leal's In"erventioil-and zlsI, factors Other 51)WIDit violatikiiv;lrdalinV ,)c0kj retai! "401.1^_ Rp,v Ampwl Fo,xj,Ci ,kod in a A-iy,-Id!,,c&bittd aids#29 - Mio,w.,lve 105`} Ati Othr, Pjjf:: 17 Reheating tot Hot Holding VIOLAT)ONS RELATED TO GOOD RETAIL PRAC710ES 3-k)3.1 1;A)&f I)) Pilk 165-T Vwc. (it emQ 23-,il I) 3-40,.€1(B) F 2 Swwlhit vhinon-, tIl at 0,04 dona; q4afem Me rekj4(wrr oin be 3-403A jl'C} Commel;ialk Pmcos,'d F'T'!-.Fttxt undin:lir Irdlz'+wg lec:ions -h I, bo,;d Codcand,P)l CAIR 140 F' no,,, I cood Retail pr,,Gt, FC bo '-t0_ j I t F) Rcmaimm, Uji!liced Pvawm�(it*Hvef l 23) k"Im"w'ne-t and per�wnnpi FC: 2 N' F",4 rid F,Xxj P, FC, j '004 18 Proper Cooling of PHFs 25 E:zui;mIeni ziid Uz-n,qiI3 FC- 4 J)Dc 3 501 14(A) i7thAing Cwk,�d PHFs trout I 10"Ft" I--- -- I- -- ---1 ��iz Aw,pli m:�:qc: '01- Within 2 Ilours and From 791' ,�I -- i'm 10ja-�te Fc- rlu� K-(l 00 2S, potson�),1::nr-Fnxlr. fT�itIiJ13 7 _008 -30; 1,;.B) Cm in:;PHF',kladv Fion, V,ithin 4 1 I'Am 1,mote, 1, P109 K)(O 105,%lK 590 f Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Giovanni's File Number:BHF-2005-000007 44 Jefferson Avenue Salem MA 01970 LOCATED AT: 0044 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0192 Jan 1,2011 Dec 31,2011 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES IDecember 31, 2011 Board of Health „ This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 — CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH x' „ r 120 WASHINGTON STREET,4".FLOOR TEL. (978) 741-1800 KLVIBERLEY DRISCOLL FAZ(978) 745-0343 MAYOR DGRrr•.NnAunfna tiAl.rn+.COM DAVID GREENB AUm,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Ora—&f— A-= . TEL#_�7��T=GI I I ADDRESS OF ESTABLISHMENT 7 ell rC5'O✓1 Give • FAX# MAILING ADDRESS(if different) EMAIL- Business': 4doo2."col wrfx,oiI - COt,r Website: L-I"J , 065i6fl P'OW li1� . Cot-4 - OWNER'SNAM�P_ I" Sf TEL# (00--Qq-6-7I19 ADDRESS Ok 4U1M/�1r?,4 .G - <I X t r/�.S4i)i>< IMG STREET 11 CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) J GSOv1 r3pHIfu CERTIFICATE#(S) Q,GO�?&LJIP (Required in an establishment where potentially hazardous food iiss-�prepared) EMERGENCY RESPONSE PERSON �($rM CVIIJ-nom HOMETEL# �Ffj�3r�r!— 10 l7 ,DAYS'OF OPERATION, t;:�.f,, 'Monday .Tuesday'; g .:rvVednesday; (' = :Th irsdayt 'z;::- 'Friday,:'':.. j-; ':;Saturday : i'!`;,::Sunday`;, HOURS OF OPERATION i _ to -10 )U IO 1(,-( U ; IU- acw.! IO - a4 X11 i0 - ao Wi � � Please write in time of day. i (For example 11 am-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ------------------------ r46------- ----------------------------------------------------------------------------------------------------- RESTAIJRARIT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210 25-99 seats =$280 more than 99 seats =$420 ------------------------------------------------- ---- BED/BREAKFAST/ YES O ---------------------------------------------------------------------------$100----- CHILDCARE SERVICES/NURSING HOME'- --------------4AL---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES O $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax retu s and paid all state taxes required under the law. /� /Ark oq3- aG3- ��l Si ature `� Date Social Security or Federal Identification Number Revised 10/7/11 FOODAP2011.adm Check#&Date - $