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62 OF WHARF RESTAURANT - ESTABLISHMENTS i , r 0 c L cc cc LL L F O � 1 N r tidy ,��/off/ iPrrn 1/0 -� 6 I 4. � .:G. _...�G-. _._._G,. ...a�i1.. ...may. . s l - t {� v i i o. t a e �i e 1 ���� u ld �I P Y :�. .^. .r^ __ tr_ y: Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 0 Floor Division of Food end Drugs Salem,MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-034 City/Town of Address: FOOD ESTAB SHMENT INSPECTION REPORT Tel. Namee _ Type of Operation(s) Type of Inspection k ( Food Service ❑ Routine AddressLa sk ❑ Retail 0,Re-inspection Telephone Level ❑ Residential Kitchen Previo s inspection 1, El Mobile Date:g a rI t)7- Owner Owner HACCP YIN ❑ Temporary ❑ Pre-operatiddn I 1 ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Timedv ❑ Bed&Breakfast L] General Complaint Inc ❑ HACCP Inspector Out � Permit No. ❑.Other Each violation checkea requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compllance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ pose an imminent health hazard and require immediate Tobacco 590.009(F) Violations marked may ❑. y p q Allergen Awareness 580.009(G) ❑ corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ' - _ El 2. FROM'CHEMICALS 2. Reporting of Diseases by Food Employee and PIC \ ❑ 14.Approved Food or Coigr Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE - F-14. Food and Water from Approved Source TIMErrEMPER4TURE:CONTROLS.(Potet816ilq HaiardoasFoodg _)- „ ❑ 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 FORHIGHLY.SUSCEPTIBLE-POPULA710NS.(H4P). ❑21. Food and Food Preparation for HSP [3 10. Proper Adequate Hantlwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22)c of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. C N 590.000/federal Food Code.This report,when signed below 23. Management and Personnel (FC-2)[590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4X590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26.Water, Plumbing and Waste (Fcs)(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-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 3: u.evc Inspector's Signature: Print: / PIC gnatu Print: ,�r�✓�O^�r�v f--�G'd G Page_ Pages Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(]) Raw Animal Foods Separated from 1 590.003(.0 As,igtmemofReF�sibilit Cooked and RTE Foods* 590.003(6) I Demonstration of Knowledge"' Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other`' EMPLOYEE HEALTH Contamination from the Environment 2 590.('X)3(C) Responsibility of the person in charge to 3-302.1 l(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants* 3.3(4.11. Foal Contact with Equipment and 590.003(F) Responsibility 01A,Ford Employee Or An Utensils* Applicant To Report To lite Person In Contamination from the Consumer Char'e'* 3-306.14".0 * 590.003(G) Re ortin by Person in Charge* 1 )(B) Returned Food and Reservice C of Food Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.1.'1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 _ Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* __ Sanitization Temperatures* 3201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewasiuno Hot Water 3-202.13 Shell Eggs" Sanitization Temperatures- 4-501,114 Eggs and Mitt Products,Pasteur zed'" 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 lee Made From Potable Drinking Water* concentration and hardness. 5-101.II DrinkingWater fixxnan Approved System* 4-601.11(.0) Utensils C Pool Contact Surfaces and 590.006(A) Bottled DrinkingWatett* Utensils Clean" 602 590.006(6) Water Meets Standards Contact Surfaces and Utensils* in 310 CMR 22.0"' 4 '11 Cleaning Frequency i Food Shetrtish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils acrd 3-201.14 Fish and Recreadanal'ly Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.1 1 Methods of Sanitization-Hot Water and. 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authorit 2-301.11 Clean Condition-Rands and Arms"` 3202.18 _ Shellstock Identification Present'* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 - When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.1 t PHFs Reeaived at Proper Temperatures" 2401.12 Discharges From the Eyes,Nose and 3-20215 Packa ge hitevgrit * Mouth* 3-101.11. Food Safe and Unadulterated * 3-301.'12 Preventing Contandnation When Tasting* 6 Taga/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 S1lellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstoek Identification Maintained* Employees* Tags/Records: Fish Products 1 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation,and Retention* 5-203.11 Numbers and Capacities* 5-204.1.1 Location and Placement* 590.0040q Labeling of Ingredients" 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operatica and Maintenance fHACCP Plans Supplied with Soap and Nand Drying 3-502.11 S ecialized Tgrocessin Methods* Devices 3-50212 Reduced oxygen packaging,criteria* 6-301.11. Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Drying Provision Denotes critical item in the federal 1999 Food Code or 105 CMR i9o.000. CITY OF SALEM a ' BOARD OF HEALTH Establishment Name: r�� � O f—aye(( eJ7L Date: i Page: ofZ_ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, 140. Reference R-Red Item - - Verified L SE PRINT CLE LY D . ( I� P O - n/ C407 2. r s Q - /`¢ / C i 'i (� / CIP f Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance o 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: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to Law Cooled to Factors(/tarns 1-22) (Cont.) _41.°F/45'F Within 4 Hours. * PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives - 19 PHF Not and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 3-50116(B) 410/450 F* 3-302.14 Protection from Unapproved Addiuves* 3-501.16(A) Hot PRFs Maintained of or above Ig Poisonous or Toxic Substances 1400F. * 7-101.11 Identifying information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* rime as a Public Health Control 7-102.11, Common Name-Working Containers* 20 3-501.19 Time as a Public Henith Control* 7-201.tI Sarafi�-Stne* 590.004(H) Variance R 7-202.11 Restriction-Presenceand Use* uiretnent 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.12 Toxic Containers-Prohibitions* POPULATIDNS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals' 21 3-801.1 I(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for WashingProduce,Criteria* .Beverages with Warning Labels* 7-204.14 encs.Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 fttcidentai Fool Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal pond and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served, 7-206.12 1 Rodent Bait Stations* 3-801.il(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* L CONSUMER ADVISORY - TIMElfEMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of 16 Proper Coasting Temperatures for Animal Foods That are Raw,Undercooked or PHFs - Not Otherwise Processed to Eliminate Eliminate Eggs- 155"F 15 Sec. Pathogens.' Eggs-immediate Service 145'Fl5sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Egg Animals-155 F 15 sec.* SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401..11(A)(2) Ratites,Injected Meats-155°F 15 sec.* catering,,mobile food,temporary and 3401.11(A)(3) Poultry,Wild Came,Stuffed PRFs, - 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 3401.2.1(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PRFs-145°F 15 sec. Y7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) 'PHFs 165°F 15 sec.* (Items 23-30) 31103.1.1(8) Microwave 165`F 2 Minute Standing .Critical,mid non-critical violations,which do not relate to the Tum* foodborne illness interventions and riskfactors listed abort.,can be 3-403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code mid 105 CMR 14WF* 590.000. 3-403.11(E) Remaining Unslimil Portions of Beef Retail Practices FC 590.000 .Roasts* �23�. 1�Ma�n 9_ement and Personnel -FC-2 .003 i 18 Proper Cooling of PHFs 24. 1 Food and Food Protection FC-3 .004 1 25. ui and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26, Water,Plumbing and Waste i FC-5 .006 V 70'F Within 2 Hours and From 70`F 27. Physical Facility FC-6 007 to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC=7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements 009 Temperature ingredients to 410F/45'F 30• Other ----- Within 4 Hours* s rte: *tknotes critical item in the federal 1999 Find Code or 105 GN4R 590.W(). Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4" Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTAB ISHMENT INSPECTION REPORT Tel. Name Datb If Type ofOperationfs) Type of Inspection I r ❑ Food Service ❑ Routine Address r Rift I [I Retail ❑ Re-inspection Telephone Level El Residential Kitchen Previou$Inspection Tele p E] Mobile Date:L(Zdl (-fOwner HACCP YIN jo [I Temporary E] Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time EliBed 6 Breakfast ElGeneral Complaint In: Z i) ❑ HACCP Inspector Ouf:6 3o Permit No. ❑.Other Each violation check requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) - Anti-Choking 590.009(E) ❑ pose an imminent health hazard and require immediate Tobacco 590.009(F) El marked may p q Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. --FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties H13. Handwash Facilities 'EMPLOYEE HEALTH PROTECTION'FROM'CHEMIOACS- ❑ 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 ® 15. Toxic Chemicals ❑ 4. Food and Water from Approved Source TIMEITEMPERATURECONTROLS.(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 HIGHLYSUSCEP.TIBLE=POPULATIONS(HS?)` El21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY [122. Posting of Consumer Advisories Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related Items Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. C N 590.000/federal Food Code.This report,when signed below 23. Management and Personnel (FC-2X590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4X590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food T!N26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order,you 7. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATEOFRE-INSPECTION: " �r�( j Inspector's Signature: Prin . J PICS Signature: Print: �� Pagel o Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foals Separated from 1 590.003(A) Assignment of s Res onibilit t Calked and RTE Faz1s* 590.003(B) Demonstration of Knowledge* Contamination from Raw ingredients 2-103.11. Person in char-e -duties 3-30111(A)(2) Raw Animal Foods Separated from Each Other" EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants;* 3-304.11. Fad Contact with Equipment and 590.003(F) Responsibility Of A Foal Employee Or An Utensils* Applicant To Report'ro The Person In nta Contamination from the Consumer Char*e* 3-306.14(A)(,B) Returned Foal and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 31 590.003(1)} 1 Exclusions and Restrictions* Food 590.003(F) 1 Removal oFExclusions and Restrictions 3-701..11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fad* 4 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Foci Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Foal in a Hermetically Sealed Container* Sanitization Tem eralares* 3.201.Li Fluid Milk and M.ilk.Products* 4-501.112 Mechanical Warewaslung-HotWater 3-202..13 Shell Eggs* Sanitization Temperatures* 3-202.14 E s and Milk Products,Pasteorized* 4-501.114 Chemical Sanitimiton-temp.,pH, 3-202.16 Ice Made Front Potable Drinking*Waterifr concentration and badness. �" 5-101.11 Dtinkm Water fivrn an Aroved S stem* 4-6011 t(A) Equipment Food Contact.Surfaces and 590.006(A) Bottled L?rinkin Water" Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.01' 4 6(>2.J 1 Cleaning Frequency of Equipment Food- 590.006(B) Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency nt Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan POW Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanutization-Hot.Water and.- 3-20115 Molluscan.Shellfish from,NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and uMushrooms Approved by Regulatory Aut hord 2-301.11. Clean Condition-Hands and Aans* 3-202.15 Shelhstock Identification Present* 2-30L 12 Cleaninv Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game-Animals* Il Good Hygienic Practices 6 Receiving/Condition 2401,11 Eating,Drinking or Using Tobacco* 3-202.1 I PHFs Received at Proper Temperatures* 240112 Discharges From the Eyes,Nose and 3-202,15 Package Inte 't * Mouth* 3-101.11 Food Safe and Unadulterated* ( 3-30112 Preventing Contamination When Tastin * 6 Tags/Records;Shelistock t U Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) preventing Contamination from 3-203.12 Shellstock identification Maintained* Employees* Tags/Records; Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Ca acmes* Labelingof Ingredients' 5-204.11 Location and Placement* 590.0040) 9 Conformance with Approved Procedures 5-205-11 Accessibility,OperationandMaintenance � /HACCP Pians Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced ox en acka -na,criteria* 6-301.i 1. Handwashing Cleanser,Availability 8-103.12 Conformance with A. loved Procedures" 0-301.1.2 Hand D in Provision Denotes critical item in the federal 1999 Fax1 Code or 105 CMR 590.1100. CITY OF SALEM BOARD OF HEALTH Establishment Name: � �/r$n 4 -n-1)J= W), Date: Pager of� Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item verified 9 PLEASE PRINT CLEARLY 4/ t. 170°F 0 3 cerl ek A42k C=3a 4 t3 1 C5 i v JJ J S �r AA �P 01/1- , I 6 _ c AJ t M Qkf'WrV1A Un DiscussionWith Person in Charge: Corrective Action Required: ❑ No gL'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/Feder od Code. I under nd that noncompliance may result in daily fines of y- ive doll s sp nsion/re cation of ❑ Embargo ❑ Emergency Closure your,food permit. 13 Voluntary Disposal ❑ Other: 3-501.14(C) PRFs Received at Temperatures ' Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Item'1-22) (Cont.) - 41.'F(45`F Withia 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Conlin Methods for PHFs 14 - Food or Color Additives 19 PHF Hot and Cold Holding 3-50I.16(B) Cold PHF.s Maintained at or below 37202.12 Additives*' 590.004(F) 41°145°F* 3-302-1.4 1 Protection from Unapproved.Additives* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 140°17 * 7-101.11 Identifying Information-Original 3-501.16(4) Roasts Held at or above 13WR Containers* 7-102.11. Common Name-Working3950E Containers* Tune s a Public Health Control 7-201.11 Separation-Storage" - 4(H} Variance Time as Ruiretnent a Public Health Control* 590.004( 7-202.11 .Restriction-Presence and Use* - 7-02.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* 7-204.11, Sanitizers.Criteria-Chemicals* POPULATIONS HSP} 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Dryingr Agents.CritCriteria* ,Beverages with Warning Labels* 7-204.14 D Agents.9•9 3-801.14B Use of Pastemized Eggs* 7-205.11 Incidental Foal Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served 7-206.13 Rodent Bait Staiions* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitorin * - .CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 C tnstmmer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.IlA(1)(2) Eggs- 1557 15 Sec. Pathogens,'"r°"1`1 EM,-hurnediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Egg Animals-155°F 15 sec. 3.401.11(3)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL.REQUIREMENTS 3-401..11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering,.mobile food,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fist.Meat, debited under the appropriate sections Poultry or Ratites-165'1715 sec. * above if related to foodborne illness 3-401.11(0)(3) Whole-muscle,truant Beef Steaks interventions and risk factors. Other 145T* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited tinder#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PRFs-14PF 15 sec. 17 Rohoa6ng for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHR 165°F 15,w.* (Items 23-30) 31103.11($) Microwave 165°F 2 Minute Standing .Critical,wtd non-critical violations,which do not relale.to the _ Time* foodborne illness interventions and riskfactors listed above, can be. 3-403.11(C) Commercially Processed RTE Food- found in the following sectiones of the Food Code wrd 105 CMR 140°F* 590.000. 3403.11(E) Remaining Unsticed Portions of Beef Rem 1 Good Retail Practices I FC 590.000 Roasts* 23. Management and Personnel I-FC 2 ( .003 1S Proper Coaling of PHFs 124.. Food and Food FC-3 .004 25. 1 Equipment and Utensils 1 FC-4 .005 I 3-501.14(A) Cooling Cooked PHFs from 140'F to 1-26• I Water,Plumbingand Waste FC-5 .008 70°F Within 2 Hours and From 70'F 27. nysicai Facility FC-5 .007 to 41°F145'F Within 4 Hours. " r. Poisonals w Toxic Matertafs ` FC-7 .008 i 3-501.14(B) Cooling PHFs Made From Ambieni 2.9. Special Requirements .009 Temperature ingredien is to 4PF145°F Within 4 Hours' -i)�notos critical item in the federal 1999 FL*d Code or 10 CMR 5911.000. i s Mom Mom. Sm "57MMMIAWAAM 3!NOW, i�2 MM tet V ! .G.:' [ -r ri MAN ROOM / -M=- l mvjo _ UNW�1- r�Flmlm U '��ii1■ �M. Mi�it t_I l YJAMM ROM te• .- .- -4110fills] Iwo 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne ltlnass.interventions and Risk According to Law Cooled to Factors(Heins 1-221 (Cont.) _41'F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS -501.15 Coolie Methods for PHFs 14 Food or Color Additives 19 PHF Not and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3,202.12 Additives'. 590.004(F) 41°145°F* 3-302.14 Protection from Unapproved Additives* 3-501.16(4) Hot PHFs Maintained at above 15 Poisonous w Toxic Substances 1400E * 7-101.11 Identifying Information-Original 3-501.16(.A) Roasts Heid at or above 130'F. Containers* rim as a Public Health ControNam7-102.11. Common Na -Working Containers* 20 3-501.19 Time as a Public Health Cortril* 1-201.11 Separation-Slora 7-202.11 .Restriction-Presence and Use* 590.004(Hl VarianceR Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11. Sanitizers.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for WishingProduce,Criteria* P P 7-204.14 n ents.Criteria* Use of a with WaE---s labels" 7-205.11 hicidentai Food Contact.Lubricants* - "s-801.11(8) Use of Pasteurized EQas* 7-205.11. Restricted Use Pesticides:Criteria* 3-801A I(D) Raw or Partially Cooked Animal Food and . Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Ro-served. 7-206.13 Tracking Powders,Pest Control and - Moriitorin * CONSUMER ADVISORY _ TiME(TEMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 1557 15 Sec. Pathens* rrnvoi Egos-hnmediate Service 145'F15sec* 3-302.1.3 1 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game Egg Animals-155'F 15 see. * SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 3.401.11(A)(2) Ratites,injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* i catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild(lame,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 1.5 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intal Beef Steaks interventions and risk factors. Other 145°F 4' 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 1650E* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs-145'F 15 sec. 19 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC710ES 3-403,11(A)&(D) `PHFs 165°F 15 sec.* (Items 23-30) 3-703.11($) Microwave-'165'F 2 Minute Standing Gritical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-103.11(C) Commercially Processed RTE Food- found in the fa(londng sections of the Food Cade and 105 CMR 14WP 590.00. . 3-403.11(E) Remaining UrWiced Portions of Beef Hem Good Retail Practices 1 ,FC 580.[kTD Roasts* 23. Management and Personnel FC--2 .003 IS Proper Cooling of PHFs 244.. Food and Food Protection FC-3 .004 1 25. Equipment and Utensils 1 FC-4 .005 3-501.14(4) Cooling Cooked PHrs from.140°F to �, I Water,Plumbing and Waste 1 FO-5 .006 70'F Within 2 Hours and From 70°F 27. PhysicaJ FactHty FC-6 007 to,110F/457 Within 4 Hours. * - 28. Poisonous or Ttuic Materials FC 7 .008 i 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41'Fi4- 30 1 Other Within 4 Hours` °Denotr critical itzat in the federal 1999 Fnai Code 01 105 CMR 590.000- CITY OF SALEM BOARD OF HEALTH Establishment Name: 9 Bim. Date: _ Page: of Item Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Item Verified PLEASE PRINT LEARLT b2 zvv IS �(Y_ Jz © t t S n _(1 Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all nditions as desc 'bed, and to Exclusion P Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal F Code. I underst that noncompliance may result in daily fines of t1wenty ive ollars or su ension/rev ation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: '.'-\stir\t • }. '-�- � y+.+.. rr..�z-Vs...-. v... :�^ _.... . 'f-r...- � �._�..-�.-w _ .. 3-50L14(C) PHFs Received at Temperatures Ylotarions Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors Mems 1-22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methocis for PHFs 14 - Food or Color Additives _ l9 PHF Not and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41°/45°F* 3-302-14 Protection from Unapproved Additives* 3-501.16(A) -Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 14U°F.* 7-101.11 Identifying Information-Original 3-501.16(.4) Roasts Held at or above 130'F. Containers* Terre as a Public Health Control7-102.11. Common Name-WorkingContainers* 20 7-201.11 Separation-Storage* 3-501.19 Time as a:Public Heald)Control* 7-202.11 .Restriction-Presence and Use 590.(104(H) Variance Requirement e* 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLYSUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chcmicals" 21 3-801AI(.A) Unpasteurized Pre- acka edJuicesand 7-2(14.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204:14 Drying Agents.Criteria* 3-801.11B) -Use of Pasteurized Eggs* 7-205.1.1 Incidental Food Contact,Lxtbricants* 3-801.11(D) Raw or Partially Cocked Annual Food and 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served. * 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Momtonn *- CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of Y6 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(I)(2) Eggs- 155'F 15 Sec. Path ens'*ee "^ntlC1 E *s-Immediate Service 145'F15%ec* 3-302.1.3. Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Came Eggs * Animals-155'F 15 sec.* SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 540.009(0)-(D) Violations of Section 590.004(0)-(D)in sec.* catering,mobile fit,temporary and 3-401.11(A)(3) Poultry-,Wild Came,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec, * above if related to foodborne illness 3-401-1.1(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under X29- Microwave 165°F" Special Requirements. 3401.11(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3403AI(A)&(D) PHFs 165*F I5 sec.* I (Items 23-30) 3-403.1.1(B) Microwave 163'F 2 Minute Standing 0itical,and non-critical violations,which do not relate to the _ Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sectiones of the Food Code and 105 CMR 140'F* 590.000, 3403.11(E) Remaining Unsliced Portions of Beef P dterrt Good Retaft Practices .FC 590.Og0 i Roasts" 23. 1 Management and Personnel FC-2 003 I8 Proper Gaoling of PHFs 24. Food and Food Protection I FC-3 004 i 3-501.14(A) Cooling Cooked PHFs from 140°F to 26 Equipment lent and Utensils FC-4 Dos l 26. i Water,Plumbingand Waste - I FC-5 .006 4 70'F Within 2 Hours and From 70`".F 27. Physical FacilityFC-6 .007 to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 j � 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements _... _ _ 1 .009 i Temperaturc Ingredients to 41`F/45'F ( ---------- .Within 4 Hours* "1>enotes critical item in the federal 1999 Food Cale or 103 CINIR 590.000. Gordon CHEMICAL AND BEVERAGE - FOOD SERVICE SERVICE REPORT Customer#: 100092121 Date: 3/4/2015 Customer: SD(TY 2 O WHARF Phone: 9787440062 Address: 62 WHARF ST,SALEM,MA 01970 Specialist: Mark Gonet Equipment Barcode Description Owner ETAFU 1282826 WAREWASH CUSTOMER Type of Service Hours Preventative Maintenance 1 Measurements Checks Bicarbonate Alkalinity: 90 PPM Appearance of Equipment: Good Detergent: 600 PPM Drain Assembly: Working properly Rack Count: 1 Fill Function: Working properly Rinse Additive: 2 ml Gauges: Accurate Rinse Pressure: 24 PSI Labels and Decals: Good Rinse Temp: 131 F NSF Decal: Good Sanitizer: 50 PPM Probe/Probe Wires: No Probe Wash Temp: 130 F Pump Tubes/Scrap Screens: Excellent Water Hardness: 4 GPG Spray Arms/Jets: Repaired-Working Properly Comments routine service to bar machine operation ok sanitizer tests at 50ppm minimum quarterly change of pump tubes primed products cycled tested 50+ppm recommend 4 way arm to lower pressure to reduce breakage Equipment Barcode Description Owner HT25 TMP735671 WAREWASH Type of Service Hours Preventative Maintenance 0.75 Measurements Checks Bicarbonate Alkalinity: 80 PPM Appearance of Equipment: Excellent Rack Count: 1 Door Guides: Good Rinse Pressure: 24 PSI Drain Assembly: Working properly Rinse Temp: 182 F Fill Function: Working properly Wash Temp: 160F Gauges: Accurate Water Hardness: 4 GPG Labels and Decals: Good - NSF Decal: Good Scrap Screens: Cleaned-Good Condition Spray Arms/Jets: Working properly Comments checked machine operation RINSE PSI CURRENTLY 24 PSI...PETCOCK MUST BE OPENED DURIND FINAL RINSE FOR PROPER READING temps good dispenser operation ok installed new springs on door of bar machine door guides wearing/will order Will v For Service Please Call 1-800-830-9770 Tracking ID: 10E9CCC3-D1EC-4DE6-8320-B7A065609A6A Ol l Page 1 of Customer#: 100092121 Date: 3/4/2015 Customer: SIXTY 2 ON WHARF Phone: 9787440062 Address: 62 WHARF ST,SALEM,MA 01970 Specialist: Mark Gonet Labor Parts Used Totals Hours Ratl Value Quantity Value Total Value Bill Amount 1.75 $84.00 $147.00 0 $0.00 $147.00 $0.00 TERMS AND CONDITIONS The equipment described on this Service Report may include equipment that is owned by GFS and has been provided to Customer by GFS free of charge(collectively,'Loaned Equipment"). These terms and conditions apply only to Loaned Equipment. Loaned Equipment does not include (a)Customer owned equipment,(b)GFS equipment Nat has been sold to Customer as evidenced by a written bill of sale or invoiceor(c)any equipment that is subject to a written lease agreement between GFS and Customer.GFS owns all Loaned Equipment,and Customer has no interest whatsoever in the Loaned Equipment,including a leasehold interest, Other than a temporary right to possession which may be revoked by GFS at any time,far any reason.GFS agrees to maintain the Loaned Equipment,and Customer agrees to use in the Loaned Equipment only products supplied by GFS.Customer shall be liable to GFS for damage to or destruction of the Loaned Equipment,beyond normal wear and tear,while it is in Customer's possession.Customer agrees to maintain property,casualty,and general liability insurance in amounts suffident to(1)pay GFS the replacement cost of the Loaned Equipment in the event that the Loaned Equipment is destroyed or damaged by fire,wind theft, vandalism,or similar occurrence;and(2)pay any personal or property damage claim brought In connection with Customer's use of the Loaned Equipment,up to$1 million per occurrence.Customer agrees to pay all personal property taxes assessed upon the Loaned Equipment. Customer agrees to indemnify,defend,and hold GFS harmless from any claim brought against GFS in connection with Customer's use of me Loaned Equipment.GFS makes the Loaned Equipment available to Customer'as is'with no warranties,either express or implied.GFS DISCLAIMS ALL WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE.If GFS,in its sale discretion,revokes Customer's temporary right to possession of the Loaned Equipment,Customer agrees to make the Loaned Equipment available forock up by GFS during regular business hours upon 24 hours notice of revocation,oral or ended,by GFS. Customer Aclmowledgment Signature: Printed Name: Tony TPoe/Posmon: Owner o, o For Service Please Call 1-800-830-9770 Tracking ID:10E9CCC3-D1 EC-4DE6-8320-B7A065609A6A IMI Page 2 of 2 Il __ °NntTq City of Salem, Massachusetts Board of Health 9 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PlnblicHealth Iramdin@salem.com Prevent. Promote. Protect. Kimberley Driscoll Larry Ramdin RS/REHS, CHO, CP-FS Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM-15-79 Permit Type: Food Establishment 25.99 seats Goods &Services: Food Service: 25-99 seats Name of License Holder: Sixty 2 on Wharf-Antonio Bettencourt Name of Food Establishment Sixty 2 on Wharf Address of Food Establishment 62 Wharf Street Salem MA 01970 Restrictions: This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: $280.00 Issued: 1/1/2015 Vv ����� � II 1 I • CITY OF SALEM, MASSACHUSETTS p„ H , BOARD or HEAI:TII 120 WASI'lING1'ON S18I?E'r,411'FI.00It KIMBERLEY DRISCOLL TEL.(978)741-1800 FAX(978)745-0343 L,\BRY RAMDIN,RS/REBS,CI 10,CP-FS MAYOR Itamdin@salem.com HEAI.I'Fl AGF.N•l Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: Cc/— S/. 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: 5 7 7 �/ y 490 0�'t' / 5) Applicant Name&Title: /7 �o<✓_`p �62��d 6) Applicant Address: 0.6e 'jeV--'1 62 7) Applicant Telephone No: ?7J�-S3i f SS 24 Hour Emergency No: 7�a39 SBS�Email:�a�esdau i•co y 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. Name Title I Home Address A cor �✓�io�e �co ra< <es�e�d An individual A partnership Other legal entity t<WP�r e �c yf e✓co e f v cPS.�e�� .s-ft/c?e 12 Person Directly Res onsible For Daily Operations(Owner, Person in Charge,Supervisor,Manager,etc. Name&Title: ���N d S3cfY'✓c u u c C 4W'� Address: Telephone No: 97& Y31 pSS Fax: 978 75141//6a Email: Q�e�c�aoK���n�zQe4Ueco t Emergency Telephone No: I F J� oZ3 I 13) District or Regional Supervisor(if applicable) Name&Tltle: Address: Telephone No: Fax: Email: Check#: I Date: Amount: Food Establishment Information 14) Water Source: 1s) Sewage Disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: s 18) Name of Person in Charge Certified in Food Protection Management: _ Required as of 101112001 in accordance with 105 CMR 590.003(A) g ��^'l� �e ✓�o ufz 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): [?/Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) / ❑ Retail( Sq. Ft) ❑Caterer Permanent Structure V 21Food Service—( ss Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service—Takeout ❑Residential Kitchen for Retail Sale ❑ Food Service—Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments (ch ck one) RETAIL STORE RESTAURANT Annual ✓ ❑ Less than 1000sq.ft. $70 ❑Less than 25 seats $140 Seasonal/Dates: ❑ 1000.10,OOOsq.ft. $280 ❑Residential Kitchens $140 ❑More than 10,OOOsq.ft. $420 B'25-99 seats $280 ❑More than 99 seats $420 Temporary/DatesMme: ......................... ....... --------.-------- ...................................... -------- ............................ 0 Bed&Breakfast/Childcare Services/Nursing Home $100 --------------------------------------.......................... ----------------- ............... ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare&private club 23) Food Operations: - Definitions: PHF—potentially hazardous food(time/temperature controls required) Non-PHFs—non-potentially hazardous food(no time/temperature controls required) (check all that apply): RTE—read -to-eat ods Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum PackaginglCook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Seif-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail.Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of:562:C. ica Pursuant to MGL sec. 49A,I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law../ 25) Social Security Number or Federal ID: a� 3 9 a-5- 26) 26) Signature of Individual or Corporate Name: ��- S�ku ra J� 9- 1 Massachusetts Department of Public Health Salem Board of Health h 120 Washington Street,4 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTABUWMJENT INSPECTION REPORT Tel. Name IHA Ty a of Operation(s) Type of Inspection 3 Lc Xood Service ❑Routine 14M ca� Address G S /Risk ❑ Retail Q Re-inspection Telephone l ❑ Residential Kitchen revio s Ins edion P �. E] Mobile Date: ' Owner CP YIN ❑ Temporary ❑ rar�fi ❑ Caterer ❑Suspect II ess Person-)n h rge(PIC) Time ❑ Bed&Breakfast E]General HACCP Complaint In: . Inspector O Permit No. ❑.Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) - Tobacc-Choking 590.009(E) [IVipose an imminent health hazard and require immediate Tobacco 590.009(F) El marked may P q Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. -FOOD:PROTECTION MANAGEMENTS El12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties . _ ._ __ ❑ 13. Handwash Facilities 'EMPLOYEE HEALTH - - )PRDTECTIONFRO,M'CHEMICACS___ ❑ 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'FRodand OVE from __ _.ce TIMEfrEMPERATURE.C.ONTROLS(PotentlaltyMaiQlausFol;ds)_�_ , ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18.Cooling P L __ "E - __ 'J ' - '- 19.Hot and Cold Holding i ROTCTION FR'" -1OM CONTAMINATION_ _ _ _ _ j 9 ❑ 8. Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing -;REQUIREMEyT,SFORHIGHLY4U$CEPTIBLE=P OPULATIONS''(HSp)`_f E]21.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_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22), of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspe on 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-zxsso.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3x590.004) 5. Equipment and Utensils (FC-4x590.005) cited this report may result in suspension or revocation of the food establishment permit and cessation of food Water, Plumbing and Waste (FC-5X590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6x590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.006) and submitted to the Board of Health at the above address 29. Special Requirements. (590.009) within 10 days of receipt of this o er. 30. Other DATE OF RE-INSPECTION: s o-ild« Inspector's Signature: Print: PICS Signature: Print: c�,, �C l'✓CO r t 2[f Psge-,L ot�Pages .-.tir,..r ,.-n ..--.M.ie�..,.'^�M1.'nry�r.'1...i".•`��.✓-.�.. x. - .m.`n.n^-. For..w.y+ -.-..�-.r.R . r T Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g Gross-contamtnailon FOOD PROTECTION MANAGEMENT 3-3Y2.1 i(A)(1) Raw Animal Foods Separated from 1 590.0(}3(A) Assignment of Res nsihilit * Cooked and RTE Foods* 590.003(3) Demonstration of Knowledgel Contamination from Raw Ingredients 2-103.11 Person in char e Buttes 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other" EMPLOYEE HEALTH Contamination from the Environment 2 390.003(C) Responsibility of the person in charge to 3-30'2.11(A) Food Protection* require reporting by food employees and 1 3302.15 Washing Fruits and Vegetables licants* 3=304.11. Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report T'o The Person In - Contamination from the Consumer CharE* 3-306.14(A)(B) Returned Food and Reservice of Food* - 590003(0) Reporting by Person in Charge* Dlspos@ion of Adulterated or Contaminated 3 .590.003( 1) Exclusions and Restrictions* Food 5!J0.003(E) Removal of Exclusions and Restrictions 3-741.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE F Food and Water From Regulated Sources 9 Food Contact Surfaces 590.4()4(A-B) Cern lianee wid Food Law'" 4-501.111 Manual Warewashing-Hot Water 3-201.12 F<ral in a Henneticalll Sealui Conte neo* Sanitization Temperatures;' 3=201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Temperatures* e perat ices* Water Sanitization Tem eraNres*- " 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-to H, 3.2{p2.14 Eggs and Milk Pnxlucts.Pasteurized* P concentration and hardness. 3-202.1.6 ice Made From Potable Drinking Grater'" ' - 4-601,11(A) Equipment Food Contact Surfaces and 5-1.01.11 Drinking Water from an A roved S='stem* Utensils Clean* 590.006(A) ng Water" 4-602.1.1 Cleaning Frequency of Equipment Food 590.006(I3) Water Meets Stand =ds in 310 CMR 22.3* Contact Surfaces and Utensils* Sholifish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreai.iona'lly Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* -_ 4-703..11 Methods of Sanitization-Hot Water and 3-201.15 MalluscanSheghshEam?dSSPt. sted Chemical* Jounces* 10 I Proper,Adequate Handwashing Game and Wild Phushrooms Approved by 2-3()1..11 Clean Condition-Hands and Arms* _ Raeulato Aumortf 3-202.13 Shellstockidentification Pr'went'" 2-30L12 WheClean Paste* re* 590,004(C) Wild Mushrooms* 2301.14 When to Wash* 3-201.1; Game Animals"... 11 Good Hygienic Practices S Receiving/Condition 2-401.11. Eating,Drinking or UsingTobacco* 3-202.11 PHFs Received at Pra r Tem mttues* 2401.12 Mouthrges.Fromthe Eyes,Nose and 3-202.15 Package lute it * _ Mouth* 3-301.'12 PreventingCor a timation When Tasting* 3-1;,1.1 I Food Safe and Unadulterated* 12VII Prevention of Contamination from Hands 6 _ Toga/Records:Shelistock - 3-202.123 Shel7stuak Identification* Preveming Comainination from Employees* 3 203.12 Shellstack identification Maintained* 13Handwash Facilities Tags/Records:"Fish Products Conveniently Located and Accessible 3'442.21 Parasite Destruction* Numbers and Capacities* 3-402.12 Records,Creation and Retention* Location and Placement* 590.004(T) LaGe'Ing oflrtgredlents' q Conformance with Approved Procedures 5-205.11 Accessibility,O en tion and Maintenance IHACCP Plans Suppled with Soap and Hand ofystg oevlces 3-502.11. Specialized Processing Methods* 6-301.11 Handwashing Clsanser,.Availabilit 3-502.12 Reduced oxygen packaging,criteria* 6-301.1.2 Hand Drying Provision &143.12 Conformance with Approved Procedures* Denotes critical item in the federal 1999 1`ax1 Cade or 105 CMR 590.000. CITY OF SALEM OARD OF HEALTH Establishment Name: Date: Pager of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verifled PLEASE PRIN CLEARLY, V 3 Eai v � l Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twent�ffive doll rs sion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other. 3-501.14(C) PHFs Received at Temperatures y Vtotatlons Related to Foodborne illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41F/45`F Within Houm* �_ PRO LECTION FROM CHEMICALS Food Cooling Methods for PHFs 14 Food or Color Additives 3-202.12 19 PHP Sint and Cold Raiding 3-501.16(B) Cold PHFs Maintained at or below i Additives*_ 590.004{F} 410t45'F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 7-101,11 Identifying Information-Original 140 F. 3-501.16(A) Roasts Held at or above 1300F. Containers* " 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* - 3-501,19 Time as a Public Health Control* 7-202.11 ,Restriction-PresenceandUse* - 590.004(111 Variance Requirement -- 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS S FOR HIGHLY SUSCEPTIBLE ' 7-204.11. Sanitizers,Criteria-Chemicals* P.11(A) T60 (HSP)7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.11(A} Unpasteurized Pre-packaged Juices and 7-204.14gots.Criteria' :Beverages with Warning Labels* Drying 7-205.11 Incidental Food Contact,Lubricants* 3-81.11 ) Use of Pasteurized 8 as* 7-206.11 -Restricted Use Pesticides,Criteria* 3-800 ( 1.11{D} Raw or Partially Cooked Annual Food and 1 Raw Seed Sprouts Not Served,� 7-206.12 Rodent Bait Stations* 3-801.1)(C) Unopened Food Package Not Re=served. 7-206.13 Tracking Powders,Pest Control and - Momitorm *- -CONSUMER ADVISORY T1MEfFEN1PERATURE CONTROLS 22 3-603.11 Consumer Advtsory Pasted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3401.1IA(1)(2) Eggs- 155F 15 Sec. Pathogens." x bBinnnor Eggs-Immediate Service 145`F15sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell E Y 3401.11(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 see. NTS 3-401.11(11)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REflUo 3-401.11(A)(2) Ratites,Injected Meats-155`F 15 590.009(A}-(D1 Violations of f Section 590.{109(A} lD}in sec,* catering,.mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec, * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other l 145°F* 590.009 violations relating to gout retail t 3-40IA2 Raw Annual Fails Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401:1I(A)(1)(b) All Other PHFs- 145'F 15 sec, 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403A I(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing Critical,and Leon-critical violations,which do nor relate to the Timm* foodborne illness interventions and risk factors listed above, can he 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef Imm I Goad Retail Practices 1 ,FC 590.000 i Roasts" 23. Management and Personnel i M-2 .003 . 1g Proper Cooling at PHFs 24. Food and Foal Protection i FC-3 .004 I 125. I Equipment and Utensils _ FC-4 .DOS 3-501.14(A) Cooling Cooked PHFs from 140`F to 128. Water.Plumbingand Waste i FC-5 .0086 70'F Within 2 Horns and From 70'F = 27. Ph weal Facility I FC-8 .007 to 41`F/45'F Within 4 Hours.* i 28. Poisonous or Toxic Materials I FC-7 .008 3-501.14(.8) Cooling PHFs Made From Ambient 29. S eeial Requirements - .009 Temperature Ingredients to 41'F/45'F 30 I Other Within 4 Hours* s:wer„ tom. : *Dermas critical nem it,,the federal 1999 Food Code or 105 C1vtR 590.000. 62 Restaurant&Wine Bar 978 744 1162 P.1 - - '1..�CHEMICAL AND BEVERAGE SERVICE REPORT vustgm 100092121 Date! 3/5/2014 Cusro er SIXTY 2 O WHARF Phano: 9787440062 Adores 62 WHARF ST,SALEM,MA 01970 Spedawu Marls Genet Equipment r. d Descnptiw Ovmer ETAFLI TMP9$6128 WAREWASH Type of Service Hours Labor-Emergency Call 0.5 Comments found sanitizer tube wpm replaced tube and primed tetsted senilizer to 50rppm Labor Parte Used Totals Hours Rate/Hr Value Quantity Value Total Value Bili Amount 0z $84.00 $42.00 0 $0.00 $42,00 $0,00 TERMS AND CONDITIONS me aqulorradi deebrDac th WE Saliba Report may imbtle equipmeat that,.owned by GFS are Mattoon prwidad la Ct aramerby GFSttee,of Charge(W alliary.Roanetl Equipment') Those lams ane ccn ftns achy ony to leaned Etluipment. LnenXtl Egmprclenl p0e6 miinclYltle:(a)Q,51pm¢r owned equipmora,(DJ GFS equiprnert mal has conn sold to Cusmmar as evpencap byawntten S,Il cl sale orimaixr,pr(W cry ¢tlDh�ipm"ah@'Itdwl i5.ubjCC13awdllanleaa¢asreamera bemeen GF5 be Guslernar,GFS¢wrs all Lnanad Equipment and CUt"'a"hasheinlnreslwhatsoev¢rit[he Leaned Eaplfmam, ndpdngdIaaS¢holtl ittaiasl, gg pcsses9i0a—hmaye4"The try'GFS ai any hme.hx any"'ba"'GESagra¢amme_b lhetLlYkd Ecuipm¢nL arytl G.stpfipr aQl066 ip U.en tll9 i.wred Equicrren;a-ty prpdUgR supplied Dy FS.Cuetdmgr Shall Reliable to G55.1 ddmagamor tleele""he"Ne Lga,a equipmenl,D¢ydMnGmdl'weerantl mea while R.s in Cusrornera paq`Aa^rlgn.Cg6lpmar agrees[omaintain property,casualq,and gereral IiaDiliry inSuraMdin amountsatlte Itq(1)pay GFS ux rpplac¢mem msl ql theLnanad Equipment In tla avant Vatthe Loannp Egnpmen[Is arsfrpyetl xdamaged byfire,wiM.IheX, arog1L'm,a as_-- _—entl(2j pay amparspw!a pm�p+eeery damage etaien bmggM in eonngClionwith Customals vaa ptdsn Lparep E.ggipmerc..ua(o$t rulliim par a;curtene¢.Cu6lamer a0r¢¢s m pay all pent;rat erappaertgaarssassa;�q wan are Loaned EquiseneN. Cusmmxs agr¢nata adamniyy,tlgfgad.antlno,GFS bamdaSa fnm arydam>rrgqppM acamY GFS in mrmedicn wish G:SKmers use al ti,a Loarrop EqupmeN.GFS maids lha Lwvad Epgipmanl0•xaiLable m CJgtpmar'as .-1, W,m Rp Waf2nllea,BXn¢"espreSs of implitxl.Grad, -,Ims F$pIAIMe ALl W 4A R4TJTIEe eF MERCMNJTAeILIT+OR FITNESS FOR A PARTICULAR PURPOSE.If GFS,in IIs ah.lueretipn,rW etas Cu3ltlmei a lempprery dgM to posnnasan of me Loaned Equiprerc.Gostaror ng�ro mare ma Coated Equipment available Lqr p'rk up by GFS PART tggUar PURPOSE r3opena Xaurs nodee of r¢vpeatlrn,ani orwriren,DY GFS. CueMmpr Acwtox7edgmenc Signature; Printed Name: Tony 7iAe/Poertlan: Owner 1 t o. o For Service Please Call 1-800-830-9770 Tracking ID:9EA87DFA-7040.4786-A35F-57EAF5B957AE d page 1 of 1 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4a' Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name ( D I Type of Operation(s) Type of Inspection Food Service ®Routine Address R) k ❑ Retail ❑Re-inspection Telephone Level ❑ Residential Kitchen Previous I�spe on ❑ Mobile Date: (/ff ' i3 Owner HACCP YIN ❑ Temporary ❑Preoperation Won 6 [ICaterer ❑Suspect Illness Person-in-Charge(PIC) " Ttm� ❑ Bed&Breakfast El General Complaint In. ElHACCP Inspector Out` Permit No. ❑.Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Vipose an imminent health hazard and require immediate Tobacco 590.009(F) Violations marked may ❑. y pAllergen Awareness 590.009(G) corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT_ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties _. � , .. _ ❑ 13. Handwash Facilities .'EMPLOYEE HEALTH _ 1 PROTECTION FROM'CHEMICAL5 1-12. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives El 3. Personnel with Infections Rest cted/Excluded 4- ,.. ._ .._ _ �. _ _.__.- _- � _ ❑ 15.Toxic Chemicals E] 4. Food FROM and Water from Approved APPROVED SOURCE , _ Source :TIMEREMPERATURE.C.ONTROLS_(06tantwhi Hazeidous Feudal ❑ 4. ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [:118. Cooling "" - ` - - - 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION _ _ w� _ _ .; 9 ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and SanitizingREQUIREMENTS FOR HIGHLY4USCEPTIBLE-_POPULATIONS'(HSP) � El 10. Proper Adequate Handwashing ElP 21.Food and Food Preparation for HSP El 11.11. Good Hygienic Practices CONSUMERADVISORY_ , . _ „-. _ _ ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590,003) by of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-sXsso.o0a) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-SX590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 9. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: / /yAl� J Y Inspector's Signature: ... Print: _ PICs Signature: Print: Page of-i Pages Violations Related to Foodborne Illness interventions and Risk Factors(Nems 1-22) PROTECTION FROM CONTAMINATION FOOD_PROTECTION_MANAGEMENT $ Cross-contamination - 1 590.003(A) Asia went of Responsibility* 3-302.1.1(A)(1) I Raw Animal Foods Separated from - Conked and RTE Fouls* 590.003(B) Demonstration of Knowledge" a . - Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.1 I(A) Focal Protection* - require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicantO 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Resecvice of Food* 590.003(G) Re •n b Person in Charge" Disposition of Adulterated or contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-70111 Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* _ 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food law* 4-501.1111 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 Producis,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water* concentration and hardness. * 5-701.'l l Drinkin Water from an Approved S tent* 4-601.1 I(A) Equipment Food Contact Surfaces and 590,006(A) Bottled Drinking Water' Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Clean ng Frequency of Equipment Ford- Shellfish and Fish From an Approved Source Contact Surfaces avid Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationaliy Caught[vlolluscan Shellfish* Food Concoct Surfaces of Equipment* _ 4-703.11 Methods of Sanitization--Hot Water and 3-201.15 Molluscan Shell&sh from'.^1SSF hiatEtl Chemical* Sources* 10 Proper,:Adequate Handwashing Regulatory Authority Game and uMushrooms Approved 4y 2-303.11 Clean Condition-Hands and Arms* - 3-202.18 Shellstock identification Present* 2-30I12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.U Game Animals* - 11 Good Hygienic Practices 5 Receiving/Condition 2401.11. Eatin ,Drinkin or Usin Tobacco* 3-202.1.1 PRFs Received at proper Temperatures* 2401.12 Discharges.Fromthe Eyes,Nose and 3-202.15 Package bite it" Mouth* 3-10LI I Food Safe and Unadulterated* 3-30L.12 Preventing Contamination When Tasting* 6 Tags7Rerords:Shelistock L12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained" Employees* TagslRecords:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* '- Convenienty Located and Accessible _ 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients- 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance (HACCP Plans Supched with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502:1.2 Reduced oxygen p acka ring,criteria* 6-301.11 Handwashing Cleanser,.Availabilit 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand1)r Provision llenatra ciiticsn i[zm in.ihf f cleral 1999 Faxl Cock or 105 CMR 590,T,0, I i WNa vMWAMM WJI1Jl�lG3. RMS ME 2MMANA l�1 3-501,144C) PRFs Received at Temperatures Violations Related to Foodbarne Oiness Interventions and Risk According to law Cooled to , Factors(items'1-22) (Cant.) 41'Fl45'F Within 4 Hours, PROTECTION FROM CHEMICALS 3-501..15 Cootia Methods for PHFs 14 Food or Color Additives I9 PHF Hot and Cold Holding 3-501.16(13) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 410145'F* 3-302.14 Protection from Unapproved_4dditives,e 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances; IAO F. 7-101,11 identifying Information-Original 3.501.16(A) Roasts Held at or above 13WF. Containers* 20 1 7-102.11. Common Name-WorkingContainers* Time as a Public Health Control C ` 4` - 3-501;19 Time as a Public Heatdt Control* 7-201.11 Separation-Stora 7-202.11 .Restriction-Presence and Use" 590.0040 Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPT16LE 7-203.11 'Toxic Containers-Prohibition* POPULATBONS HSP i 7-204.11 Sanitizers,Criteria-Chemicals* 7-204.12 Chemicals for WashingProduce,Criteria° 21 3-&61.17(A) BeveraIjupasges wit Wanting ad Juices and 7-204.14 in encs.Criteria* _ .Beverages with Wanting Labels* 7-205,11 Incidental Food Contact Lubricants* 3861.21(13) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides;Criteria* 3-801.11(D) Raw or Partially Cocked Animal Food and Raw Seed Sprouts Not Served. 7-206.12 Rodent:Bait Stations* 3-$02.11 C Unopened Food PackageNot Re-served. ° 7-206.13 Tracking Powders, Pest Control and Monitorin * -CONSUMER ADVISORY TIMET TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That.are Raw,Undercooked or ]6 Proper Cooking Temperatures for Not Otherwise-Processed to Eliminate f PHFs j Patho yens.*ms`s,*vn,�r 3401.11A(1)(2) Eggs- 155'F 15 Sea Eggs-Immediate Service 145'F15sec* 3-302.13, Pasteurized Eggs Substitute for Raw SheII y 3-401.11(A)(2) - Comminuted Fish.Meats&Game E j Annuals-155'F 15 see." 3.401.11(B)(1)(2) Pork:and Beef Roast-130'F 121 mm* SPECIAL REQUIREMENTS � 590.009(A)-(D) Violations of Section 590.009(A}(D)in _ 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 catering, mobile food,temporart,and sec. 3-401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be i Stuffing Containing Fish,Meat, debited under the appropriate sections Paul or Ratites-165017 15 sec, * above if related to foodborne illness 3-401.1I(C}(3) Whole-muscle,low Beef Steaks interventions and risk factors. Other i 145'F* 590.009 violations relating to good retail 3401.12 Raw Animal Foals Cooked in a practices should be debited under#29- SMicrowave 165°F* Special Requirements. S 3-401a1(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Not Holding vioLATloNS RELATED TO GOOD RETAIL PRACTICES 3-AWAI(A)&(D) PHFs 165T 15 sec.* (Items 23-30) 3-403.11(13) Microwave-'165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the Tithe* foodborne illness interventions and risk factors listed above, cam be _ 3-403.11(Q Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140017* 590.000. 3403.11(E) Remaining Unsticed Portions of Beef iItem 1 Good Retail Practices FC 590.000 i Roasts* _ 23. 1 Mand ement and Personnel -FC-2 .OA3 - .I 18 Proper Cooling of PHFs -- I Foal and Food Protection FC-3 .004 25. 1 Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140`F to 26, i water.Plumbing and Waste FC-5 .006 1 70'F Within 2 Hours and From 70' 27. Ptivaical Facility FC-6 .007 to 41'F14-5'F Within 4 Hours.* - f 28. Poisonous or Toxic Matenats I FC-7 008 j 3-501.14(B) Cooling PHFs Made From Ambiens 29. Specia R uiremems 009 Temperature Ingredients to 41'F/45'F f Other 1 _ } Within 4 Hours* 'tienoeu coccal sum in the federal 1999 Foci Cade or IV CMR 590.0()0. CITY OF SALEM BOARD OF HEALTH Establishment Name: X002 ) rr MI rV eQo Date: k Pager_ of f Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Veri led PLEASE PRINT CLEARLY / r , / c 4 l/l�l A Discussion With Person in Charge: Corrective Action Required: ❑ No IL13 >S 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 dollar r suspension/rev o Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 1 501.14(C) PHFs Received at Temperatures Violations Rotated to Foodborne Illness Interventions and Risk According to Law Cooled to i Factors(itema 1-22) (Cant.) 41'F/45°F Within 4 Hours. t PROTECTION FROM CHEMICALS 3-501..15 Cuolin Methods fru PHFs14 Food or Color Additives t9 PHF Hot and Cold Holding 3-50116(6) Cold PIFs Maintained at or below 3-202.12 Additives* 590.004(171 410/450 F* 3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. * 7-101,11 Identifying Information-Original 350116(A) Roasts Held at or above 130'F. Cmuamers* 20 7-102.11. Common Name-WorkingContainen4 Time as a Public Health Cartrol "r?01.11 Separation-Stora e* - 3-501:19 Time as a Public Health Control* 7-20111 .Restriction-Presence and Use* 590.004(H} Variance Requirement 7-202.S2 Conditions of Use* 7-203.12 Toxic Containers hers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPT16LE 7-204.11 Sanitizers.Criteria-Chemicals* - ROPULATION5 NSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Tirvinff Auents.Criteria° Beverages with Warning labels* 3-801.21(6 Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact.Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served- 7-206-12 - Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not'Re-served. '° 7-206.13 Tracking Powders,Pest Control and 1 Monitoring* CONSUMER ADVISORY TIME7TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted fro Consumption of 26 - Proper Cooking Temperatures far Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate Pat120 F 5v iH,'NT.I 3401.11A(1)(2) Eggs- 155°1715 Sec. Eggs-immediate.Service 145°F15sec+ 3302.13 Pasteurized Eggs Substitute for Raw Shell E 3-401.11(A)(2) Comminuted Fish.Meats 8 Game Animals-155'F 15 sec. SPECIAL REQUIREMENTS 3-40111(11)(1)(2) Pork and Beef Roast-130'F 221 min* 590-009(A)-(D) Violations of Section.590.009(A)-(D)in 1 3-401.71(A)(2) Ratites,Injected Meats-155°F 15 i Sec.* catering, mobile food,temporary and 3 401.1 t(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,&feat, debited under the appropriate sections Poultry or Ratites-165'F t5 see, * above if relate}to foodborne illness 3-401.11(00) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other t 145°F* 590.009 violations relating to good retail i 3-401.12 Raw Animal Fails Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. f 3-401:11(A)(1)(b) All Other PIIFs-145'F 15 sec.$ 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3403.41(A)&(D) PHFs 165-F 15 sec. * (Iteins 23-30) 3-403.11(B) Microwave 165`F 2 Minute Standing Critical,and non-criRcal violations, which do not relate to the Time" foodborne illness interventions and ris&,factors listed above, can be 3403.11(C) Commercially Processed RTF Foal- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(5) Remaining Unsiiced Portibus o£Beef �- item ; Goad Retail Practices FG 540.1)w Roasts" 123. ; Management and Personnel FC-2 .003 - 1 1g Proper Cooling of PHFs 1 24. Food and Foci Protection FC-3 Wt i 25. Equi ment and Utensils I FG-4 .005 j 3-501.141,A) Cooling Cooked PHF%from 140'F to 1 26 Water.Plumbino and Waste i FC-5 .006 70017 Within 2 Boars and From 70'F 27. Physical Facility FG-6007 to 41`F/45'F Within 4 Hours. * 1 28. 'Poisonous or Toxic Materials FG-7 .008 3-501.74(6) Cooling PHFs Made Froin Ambient r29. S aciai Requiremerns .009 Temperature Ingredients to 41'F/45°F 30 I Other Within 4 Rours* 'Denotes critical neni in the ledecal 1999 Foal Cale or 105 CIMR 590.0()0. l I. TT -p s yv .R$ M * }�� Commonwealth of Massachusetts- X26 ,g ,' t k Board of Health Kimberley Dnscoll Rtrs tis.:. 4A, °�. r 7 -.. -+v'Fq,Y „ 120 WasWugton Street,4th FlaoV.r MByOf y „� , 3 • '6. krp t•�.im s _d `: M1.m' 'ti4 a+es� +, i d T�' U SALEM,MA a 01970 s" �f r r k s v �r Fi �,, �qFoot�/Reta11stabbshment Permltfi DATE PRINTED 12/17/2013 KA r s s r £^ ` �" �- p'.' ,'x `• `' - �X 5... , �tF #• ` k"" s� re. sl�cx l ESTABLISHMENT NAME F ��/��2son Wharf r e , ' y, �.Number BFO:2003-0000242WI1 Sticet`".,n, t �.G-� ,i"+k•.4 v .`'" � .,�t*g" .f�,�". "t-� <gt* s +i+ r ' - i "? :s .�,. �✓ € - #re �e�,g i S� „ `� ,s Salem ��.� `' -t- #`az.. �" MA"'f`'a•01970£r �' s�`' .' u mak ,.- _ k vim. _" .Y' xS.. z •u: n.y ,qn ^'.P „^ a -s' ,c i LOCATED'AT -'0062 WHARF STREET w � SALEM,-MA 01970 '"'' .Tiw3 N; �S, ?'°; .k '_ Y mx. a r .." k s"Nu. ? " i*m`` r '1�xa''z.•F� �r ` �',-cfi3� '�r n Permit Type -Pernut No Permit Issued Pernut Expires ,Fee Restrictions!Notes � > S k,�.,. +�,y'r�- •_' �3 F]OpO,D,�ppSERpppV}}��I,C,���E�� BFiP 20140105 - Jan.i,2014 -D�ge'c 31`1014 �jr $280 00 -' ' ., ESTABLJSt11v1P1'1� ,� i ,'�� hy. V. 'R TXA V. -u..- -p Via` ' -,t,. ,,.c. - s:. .�,y pis ax;+,. 4E x+ .x`.y Asx s,s u^•� 4F . k`£x x? a' `� s s Z �' 3 '�'e n v`i »TM s #t IT Z- 11, .'�.. 3, "fir' TZ r "si^ .?5�tq�'}3'' . ",L •..f- h+ � �§�,..y 5, ."'r 's.-$ r"^ �"S-. � $ a` a '" #` r*x' `t4. �,". '3 { ,+�` �'� Sn t� 3• >� 3� ,,.. r 1 � ��^�y,*�' � fr s �".�, �"�» �' �� 3 F e fes. � �$`.r, z _ r x 3 A �k,{� a ^Sa .- ' aa :h �sx ;g r h y �. •y ',` a ,?' a;s^`i'`�'"�• '.""�e,,nr ,�"�'° .� r _ i •# {Y m2 3^: # _"°.�?-'r4'w' ' �+.,: �?,,,,•�" , , RFs tr "ts,:'y` 'e "n,:r"*'-. � s$ a 4 'pEt :" xF, --PERMIT EXPIRE$ ecember 31,2014 , , x �� � , 3 taBoard of Healthy ' au" .st �Y` � s t'a>F $• -Y" .x,a;.„t ss Xy Fw 'r�yx 47� t ,•r.-5- fes. �sd�7 -y- 's. x¢F,*j''- ��{' x r a x`1i3 "gal lb, t z "eat ,. -' a-, ,,,_ .. This Permit is not transferable and must be reissued upon than ownership or location The permit must be posted a inaprominentlocahon_mtheEstablishment` r , rIn accordance with the State Sanitary Code, eq re any°revonahans,improvements or equipment changes are made; A plans for such must be submitted to and approved by�the Salem$oar&of Rbil&c '`page 1 l � �. ,{ �.._ � 4 � * #� �k :r � s '�`k nh3" .�q� p�'d`�• qhs�',#' �7 �N � h ��n � '�•� k �'� �" > 'x` IT t y CITY OF SALEM, IV MASSACHUSETTS REC"'EIVEDPU u, BOARD or Ht;Aures 120 WASHINGTON S7R@'in',4"'FLOOR 'EC 112013 KIMBERLEY DRISCOLL Te>I..(978)741-1800 FAx(978)745-0343 LARRY RAMDIN,ILS/RE'J-IS,Clio,CP-fS MAYOR lramdin(t�salem.com �,� ' .r OF SAI =M Hi-,W:rH AGENT OAAL) OF HEALTH Food Establishment Permit Application (Application.must be submitted at least 3/0 days before the planned opening date) 1) Establishment Name: 600 �C�SQIcc u�oY-Jp 9 /i✓�iJ� / 2 2) Establishment Address: M-)Aq.0 3) Establishment Mailing Address(if different): U r _ 4) Establishment Telephone No: //�eq P �y( p0 co 5) Applicant Name&Title: A✓<nL✓rc� Le�CO ��T C��f D �✓,✓c 6) Applicant Address: ,,O? 7) Applicant Telephone No:f� 24 Hour Emergency No:!"7�S`-'U?6-9V 8) Owner Name&Title(If different from applicant): Ski�4 9) Owner Address(if different from applicant): S� 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address - TT ivldual .✓�.✓,o �✓G'o�� Rc ,.-n✓� A partnership pot/e-rc 4ele.-A I—el �//� �v 54 G. Other legal entitycsi C✓ `' 12 Person Directly Res onsible For Daily Operations �(Owner, Person in Charge,Su ervisor,manager,eta Name&Title: G.�e` O��e2, Address: /e- -57 �c'aSo�e /Lt q y Telephone No: 7S 7�J GY>(o.� Fax: f7 '8' 710 //6v' Email: Q 6CylP-�cou?� con Emergency Telephone No: 97Sw 0139 S-8ff� 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: 5 w Date: �� 3 i3 Amount: \ • Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) Olt 16) Days and Hours of Operation7=$K 42'tm 17) No.of Food Employees: Co 18) Name of Person In Charge Certified in Food Protection Management: Required as of 101112001 In accordance with 105 CMR 590.003(A) ,.g ��e ✓ 0 6e ,✓eo k 2>< 19) Person Trained In Anti-Choking Procedures(if 25 seats or more): 6'1'es_ No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) 13Caterer Permanent Structuret// 21 Food Service-( So Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: ...,_,,,_..Breakfast Establishments ......................................................... (�ick one) RETAIL STORE RESTAURANT Annual ❑ Less than 1000sq.ft. $70 ❑Less than 25 seats $140 Seasonal/Dates: ❑1000-10,OOOsq.ft. $280 residential Kitchens $140 ❑More than 10,000sq.ft. $420 5-99 seats $260 ❑More than 99 seats $420 Temporary/Dates/Time: -----............................................................................----•--....------.............................. ......--- ❑Bed&Breakfast/Childcare Services/Nursing Home $100 -------------------------------- -------- -------- ---------- ---....................................-------........................... ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT` $25 *Including, church kitchens, state funded childcare 6 private club 23) Food Operations: Definitions: PHF-potentially hazardous food(dmeltemperature controls required) Non-PHFs-non-potentially hazardous food(no dna/temperature controls required) (check all that apply): RTE—rea ta-"I foods Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be comofeted by the Board o(Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. 1 have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applica Pursuant to MG Ch.62C, sec.49A,I certify under the penalties of perjury that 1,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: aC4 // 3 y 26) Signature of Individual or Corporate ServSafe Student Name ANTONIO BETTENCOURT _ Class Nun15v 1290174 o- EXAM FORM N O. 4856 Exam Date tN/I6/2013 Expiration Date 09/16/2018 Instructor Name RICHARD DUYUN CERTIFICATE N O. 10361375 Sponsor Name Pilgrim I1o5pitel,N ServSafeExam Location MA National Restaurant Ass.claLio. Foam Form Name 4856 QDN ServSafe Overall Point Score 76 Overall%Score 95 Passing%Scoro 76 � Status PASSED CERTIFICATION Pertece Your Point Point Score Score 80 76 IMmain Names nd Implement Food Safety SOPS 16 12 ie ANTONIO BETTENCOURT Empinyocorage,eansoxt 12 12 Receipt,Storage,han Se 13 13 Food Papp,Displaygul Service 26 26 Complienco wilM1 Regulatory 11 I1 for successfully completing the standards setforth for the SemSaW Food Protection Manager Certification Emmination, which is accredited by the American National Standards Institute(ANSN-Conference for Food Protection RFP). m me rex o a p ms'lle rtrameai tftr No a eo,nunlo Rnqu.vl man nn em 2 aserao.R asaR.l rwoml..o�pR.le e.ma.aa w.aw�n..s�xemla ia�a DATE O c 09/16/2Ina„ .,.me+.o.i,.,„ra.....,r,.ea,A 11, 11, lanwl DATE OF EX NLocal laws apply.Ch remrtification requirements. a„nmrnim no.I..co ServSafe - eorl.no_ 1W61aI5 ServSafe' sr CERTIFICATION o ANTONIO BETTENCOURT n ant Association 110655 Om W bl.eixne is"Lodela 6201$NaliunA Reaw —A Ne.NRAfF.usr4 untl+ii+en+o Ly xauonal No+launnln++rcialion Snnnims,llf, hal M`isil us).nnrkM+.ss.7e ' naAole 'L�NAerv'RFoum, . Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax (978) 745-0343 City/Town of L4Address: FOOD ESTABLISHME)qf jNSPErtION REPORT Tel. Name Da �TT yofOperationfs) Type Inspection li❑. Ud Service 93<5utine Address Risk ❑ Retail ❑Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection juw ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑Suspect Illness Person-in harge(PIC) Time iW Li Bed 8&Breakfast ❑ General Complaint ❑ HACCP Inspector Out: t Permit No. Other Each violatio cked requires an Kiplartation on the narrative 0606(s)and a citation of 91pecific provision(s)violated. Non-compliance wtth: Violations Related to Foodborne illness Interventions and Risk Factors-(Red Anti-Choking 590.009(E) ElItems) Tobacco 590.009(F) ❑. Violations marked may pose an imminent health hazard and require immediate Allergen awareness 590.009(G) ❑ corrective action as determined by the Board of Health. - - , :F :PROTECTION MANAGEMENT_- _. __- -._ _ ❑ 12. Prevention of Contamination from Hands 1 PIC Assigned/Knowledgeable/Duties ❑ _ . 13. Handwash Facilities EMPLOYEEHEALTH ,�, m�- „a iPROTECTION FROM'CHEMICALS`._ ❑ 2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded _ � _� _ ��_ - _ �. ❑ 15 Toxic Chemicals .FOOD_FROMAPPROVEDSOURCE._-4. ,_ _ - .:_ � 4. Food and Water from Approved Source -" ;TIMErrEMPERATURE.CONTROLS tPotenUalty Ha:erdouus F.00de)= ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6..Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROT ON FROM CONTAMINATION _ _ ❑ 19. Hot and Cold Holding Separation/Segregation/Protection v ❑20.Time as a Public Health Control [Food Contact Surfaces Cleaning and Sanitizing .REQUIREMENT5 FORNIGHLYSUSCEPTBLE=POPULATIONSt(H8P)�] 17110. Proper Adequate Handwashing E]21.Food and Food Preparation for HSP _ ❑ 11. Good Hygienic PracticesiCOONSUMERADVISORY __ _ _ ___ ❑22 Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Connection: 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-2x order of the Board of Health. Failure to correct violations 2 nod and Food Protection (Fc-0x8890.000.00 3)4) cited in this report may result in suspension or revocation of 5. Equipment and Utensils (FC-4x590.005) the food establishment permit and Cessation of food 2,W Water, Plumbing and Waste (FCsx590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-8x590.007) have a right to a hearing. Your request must be in wrifing 28. Poisonous or Toxic Materi (FC-7x590.008) and submitted to the Board of Health at the above address 29. Special Re (580.008) within 10 days of receipt of this order 30. Other DATE OF RE-INSPECTION: l S bAi drc Inspector's Signa r . Print: 1 P[Cs Signature: Print: ` - Page 1 ofPagea Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination Y 590.003(A) Asia went of Res onsibilit * 3-302.11(A)(]) Raw Animal Foods Separated from Cooked and RTE Foals* 590.003(B) Demonstration of Knowledge" Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302.11(A)(2) Raw Animal Foals Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3302.15 Washing Fruits and Ve etables applicants* 3-304.11. Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person to Contamination from the Consumer Charge* 59Q003 0 Reporting by Person in Charge' 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-7,01.1.t Discarding or Reconditioning Unsafe _FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources FT Food Contact Surfaces - 590.004(A-B) Compliance with Food.Law* 4-501..111 Manual Warewashing-Hot Water 3-201.12 F<xxi in a Hermetically Sealed Container* Sanitization Temperatures* 3.201.13 Fluid Milk and Milk Products* 4-501.1 t2 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Satutization Temperatures* 3-202.14 Eggs mid i lilk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Pntabie 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(.4) Bottled Drinking W ater=' - 4-602.1.1 Cleaning Frequency of Equipment Food 590.006(B) Water Meets Standards in 310 0VIR 22A * ; Contact Surfaces and Utensils*, Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught'vIolluscaa 4-702.11 Frequency of Sanitization of Utensils and Shellfish* Foal Contact Surfaces of Equipment* 3-201.154-703.11 Methods of Samtization-Hut Water and Sources*an M Shellfish from,1SSP L.isttnf Chemical* 10 Proper,Adequate Handwashing Game and Wild AAushrooms Approved by Re u/atoAuthorlt 2-301.11 ClemCondition-Hands and Arms* - 3-202.18 Shellstock Identification Present:' 2301.12 Cleaning Procedure* 590.004(0 Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game-Animals* , 1 11 Good Hygienic Practices - 3 Receiving/Condition 2401.11 Eatin ,Drinking or Using Tobacco* 3-202.11PHFs Received at Proper Tem eratutes* 2-401.12 Discharges.From the Eyes,Nose and 3-202.15 Package lute rit * Mouth' 3-101.11 F orf Safe and Unadulterated* 3-30L 12 Preventin Contamination When Tastin * 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained*' -Employees* TagslRecords Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Ca acities* 590.004(n Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 --Accessibility.Operation and Maintenance /HACCP Pians Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502:1.2 Reduced ox gen acka ng,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.t2 Confo mance wi h A roved Procedures* 6-301.12 Hand Drying Provision Denotes critical item in the federal 1999 Paid Code or 105 CMR 590D00. I .�.r!!��► ,: ..���.,�RM 1- f/.III/'L 1 i 3-501.14(C) PHFs Received at Temperatures Viotations Related to Foodborne 07ness Interventions and Risk According to Law Cooled to Factors(ttetns 1-22) (Cant.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs ' -- ig - PHF Hot and Cold Holding 14 Food or Color Additives 3-501.16($) Cold PRFs Maintained at or below i 3 202.12 Additives* 590.004(F) 41'145°F* r 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Mairitamed at or above 15 Poisonous or Toxic Substances 140`F. * 7-101.11 Identifying Information-Original 3.501.I6(A) Roasts Held at or above 130'F. Containers* Time as a Public Health Control ..t 7-102.11. Common Name-Working Containers* 20 i 7-201.Ii Separation-Seo e* 3-501:t9 Time as a Public Heaitit Control* 7-202.11 .Restriction-Presenceand Use* - 590.004(H) Variance Requirement 7-202.12 Conditions of Use's REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals' 1 21 3-801.11(A) Unpasteurized Pre-packaged luices and 7-204.12 Chemicals for Washing Produce,Criteria' 7-204.14 Drying Agents.Criteria* Beverages with W-arning Labels* 7-205.11 Incidental Food Contact Lubricants* 3-80I.11(B) Use of Pasteurized Eggs* i 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria$ Raw Seed Sprouts Not Served ,-206.I2 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and 'Monitorin * - CONSUMER ADVISORY 71MEITEMPERATURE CONTROLS 22 3-603.11 Consumes Advisor+Posted for Consumption of t 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or t PHFs Not Otherwise-i roeessed to Eliminate ' PPathogens.'3 401.S1A{1}(2) Eggs- 155 F 15 Sec: ro e Eggs-Immediate.Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shea 3401.11(A)(2) - Comminuted Fish.Meats&Game E * Animals-155`F 15 see.* SPECIAL REQUIREMENTS 3.401.11(B)(I)(2) Pork and Beef Roast, 130OF 121 min* l 3-401.11(A)(2) Ratites,Injected Meats 155`F 15 590.009(A)-(D) Violations of Section S9(1.{Xt ary a in i * catering.mobile food,temporary and y see. `t 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be ! Stuffing Containing Fish,Meat, debited undeaa the appropriate sections { Poultry or Ratites-165°F 15 sec ' above if related to foodborne illness f 3-901.11(()(3) Whole-trancle,Intact Beef Steaks interventions and risk factors. Other i 145°F* 590.009 violations relating to good retail '1 3-401.12 Raw Animal Foods Cooked in a practices should be debited tinder#29- i Microwave 165°F* Special Requirements. i 3.401a(A)(1)(b) All Other PHFs-145"F 15 sec.* 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165°F 15 see.* (Items 23-30) - ! 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can be t 3403,11(C) Commercially Processed RTE Food- found in the follawing sectionsof the Food Code and 105 CMR 140°F* 590.00O. 3403.11(E) Remaining Unstic:ed Portions of Beef ; Item i Good Retell Practices FC 590.000 Roasts" 23. i Ma Food and Personnel FG-2 .003 15 Proper Coaling of PHFs 24 Food and Food Protection FC-3 .004 1 25. t Equipment and utensils ( FC-4 .005 1 3-501.14(A) Cooling Cooked PHFs from 140`F to 26. 1 Water.Plumbing and Waste 1 FC-5 006 r - 70`F Within 2 Hours and From 70°F 27. Physical Facility 1 FC-&- .007 to 41`F/45°F Within 4 Hours. * 128. Poisonous or Toxic Materials FC-7 .008 I 3-501.14(11) Cooling'PHFs Made Frnm Ambient 29. Special R virements .009 Temperature Ingralients to 41°F/45°F On - Within 4 Hours* i -D wins critical iwni in the federal 1999 Foal Coale or 105 CMR 590.000. FREM rfrOffia(rod(MI ff FIMM WHIAMM. ` _,. 'L►��/I1�.1MO.. ► Il tIl/,ISE MA ` !...R�, i ._ _ i�:/��/�.{_��! ' 1/��1�L�/�i .! Rim. IN, TLwI:t.MEMO / �'.�. � /s.15I/L�71�/%!�,yS�/�l'�• lI.��L7 ��WflM.t i..� .� �I r Lrw I la .. 7i r MY A .AL. 11 ALJ i r r 3-307.14(0 PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to �I d Factors(Hems 1-22) (Cont.) 41'F/45'F Within 4 Hours,PPROTECTION FROM CHEMICALS 3-501..15 Coolm Methods for PHFs 19 PHF Hot and Cold Holding ir 14 Food or Color Additives 3-50I.16(B) Cold PHFs Maima ned at or below f 3-202.12 Additives* 590.004(0 4101450 F* 3-302.14 Protection from Unapproved Additives'§ 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 1400E * 7-101,11 ldenti6ing Information-Original 3-501.16(A) Roasts Held at of above: 1300F. '* Containers* 7-102.11. Common Name-WorkingContainers* 20 Time as a Public Health Control 7-201.11 5 'on-Stora e* - 3-501:19 Time as a Public Health Cootrvd* 7-202.11 .Restriction-Presenc:eand Use* - 590.004(H) Variance Re uiremant 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sanitizers.Criteria-Chemicals* POPULATIONS HSP - t 7-204.12 Chemicals for WashingCri Produce, teria' Bevera es with Warning labeels21 3-801.1 l(A) Unpasteurized Pre-packages! lse* asci 7-204.14 Drviruz Aizents.Criteria* 7-?05.11 Incidental Food Contact,Lubricants* 3-801.11(6) Use of Pasteurized Eggs* 7-206.11 -Restricted Use Pesticides,Criteria* 3-801..11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served * 7-206.12 - Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Rt:=served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY PIMEfi EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of 16 Proper Conking Temperatures for Animal Foods That are Raw.Undercooked or C PHFs Na Otherwise Processed to Eliminate nate Eggs- 155F 15 Sec. PalhO ens.* E -Immediate Service 145 FlSsec: 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155`F 15 sec. " 3-401.11(B)(1)(2) Port:and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155`F IS 390.009(A)-(D) Violations of Section 590.049(A)-(D)in see.* catering,.mobile fbod,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 see. * above if related to foodborne illness i 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-4010 I(A)(1)(b) All Other PHFs- I45'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403A I(A)&(D) PHFs 165"F 15 sec. * (Iterns 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical.mid non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can be 3-403.11(0) Commercially Processed RTE Food- found in the following sectionsofthe Food Code and 105 CMR 1400F* 590.000. 3403.11(E) Remaining Unsliced Potiitms of Beef Fltem i Good Retail Practices FC 590.000 Roasts* 1,�23. .1 Management and Personnel i FC-2 .003 1g Proper Cooling of PHFs 2i 4.. i Food and Food Protection l FC-3 .004 1 25. Equipment and Utensils ( FC-4 .005 i 3-501.14(A) Cooling Cooked PHFs front 140`F to ! Zg, Water.Plumbing and Waste FC-5 .906 ' 70'F Within 2 Hours and From 70'F 27. Ph s�� Foci' FC-6 fJ07 .t to 41`F/45'F Within 4 Hours. ' Poisonous or Toxic Materials i FCG=7 .008 3-501.14(B) Cooling PHFs Made From Ambient ~2S. S eclat R uirsanems .009 Temperature Ingredients to 41'F/45'F 30 1 Other - r Within 4 Hot=* Denotes critical vera in the federal 1999 pored Cole a'105 C-MR 590.000. .1 e Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHME IN PE ION REPORT Tel NameDat T p " fOperation(s) Type o Inspection Food Service ❑ Wtine -AddressRisk V ❑ RetailMe-inspection Telephone Level ❑ Residential Kitchen Prev io��z�ct,n� ❑ Mobile Date: ��II Owner HACCP YIN 11 Temporary ❑Pre:o e o ❑ Caterer ❑Suspect Illness Person-in-ChargeI Time L) Bed& e �st El General Complaint In: 1 ❑ HACCP Inspector Out ( Permit No. ❑.Other Each violqW chficked r uir n explanation on the narrative d )and a citation o specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ q corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) [3 SFO 6131 OTECTION MANAGEMENT_ _ -_ _j ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH - ---- ❑ 13. Handwash Facilities ._ --�� L] 2. Reporting of Diseases by Food Employee and PIC tPROTECTION FROM'CHEMICACS' m _ 1 El 14.Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded -._..- ❑ 15 Toxic Chemicals FOOD Food an Water SOURCE 'fwErrkK ERATURE:CONTROLS_(Poiardlalty kazerdous Foods)_-�' ❑ 4 Food and Water from Approved Source a _ ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling r'PROTECTION FROM CONTAMINATION 'S -1 ❑19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing !7REOUIREMENTS FOR,NIGHLYSUSCEPTIBLE=POPULATIONS;(HSP)J E]21. Food and Food Preparation for HSP ❑10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISGRY`_ ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non critical (N)violations must be corrected Official Order for Correction:Based on an insction 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-2X order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3X590.004) ) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5X590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address ffi29Special Require ents (990.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: . �aaa Inspector's Signature: Print: y PICs Signature: Print: page. of ages w � Violations Related to Foodbome Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination _ FOOD PROTECTION MANAGEMENT 3-302.19(A)(1) Raw Animal Foods Separated from 1 590.003(.0) Assignment of Responsibility Cooked and RTE Foods* 540.003(B) Demonstration of Knowledge* Contamination from Raw ingredients 2-103.11. Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(.0) Food Protection* ` require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting y b Person in Charge" 3 590.003(0 Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590,003(E) I Removal of Exclusionsand Restrict ons Discarding or Recondili 3-70 E_1'toniag Unsafe FOOD FROM APPROVED SOURCE Food* q 1 Food and Water From Regulated Sources F 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4501.111 Manual Warewashing-Hot Water 3-201.12 Food in a.Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* - Sanitization Temperatures* 3-202.14 Eggs and iNlitk Products.Pasteurized* 4-501.114 - Chemical:Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101.11 Drinking Waterfrom an A roved S rotent* [4-60201_1I(A) Equipment Food Contact Surfaces and590.006(A) Bottled Drinking Water* Utensils Clean* 590.fla6(B) Water Meets Standards in 310 CMR 22.0"` 4-6 .11 Cleaning Frequency of Equipment Food- 590.006(B) Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Fre uencv of Sanitization of Utensils and 3-201.19 Fish and Rec eationally Caught Molluscs Food Contact Surfaces of Equipment* S1telLisit* 4-703.11 Methods of Sanitization--Hot Water and- 3-201,15 Molluscan Shellfish from NSSF LisE Chemical* Sources* 10 Proper,Adequate Handwashing Regulatory Authority Game and Arad Mushrooms Approved by 2-301..1.1 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.Ammals* 11 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinkin or Using Tobacco* 3-202.11 PHFs Received at Proper Tern ratunes* 2"401.12_ Discharges:From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-)01.11 _Food Safe and Unadulterated* 3-301.12. Preventing Contamination When Tasting* 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination.from 3-203.12 Shellstock Identification Maintained'" Employees* Tags/Records:Fish Products - 13 Handwash Facilities 3402.11 Parasite Dcstruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Ca acibes* - 590.004(1) Labeling of Ingredients* 5-204.11 Location and Placement* 9 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans - Supplied with Soap and Hand Drying 3-502.11. Spechdized Processing Methods* Devices 3-502.1.2 Reduced Ox en acka in&criteria* 6-301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with A -oved Procedures* 6301.1.2 Hand Drying Provision 'Denotes critical item in.the Weral 1999 Poaxi Code or 105 CMR 590.000. CITY OF SALEM rr r BOARD OF HEALTH Establishment Name: l� 1 Date: Page: Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red item Verified E P INT CLE LY o az all [Aja 1 ` Discussion With Person in Charge: Correctiv Action Required: ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all oluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P C3 Re-inspection Scheduled (3Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five do tars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. Voluntary Disposal ❑ Other: I t 3-547.14(() PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-211) (Cont.) 41'F145°F Within 4 Hours, t ROTECTION FROM CHEMICALS 3-501.,15 CoolingMethods for PHFs P ._.C7 Ig PHF Not and Cold Holding 14Mit ood or Color Additives k - -•••-•••-- 3-541,16(B) Cold PHFs Maintained at a below 3-20212 Additives*' 590.004(F) 4101450 F* 3-302.14 Protection from Una roved Additives* 3-501,16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances - 1400P, * 7-101,11 Identifying Information-Original 3-501-16(A) Roasts Held at or above 1300F, i Containers* 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* - 3-501:19 Time as a Public Health Cnntrul* 7-201.11 Separation-Storage* 7-202.11 ,Restriction-Presence and-Use$ - 590.004(H) Variance Requirement '. 7-20212 Conditions of Use* REQUIREMENT'S FOR HIGHLY SUSCEPTIBLE 7-2033.11 'Toxic Containers-Prohibitions* POPULATIONS NSR � 7-204.11. Sanitim".Criteria-Chemicals* l 7-204.12 Chemicals fou WashingProduce,Criteria* 21 3-801.!I(A) UnpasteurizedPre-packagedJuices and 7-204.14 Drying Agents.Criteria" . .Beverages with Warning Labels* 7-245.11 Incidental Food Contact,Lubricants* 3-801.11(B Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Critetis* 7-306.12 - Rodent Bait Stations* Raw Seed Sprouts Not Served. 3-801.11(C) 7-206.13 Trar:king Powders,Pest Control and Unopened Food Packa Not Rev-served. Sl Montt ttin * CONSUMER ADVISORY 1 TIMErTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Choking Temperatures for Animal Foods That are Raw,Undercooked or l PHFs - Not Otherwise,Processed to Eliminate y Pathogens. ! 3-401.I1A(1)(2) Eggs- 155F 15 Sec. I Eggs-Immediate Service 145°1`15sec- 3-302.13. Pasteurized Eggs Substitute for Raw Shell 3-44111(A)(2) Comminuted Fish.Meats&Game E * Animals-155'F 15 sec. 3401.11(B)(1)(2) Port;and Beef Roast-t30°F 121 min* SPECIAL REQUIREMENTS 3 401.71fA)(2p Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section .590.009(A)-(D)in j sec.$ catering,mobile food,temporary and 3401.1 I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections '1} Poultry or Ratites-165'F 15 sec, * above if related to foodborne illness 3•-401,11((}(3) Whole-muscle,Intact Beef Steals interventions and risk factors. Other 145T 4c 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited render#29- Microwave 165'F* Special Requirements. 3-40LI l(A)(1)(b) All Other PHFs-145'F 15 sec, 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL€rRAC77CES 3403AI(A)&(D) PHFs 165F 15 sec. * (Itents23-30) 3-4M.11(B) Microwave- 165`F 2 Minute Standing Critical,mrd non-critical violations, which do not relate to the Time* foodborne illness interventions and ris&.factors listed above, can be 3-443.11(C) Commercially Processed RTE Foal- found in the following sectionsof the Food Code and 105 CMR 1400P 590.000. 3-403.1 l(E) Remaining Unsliced Portions of Beef 1 Item 1 Good Retail Practices � .FC 590.000 .Roasts* i 23.__ 1 Management and Personnel ! FC-2 003 1g Proper Cooling of PHFs 24. mood and Foal Protection FC-3 .004 25. E2uip_meM and Utensils FC-4 .005 3-501.14(0) Cooling Cooked PHFs from 140°F to , 26. 1 Water.Plumbing and Waste FC-5 .006 7WF Within 2 Hours and From 70'F 27. Physical Facility FC--6 ,007_ to 41`F(45'F Within 4 Hours.* 128. ' Poisonous or Toxic Materials FC-7 .008 j 3-501.14(B) Cooling PHFs Made From Ambient 29. -Special R viremerns 009 j Temperature Ingredients to 41*Ff45'F - i330. i other Within 4 Hours° "Dewte critical vzni in the federal 1999 Fcad Cain or 105 CMR X90.000. i 71 Commonwealth of Massachusetts �a a City of Salem Kimberley Dnscoll - 22 Board of Health r , � • 120 Washington Street,4th Floor M8y0r 'v4- _ ,z max , r SALEM,MA 01970 F ' * •;x s T 3i FOM/Retail Estanitblishinent`Perl g 01/03/2013DATE PRINTED: . e a x s a. r >. ESTABLISHMENT NAME: ` _ rSixty�2 on Wharf � .i File Number BHF-2003-000024r +, _ 62 Wharf Street >P, ".�' `' { _ m ', # ." s s pm �...,: q `b,? ,t Y ice.,. is ,` tia Salem` MA 01970 V LOCATED AT 0062 WHARF STREET ..` ;� 4 4F SALEM, MA i01970 ; u: Permit Type Permit No. Permit Issued" Permit Expires+ .r-.F Fee Restrictions/Notes FOOD SERVICE BHP-2013-0327 Jan 1,2013 =Dec 31,2013 $280 00 _ ESTABLISHMENT . '. gas • a 4 .Total Fees: _ 280.00 { g fit '. xt -4§`Ai;, ;N str a . i y kv r> PERMIT EXPIRES -,December 31,1013 { `Board of Health e This Permit is not transferable and must be reissued upon change of ownership or location:The permit must be posted A in a prominent location in the Establishment: In' - m x n t In accordance with the.State Sanitary Code beofre any revonations,unprovements,or equipment changes are made, + all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 :-Sp , < f tr• CITY OF SALEM, MASSACHUSETTS Public Health ' BOARD OF HE?AI,T4I 120 WAST IINGTON S'l u..c•;r,4111 FLOOR KIMBERLEY DRISCOLL Till..(978)741-180^0 FAQ(978)745-0343 Lmm,Y RAMDIN,RS/Rla.l-IS,(1I10,CP-FS MAYOR 1ramdui(a)salcm.com HII.AI.;PLi AGFN'I' Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: C9 c7� u2grl✓ ¢ e Qg2 2) Establishment Address: Q2 + Sf 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: ! J� yy 00 a 5) Applicant Name&Title: ��J�oi✓io e ? ✓Co ^ e f // ��e f ®��c 6) Applicant Address: /<7 7) Applicant Telephone No: f! 201 7y9aorpl. 24 Hour Emergency No: } .S Email: 6a �esdrtu ca 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An associabon,_ Name Title Home Address An individual ✓per`a"� ✓ie o f evL Q-TkA"a IV O` A partnership p f sq 4 p Other legal entity rolec, PJc7k - 1� p���PS.[Q�✓� 12 Person Directly Res onsible For Daily Operations Owner, Person in Char e, Su ervisor,Mana er,etc. Name&Title: �•�o✓./o' /de P�✓cvr ref Gtict/i✓enc Address �� (�cL��^ S� O 260 Telephone No: 7,2k Sql 9575 Fax: $'787 g116 L Email: �'�e�p^[a4r' to 'rs� ✓f Emergency Telephone No: %7 S- 3 S�8oZ 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: ��r� " Date: O— Amount: 0 v Food Establishment Information 14) Water Source: C"/r 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation:Sum- S'af S-/ 17) No. of Food Employees: $ 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures( if 25 seats or more): R/Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) / ❑ etail( Sq. Ft) ❑ Caterer Permanent Structure t/ lir Food Service-( $o Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit:. ---------------- ----------------------- - ..................................Breakfast Establishments-------,-----.------.--- - (ch ck one) RETAIL STORE RESTAURANT Annual ❑ Less than 1000sq.ft. $70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 e•25-99 seats $280 ❑ More than 99 seats $420 Temporary/Dates/Time: - - --- - -- ------ --------- -- ---- -- ------ --- ---- -- --- -- I Bed&Breakfast/Childcare Seryices/Nursing Home $100 ------ ------------------------------------------------------------------ ---------------- --------------- --------------------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare&private clubs) 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperature controls required) check all that apply): RTE-ready-to•ea foods(Ex,sandwiches,salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applic law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. ,1 certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: L 26) Signature of Individual or Corporate Name: ✓>ue/'1 ed- I�eS Gleor� 6061 6:9-�oa-� �`�� I,d,Ne ��2 m 4 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH - 120WASHINGTON STREET 4`"FLOOR PablicHealth i o r­cm.rromotc.Protect. TEL. (978) 741-1800 Fax(978) 745-0343 KIMBERLEY DRISCOLL Iraindin@salel-n.com salem.com - - L[11t1iY R.\bIDIN,RS/REiIS;CHO;CP-CS MAYOR HI-"AIXI1 AGENT This Form will be collected during your next Hoard of Health inspection. QUESTIONAIRE -GREASE TRAPS 2012 1. NAME OF ESTABLISHMENT: Cock �S l✓� w e ��2 2. ADDRESS OF ESTABLISHMENT: d%�- 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP?71 �S 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? ©/.rT'i`G2 C�PcC�✓�%�7V .5�2 � iCL' 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 2 ✓e�y 6/LtOS, 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? 3°��- r Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax(978) 745-0343 City/Town of Y ' Address: FOOD ESTABLISH ENT I SPECTION REPORT Tel. Name Dat Typ Operadon(s) Type of Inspection cod Service ❑ Routine Address Ris ❑ Retail P) e-inspection -66-An UTAH Telephone Level ❑ Residential Kitchen Previous I spa ion VIM IL40 ❑ Mobile Date: �i Owner HACCP YIN ❑ Temporary ❑Pre or2Lbd� ❑ Caterer ❑Suspect Illness Person-in Charge(PI ) Time ❑ Bed& r a5( ❑General Complaint In: P ❑ HACCP Inspector 4101- U 46WOut Permit No ❑.Other Each violation ch ed requires ahVkpliffiation on the narrative g (s)and a citati o specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑. ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) _ _ _ % ._ FODDPROTECTION MANAGEMENT' -_ . ___ .. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ,'EMPLOYEE HEALTH - --- - El 13. Handwash Facilities .. ... _ _ . _ ._ - _ ._.. - . PROTECTION FROM'CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded _ .,.w, ❑ 15. Toxic Chemicals .FOOD.'FRod and Water SOURCE_ - _ . tiMEtTEMPERATUF CONTROLS(Potentially Hazardous FOods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling ,PROTECTION FROM CONTAMINATION _ ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20. Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing IREQUIREMEyTS FOR HIGHLYSUSCEPTIBLE=POPULAT(ONS:(HBP)'_, 10. Proper Adequate Handwashing El 21. Food and Food Preparation for HSP ❑ _ _ El 11. Good Hygienic Practices ;CONSUMERADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22)- of Health. Noncritical (N)violations must be corrected ID 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-2x590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3xsso.004)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4x590.005) the food establishment permit and Cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6x590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. SpeciARGuient (590.009) within 10 days of receipt of this prder •30. Other !, )tAf DATFrOFRE-INSPECTION: Inspector's Signature: - - ----- Print: V�IYYVI/ PICS Signa Priot: _ J Page oL Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT g Cross-contamination I 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* 2-103. 51 Demonstration of Knowledge* Contamination from Paw ingredients r2-103.11. Person in charge-dories 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Outer" Contamination from the Environment 2 590,003(C) Responsibility of the person in charge to 3-302.11(A Food Protection* require reporting by food employees and a hcants* 3-302.15 WashingFruits and Vegetables 590.003(P) Responsibility Of R Food Employee Or An 3-304.11 Food Contact with Equipment and Iitensils* Applicant To Report To The Person In - Contamination from the Consumer Charge* 590.003 G Reportmg by person;n Charee* 3-306.14(A)(B) Returned Food and Reservice of Food* Disposition of Adulterated or Contaminated 3 59U.003(D) Exclusions and Restrickions* Food 990.003(E) Removal of Exclusions and Restrictions 3..701,11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water Fmm Regulated Sources 9 Food Contact Surfaces 590.004(.A-B) Compliance with Food Law* 4-501.11 I Manual Warewashmg-Hot Water 3-201.13 Food in a Hermeticall•Seale);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 F&Es and;Milk Products,Pasteurized* 4-501.11.4 Chemical:Sanitization-temp.,pH, 3-202.16 lee Made From Potable Drinking Water* - concentration and hardness. 5-10,1.11 Drinking Water lion))an Approved System* 4'601.l l(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DriiikmE Water" Utensils Clean* 590.006(B) Water Meets Standards f_3p.r CMR 2211 CleaningFrequency of Contact Surfaces and Utensils* Equipment Food Shelt/ish and Fish From an Approved Sourcece 4-602. Fish 4-702.1 I. Frequency of Sanitization of Utensils and 3-201.14 het and Rec a unally Caugbt Molluscan Foal Contact Surfaces of Equipment* ShelMolllfish* _ 4-703.11 Methods of Sanitization-Hot Water and 3-201.25 Srrurescan Shellfish from NSSF( sted Chemical* Game an 30 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2.301.1 I Clean Condition-Hands and Arms* Regulatory Authority - 3-202.18 SheilstockIdentification t'resent` 2--301..12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals' Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PRFs Received at Proper Tem erahues$ 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-10'.11 __ Foci Safe and Unadulterated* 3-301.12 PreventingContamination 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.i2 Shellstock Identification Maintained* Employees* Tags/Records;Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction' Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 . Numbers and Capacities* 590.004(_ Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance 1HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced ox en acka"ng,criteria" 6-301.11 Handwash;_ Cleanser,Availability 8-103,1< Confoimance w;th R ;uved Procedures` b-301.1.2 Hand Drying Provision Denotes ctitical gem in.the federal[999 ro)d Code or 105 CMR 590.000, Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of C- Address: FOOD ESTABISHWNTIMOE&110N REPORT Tel Name DateTem�{y,pe f Operation(s) Type of nspection Iy rood Service outine AddressRisk ❑ Retail EllRe-inspection Telephone Level [1 Residential Kitchen Previous Inspection ❑ Mobile Date: OwnerHACCP Y/N ❑ Temporary ElPre-operation ❑ Caterer ❑Suspect Illness Person-in arge(PIC) Time, ❑ Bed 8 Breakfast ❑ General Complaint In ❑ HACCP Inspector Oa ermit No 4 24) ❑.Other Each violati ec ed requires an explanation on the narrative ,e s and a citati6tflbf specific provisions violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.099(F) ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties _ ❑ 13. Handwash Facilities 'EMPLOYEE HEALTH R _ j aPROTECTION FROM'CHEMICALS���, ❑ 2. Reporting of Diseases by Food Employee and PIC _ El 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded .� _�..__.�-- _-... ❑ 15 Toxic Chemicals C,FOODFROMAPPROVEDSOURCE .-. .__._,4, - - �v Source -- �TIME/TEMPERATURE CONTROLS(P.oteMlali Nazardous F.00do)='� i ❑ 4. Food and Water Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling = 19. Hot and Cold Holdin PROTECTION FROM CONTAMINATION - 9 ❑ 8. Separation/Segregation/Protection El 20.Time as a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing IREQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPULATIONS_(NSP);_] ❑10. Proper Adequate Handwashing ❑21.Food and Food Preparation for HSP El 11. Good Hygienic Practices CONSUMERADVISORY _1 ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 5. Equipment and Utensils (F134X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5X590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7X590.008) and submitted to the Board of Health at the above address 9. Special Re 'r ents (590.009) within 10 days of receipt of this ord . 30. Other DATE OF RE-INSPECTION: �YI�I/ Inspector's Signature. Print: ' PICS Signature;,5 // Pagel of'Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 I Cross-contamination 3-302.11(A)(1.) - Raw Animal Foods Se aratedfrom 1 590.003(A) Ansi meat of Responsibility*ed Cooked and RTE Fords* 2-103.11. Demonstration of Knowledge'er' Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302.11(A)(2) Raw Anir 611 Foods Separated from Each Other" EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.1.1(A) Food Protection* require reporting by food employees and 3-302.15 Washmt Fruits and Ve etables applicants'Responsibility 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Fad Employee Or An Applicant To Report'Io The Person In Utensils* Contamination from the Consumer Charge*- 3-306.14(A) Retuned Food and Reservice of Food* 590.003 G) Re t n b Person n Charge* Disposition of Adulterated or Contaminated 31 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3--101.11 Discardmg or Reconditioning Unsafe _ FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 590.004(A-B) _Compliance with Food Law*_ 4501.1.11 Manual Wazewashing-Hot Water 3-201.12 poral in a Hermetically Sealed Container* Sanitization Temperatureo, 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.73 Shell Eggs* Sanitization Tem ratures* 3-202.14 Eggs and Milk Prafucis.Pasteurized* 4-501.113 Chemical Sanitization-temp.,pH; 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-i01.11 Drinking Water from an Approved System* 4-601..1 I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinkin Water' - _ Utensils Clean* 590.006(B) Water Meets Standards is 3]0 CMR?-2.l)* 4-602.11 Cleaning Frequency of Equipment Ford- Shelflish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and - 3-201.14 Fish and Reoaeational3y Caught Melia;can Food Contact Surfaces of Equipment* Shellfish* 4703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Mid Adushrrmms Approved by Re u/afoAuthcrft 2-301.1.1 Clean Condition-Hands and Arms* _ 3-202.1.3 Shellstock identification Present" 2-301..1.2 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game.Animals* 11 Good Hygienic Practices 5 RerelvingrCondition 2401.11. Eating,Drinking or Using Tobacco* 3-202.1.1: PHFs Received at Proper Tem ratures* 2401.12. Discharges.Fromthe Eyes,Nose and 3-20215 Package tette.it " Mouth 3-101.1 i Food Safe and Unadulterated* 3-301.12 Preventin>Contamination When Tasting* 6 TagstRocords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 -Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock identification Maintained* Employees* Tags/Records:Fish Products 13 Handwesh Facilities 302.11 Parasite Destruction* Conveniently Located and Accessible 3-40212 Records. Creation and Retention" 5-203.11 Numbers and Capacities* 590.004(.-) Labeling of Ingredients' 5-204-11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11. -Accessibility. Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.1] S ecialized Processing Methods* Devices 3-502.12 Reduced bx gen acka'ng,cri[eria* 6-301.11 - Handwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures* - 6-301..12 Hand-Drying Provision *Denotes critical item in.the-decal 1999 Faai Code or 105 CMR 590DOo. CITY OF SALEM BOARD OF HEALTH ��JJ Establishment Name: Date: Page: L/ of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dete No. Reference R-Red Item verified PLEASE PRINT CLE RLv )O I 1 i i c 1 Discussion With Person in Charge: Corrective Action Required: ❑ No s 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 e-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Cod e—l-understatad that noncompliance may result in daily fines of twertt= ars or sus ion/revoca 1 ❑ Embargo E3 Emergency Closure your food permit. Voluntary Disposal ❑ Other: f k 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodbarne illness triter✓entlons and Risk According to taw Cooled to Factors Merns 1-22) (Cont.) 41'Ff45'F Within 4 Houm t PROTECTION FROM CHEMICALS 3-501..15 Coolie Methods for PHFs P lg Food a Color Additives 19 PHF Hot and Cold Holding Hot 590'004{F) P 3-50uti(B) Cold PRFs Maintained at a below 3-202.12 Additives* I 3-302.14 Protection from Unapproved Additives* F 15 Poisonous or Toxic Substances 3-541.1(i(A) HHot PHFs Maintained at or above 144`F. 7-1 OI,f i Identifying Information-Original 3-501,16(A) Roasts Held at or above, OWE Containers" - 70 Time as a Public Health Carmol f 7-102,11. Common Name-WorkingContainers* - 7-201.1.1 Separation-Storage* 3-50IA9 Time as a Public Health Control* 7-202.11 ,Restriction-Presence and Use* 190•004(H) Variance Requirement r 7-202.12 Conditions of Use+ REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 'Toxic Containers-Prohibitions* POPULATIONS HSP 7-204,11 Sanitizers.Criteria-Chemicals" 3-841.11(A) Unpasteurized 7-204.1.2 Chemicals for WashingProduce,Criteria* UnpastUnpasteurized Pre-packaged]vices and .Beverages with Warning Labels* 7-204.14 n ents.Criteria° 3-801.118 Use of Pasteurized Eggs* 7-245.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 -Restricted Use Pesticides,Criteria$ Ran Seed Sprocas Not Served. 7-2K 12 Rodent Bait Stations* 3-841.11(C) Unopened Food Package Not Re=served. 7-206.13 Tracking Powders,Pest Control and _ Monitoring* CONSUMER ADVISORY i TIME/TEMPERATURE CONTROLS 22 3-60.11 1 Consumer Advisory Posted for Consumption of F6Proper Cooking Temperatures far Animal Foods That are Raw.Undercooked or Not Otherwise Processed to Eliminate PHFs - Pathogens.'er«rre rnrza�r 3401.11A(i)(2) Egg- 155F 15 Sec. E -,-immediate ServiIL- 145'Fl5.see. 3-302.13. Pasteurized Eggs Substitute for Raw Shell 3-441.11(A)(2) Comminuted Fish.Meats&Game E { - Animals-155'F 15 sec, 3 401.11(B){I;(2) Pori and Beef Roast- 130'F t21 min* SPECIAL REQUIREMENTS 1 0 590.009(A)-(D) Violations of section 590.009(A)-(D)in 3-401.11(A)(2) Ratites, Injected Meats-155 F 15 sec.* catering,.mobile food,temporary and 3-401.1.1(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be 1 Staffing Containing Fish.Meat, debited under the appropriate sections Poultry or Ratites-165017 15 sec. * above if related to foodborne illness 3-401..11(C)(3) Whole-nimcle,Intact Beef Steaks interventions and risk factors. Other 145OF* 590.009 violations relating to good retail ? 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. `t 3-401.11(A)(I)(b) All Other PHFs- 145F 15 sec. 17 Reheating for Not Holding VIOLATIONS RELATED TO 0000 RETAIL PRACTICES r3.403AI(A)&(D) PRFs 165`F 15 sec. * i (Items 23-30) 1 3-403.1 I(B) Microwave--165`F 2 Minute Standing Critical,mid non-critical violations, which do not relate to the Ting* f<wdborne illness interventions and risk facaors listed abase,can be 3403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsl'tced Portions of Beef item i Goad Rotall Practices .FC 6_90.000 Roasts* 21 i Management and Personnel FO-2 .003 l8 Proper Cooling of PHFs 24. 1 Foal and Food Protection FC-3 .004 II 2�pment and Utensils 1 FC-4 .005 i 3-501.14(A) Cooling Cooked PHFs from 140`F to C 26. 1 water.Plumbing and Waste i FC-5 .006 70'F Within 2 Hours and From 70`F 27. j Ptiysical Facility i FC-6 007 j to4VF145'FWithin 4Hours. * 128. PoisortousorToxicMatenals FC-7 .008 3-501.14(6) Goofing PRFs Made From Ambient X29 Sp ia1 Reguiremems i 009 Temperature Ingredients to 41'Ft45°F 130 61her Within 4 Hours* ssw:r:,mv.•.c, Denotes critical iu.m in the federal 1999 Fw1J Cale a 105 C:'MR 590.000. 1 r i Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"'Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD EST LISHMENT4 P CTION�REPORT Tel. NameDa TTyLW of Operatiori(s) Type of Inspection (9 Food Service ❑Roaffne AddressRisk ❑ Retail2011-inspection Telephone Level El Residential Kitchen Previous Inspection ❑ Mobile Date: Owner HACCP YIN ❑ Temporary [I Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Tim4= 4e ❑ Bed 8 reakfst E]General Complaint LGI In: �/ ❑ Inspector Out: Permit N ❑Other HACCP Each viola£ he ked re i es an-exoffiriation on the narrative page )and a citati n o speci is provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti-Choking 590.009(E) ❑ Items) Tobacco 9 590.009(F) E],Violationsmarkedma y pose an imminent health hazard and require immediate Allergen awareness 590.009(G) ❑ corrective action as determined by the Board of Health. FOOQpROTECTION MANAGEMENT: _ _ ] ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH .: ❑ 13. Handwash Facilities 'PROTECTION FROM'CHEMICALS` ❑ 2. Reporting of Diseases by Food Employee and PIC - E] 3. Personnel with Infections Restricted/Excluded ❑ 14.Approved Food or Color Additives ., _._. [__115.Toxic Chemicals ,.,FOOD'FR Food and Water from Approved Source APPROVED SOURCE ❑ 4. Food TIMErr_ EMPERATURE:CONTROLS(Potenttalty 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 HIGHLY4U$(:EPTIBLE=POPULATIONS:(Hap),. 10. Proper Adequate Handwashing El 21. Food and Food Preparation for HSP ❑ _ ❑ 11. Good Hygienic Practices CONSUMERADVISORY _ _ ,_ w 7 ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related El Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2x590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-axsso.004)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4x590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FCsx590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6x590.007) have a right to a hearing. Your request must be in writing 28. Pois us or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. Sp irements (590.009) within 10 days of receipt of this order. 30. DATE OF RE-1NSP TION: s: w,.. Inspecto ' Print: PICS ;! "" Print: pia✓�'O �.-rJ�'O H ge of Pages • ,.- _-�.•,� .•.,.•^-ti. .. ,e,T ._-r.. -a w .d."rj,. i41✓'- a A .. .-r . Violations Related to Foodbome Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Crass-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) I Raw Animal Foods Separated from Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302,1,I(.A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.1 I(A) - Food Protection* require reporting by food employees and 3-302.15 Washut Fruits and Ve etables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Foot!Employee Or An Applicant To Report'To The Person In - - Utensils* Chat * Contamination from the Consumer +-. 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 3?Oi,i'1 Discarding or Reconditioning Unsafe _ FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces - 590.004(.A-B) Compliance with Fond law* 4-501.11 I 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 Tem eratures* 3-202.14 Eggs and Milk Products.Pasteurized* 7501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101.11 Drelcing Water from an Approved S tem* 4-60]-11(A) Equipment Food Contact Surfaces and- 590,006(A) Bowled Drinking Water' Utensils Clean* t a 22,)* 4-602.1.1 Gleaning Frequency of Equipment Fnod--' 5)0.006(B) Water Meets Standards n Approved CMR.< .,, Contact Surfaces and Utensils* ShWllish and Fish From an Approved Source 3-201.14 Fish and Recreaeionahy Caught rvlolluscan 4-702.11 Frequency of Sanitization of Utensils and Shellftsh* Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization-Hot Water and 3-201.I5 Molluscan Shellfish fn>m NSSF lasted i Chemical* 10 Game and Witt Mushrooms Approved by Proper,Adequate Handwashing Reculatory Authority 2-301..1.1 Clean Condition-Hands and Anus* 3-20118 SheiNteck Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 1 When to Wash* 3-201.17 Game Animals* F11 Good Hygienic Practices 5 ReceivinGfCondition 2401.11 Eatin ,Drinkin or Using Tobacco* 3-202.1.1 PHFs Received at Proper Temperainres* 2401.12. Discharges From the Eyes,Nose and 3-202.15 Package late,ir* Mouth* 3-10,L11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Recosds:Shelistock 12 Prevention of Contamination from Hands 3-202.18 She0stock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* -� Em plo ees* - - TagslRecords;Fish Products 13 Handwash Facilities 3--X02.7.1 Parasite Destruction*- - Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* • 590.004(f) Labeling of Ingredients' 5-204.11 Location and Placement* F7 Conformance with Approved Procedures 5-205.11. Accessibility, Operation and Maintenance IHACCP Plans Suppfted with Soap and Hand Drying 3-502.11 S ccialized Processing Methods* Devices 3-502.12 Reduced ox gen acka"ng,criteca* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301..12 Hand Dr)ring Provision Denotes,critical item;n.the feral 1999 Fahl Code or 105 CMR 590.000, CITY OF SALEM BOARD OF HEALTH Establishment Name: 69 e inV Y Date: Page:_ of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date. No. Reference R-Red Item Verified PLEASEIP111NT CLEARLY f r' Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all o voluntary Compliance a Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled o Emergency Suspension comply with all mandates of the Mass/Federal F `End' I understand that - noncompliance may result in daily fin -o we five dollars or cusngnci __ ocation of ❑ Embargo u Emergency Closure your food permit. � �~ -� oluntary Disposal 0 Other: 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodbarne 111neirs lntenrennons and Risk According to Law Cooled to Factors{Items 1-22) (Cont.) 41'F145'F Within 4 Hours. PHFs PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for Holding 14 Food or Color Additives 19 P of Hot end MainColdtained Holding 3-202.12 Additives* 3-501,4(F) 4101 PILF#Maintained at or below 3-302.14 Protection from Unapproved Additives* 540.004{F) 41 td S'F 19 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 741.11 identifying Information-Original 3.501.16(A) Roasts Held at or above 130'F. Containers* Time as a Public Health Contra! 7-102.11, Common Name-Working Containers* 20 3-501:14 ) Variance as a Public mea th Control* 7-301.11 Separation-Storage* 590.004{H) Vari 7-202.11 Restriction-Presence and Use* - - ance R uitemem 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 'Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Saratizers.Criteria-Chemicals 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pte-packaged iuices and 7-204.14 eels.Criteria* Bevcra>es with Warning Labels* 3-801.i 1(B Use of Pasteurized E * 7-205:11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Serva° 7-206.12 - Rodent Bait Stations* 3-801.11 C Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Moniturin * CONSUMER ADVISORY22 - 1 TIMET TEMPERATURE CONTROLS 3 603.I4 C ousumer Advisory Posted fur Consumption of t Animal Foods That are Raw,Undercooked or 16 Proper Cooking Tom pera tures for .. Not Otherwise Processed to Eliminate PHFs - Patti .x avxas,n,2mi 3-401.IIA(1)(2) Eggs- 155F 15 Sec. Eggs-Immediate Service 145'F15sec^ 3-302.13 Pasteurized Eggs Substitute for Raw Shell { E * 31tO1.11(A)(2) f.'t:nuninuted Fish.Meats&Game Animals-155'F 15 sec.* SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* 3-401.11(A)(2) Ratites,Injected Meats-'155°F 15 590.009(A)-(D) Violations of Section 540.009{A}-(IJ)in r see * catering, mobile food,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited udder the appropriate sections 1 Paultry or Ratites-165'F 15 sec * above if related to foodborne illness 1 3-401.11(()(3) Whole-muscle,Imact Beef Steaks interventions and risk factors. Other r 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. r 3-401 A IW(1)(b) All Other PHFs-145F 15 sec. + 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403A I(A)&(D) PHFs 165"F 15 sec. * (Items 23-30) • 3-403.11(B) Microwave-'165 F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Ti=* foodborne illness interventions and risk factors listed above, can be i 3-403.11(C) Commercially Processed RTE Foad- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3403.I1(E) Remaining Unsliced Portions of Beef item I Good Retall Pract9css _ .FC 690.!7!10 ? Roasts* 23._ 1 Management and Personnel FC-2 .003 1$ Proper Cooling of PHFs 24. i Food and Food Protection FC--3 .004 1 25. Equipment and Utensils ( FC-4 .005 1 3-501_14(A) Cooling Cooked PHF%from 140`F to 26, Water.Ptumbino and waste FC-5 .006 70'F Within 2 Hours and From 70°F 27. Physical Facility i FC-6 .007 to 41'F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(,B) Cooling PHFs Made From Ambient 29. Special Requirements - .003 I Temperature higredierib to 41°F/45°F 130. 1 Other Within 4 Hours* *Denotes critical hens in the federal 1999 Food Cmie w-105 CMR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,40'Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 CIty/ToWn Of Address: FOOD ESTA LISHM IN ECTION REPORT Tel. Name Date Type of Operation(s) Type o Inspection (171 )) D{ Food Service utine AddresstHkwv Risk ❑ Retail ❑ Re-inspection Telephone Level El Residential Kitchen Previous Inspection El Date: Owner HACCP YIN ❑ Temporary ❑Pre-operation ❑ Caterer ❑Suspect Illness Person-in-C arge(PIC) Tim ❑ Bed&D f st ❑General Complaint Inspector In. Permit No. ❑.OtherHACCP Out: Each viola checked requires arrIkordnation on the narrative page( and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑. ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) _FOOOPROTECTION MANAGEMENT _ - ❑ 12 revention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties 13 Handwash Facilities �MPLOYEE HEALTH _.,-._- ❑ 2 Reporting of Diseases by Food Employee and PIC IPROTEGTION FROM"CHEMICALS _ El 14.Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded _ ❑ 15 Toxic Chemicals [OOPTROMAPPROVED SOURCE�,���� _... .� ,� ❑ 4 Food and Water from Approved Source `?IMMEMPERATURE CONTROLS_(Potential119_Hazerdous Foods)_ ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling FFROMCONT:MIN_ATION ���i -' ❑ 19. Hot and Cold Holding aration/Segregon/Protecti ❑20 Time as a Public Health Control d Contact Surfaces Cleaning and Sanitizing [REQUIREMENTS FOR HIGHLY-SUSCEPTIBLE-POPULATIONS(N8P) ❑21:Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ICONSUMER ADVISORY- El 22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk FactorsRed Items 1-22): of Health. Noncritical (N)violations must be corrected Factors ( ) rwi i Official Order for Correction:Based on an inspection immediately n 90 da s as determined b the Board o within y y today, the items checked indicate violations of 105 CMR of Health. C N 590.000/federal Food Code.This report,when signed below ' A. Management and Personnel (FC-2x590.003) by a Board of Health member or its agent constitutes an 4. Food and Food Protection (FC-3x590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils cited in this report may result in suspension or revocation of (FC-4x590.005) the food establishment permit and cessation of food 6.Water, Plumbing and Waste (FCsx590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6x590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of thisr. 30. Other DATE OF RE-INS EC TION. �1� s: drldec Inspector's Signature• Print: PICS rgna �.✓ OiYp �� ��✓lOtr.� Page_Lof_�IPages r ,.... .,. _.,. , . ,,. - � r.. . ...,.^.^-R. .. ,..=-a!»..; .•"313�...<.+. . ;.,,-:.. � ... .. Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 C oss-contamination _ 3-302.11(A)(1) Raw Animal Foals Separated from I 590.003(A) Assignment of Responsibility*Knowledge* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw ingredients 2-103.11. Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Ve*etables applicants" 3-304,11. Food Contact with Equipment and 590.003(F) Responsibility Of A Foal Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 590.003(G) Reporting by Person in Charge" 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and:Restrictions 3-',01.31'1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE __ F0od* _ 4 Food and Water From Rsgulated Sources 9 Food Contact Surfaces - 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* �: * 4-501.112 Mechanical Warewashin H 3-.A1.13 Fluid Milk and Milk Products g- _ of Water 3-202.13 Shell Eggs*. - Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 501 114 Chemical:Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking A'ater* concentration and hardness. * 5-101.11 Drinking Water front an Approved System- 4-601'1 I(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled ? tStg Water* 590.006(B) Water Mees Standards in 31.0 CMR 22.0* 4-60111 Cleaning Frequency ofEquipment Food Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source r 4-702.11 Frequency of Sanitization of Utensils and 3-201.14- Fish and Recreationally Ctaight Molluscan _ Fad Contac[ * shellftzn* Surfaces of Equipment* ----- -- 4-703.11 Methods of Sanitization-Hot Water and " 3-201.15 Molluscan Shellfish from*{ SSP fisted Sources* Chemical* Game and Wild Mushrooms Approved by 30 Proper;Adequate Handwashing Re u/ato Authority2-301..11 Clean Condition-Hands and Arms* 3-202.1.3 Shellstock Identifcation.Present" 2--301.1.2 Cleaning Procedure* 590,004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals*- - 11 Good Hygienic Practices " 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11: PHFs Received at Proper Temperatures* 2-401.12 Discharges.From the Eyes,Nose and 3-202.1.5 Package htte it'* Mouth* 3-10 L I 1 F_oW Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Aerords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 -Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained" Employees* Tags/Records:Fish Products 13 Handwash Facilities - - 3-402.11 - Parasite Destruction* Conveniently Located and Accessible 3-402.12 . Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(.1) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-50211 Specialized Processing Methods* - Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability - 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision Denotes critical item inthe federal 1999 Pool Code or 105 CMR 590.000, i CITY OF SALEM BOARD OF Establishment Name: Ch L1Date: Page: of -aim !w"v . '".hl. . u� .. .�'1. �11►'.�.t c 3.501.14(C) PHFs Received at Temperatures Vtolstions Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors fltems7-22) (Cont.) 4I'F145`F Within 4 Hours. t 3-501..15 Conlin Methods for PHFs PROTECTION FROM CHEMICALS 19 PHF Hot and Cold Holding Food iv *Color Additives 3-501.16(13) Cold PHFs Maintained at or below 3,202.12 _Additives590.004(F) 410145'F* 3-302.14 Protection from Unapproved Additives" 3-501.16(A) - Hot PllFs Maintained at or above 15 Poisonous or Toxic Substances 1407 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1300F." Containers"`. t ' 7-702.11. Cotnnton Name-WorkingContainers* 20 Time as a Public Health Control Y 7-201.11 Separation-Stora * 3-501.£9 Time as a Public Health Control* 590.004(H) Variance Requirement 7-202..11 .Restriction-Presence and Use* - 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.71 Sanitize".Criteria-Chemicals* 7-204.12 Chemicals far Washing Produce,Criteria* 21. 3-841.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agetim Criteria* :13everages with Warning labels* 7-205.11 incidental Food Contact,Lubricants* - 3-80LII(B) Use of Pasteurized Eggs= , 7-206.31 Restricted Use Pesticides;Criteria* 3-801.1 I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 7-206.12 - Rodent Bait Stations* 3-$01.11 C} Unopened Fcwd Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* - CONSUMER ADVISORY 22 3-603.I1 Consumer Advismy Posted for Consumption of T(MEffEMPERATURE CONTROLS t Animal Foods That are Raw.Undercooked or F6 Proper Cooking Temperatures for Not Otherwise-Processed to Eliminate PHFs 3-40£.IIA(l)(2) Eggs- 155°F 15 Sec. pa{ho•etes.* "a "'n. r _ -Fags-immediate Service 145°Fl5sec* 3-30213 1 PasteuErized Eggs Substitute for Raw Shell 3-401.11(A)(2m ) Comminuted Fish.Meats&Game Animals-155°F 15 sec.* _ SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast-130-F 121 min* 3 4(11.71(A)(2D Ratites,Injected Meats-155`F t5 590'049(A)-(D) Violations of Section 590.009(A)-(I)).in sec., catering,.mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited udder the appropriate sections Poultry or Ratites-.165*F 15 see. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Focxis Cooked in a practices should be debited tinder#29- Microwave 165F* Special Requirements. 3-401 A l(A)(1)(b) All Other PHFs- I45°F I$sec.+ 17 Reheating for Hot Folding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 1657 15 sec. * (Items 23-30) 3403.11(B) Microwave- 165°F 2 Minute Standing Crificaiatid non-critical Violations,which do not relate°to the Titre" foodborne illness interventions and risk,factors listed above, can be 3-403,11(C) Commercially Processed RTE Food- jound in the following,sectians,of the Food Code and 105 CMR 1400F* 590.0010. 3-103.11(E) Remaining UnsiicedPortions ofBeef - ( Item GaodRotatlPracNces FC 530.040 Roasts" c 23_ 1 Management and Psrsonriel �-FC-2 .003 i lg i 24. Food and Food Protection I FC-3 .004 Proper Cooling of PHFs 125. c Equipment and Utensils 1 FC-4 .00.5 ; 3-501.14(A) Cooling Cooked PRFs from 140°F to28. Water.Plumbingand Waste i FC-5 .008 i 70°F Within 2 Hours and Front 70`F 27. Physical Facliity FC-6 .007 to 41`F1450F Within 4 Hours. * 128. Poisonous or Toxic Materiais ' FC 7 008 3-501.14(B) Cooling PHFs Made From Ambient al Requirements - .009 Temperature Ingredients to 41`Ff456F 30 i Other Within 4 Hours* l 'D noes crifical iwm in the federal 1999 FooA Crede w IV CMR 590.000, i` i rim El I m PAO Imo. 0'� �.'����►.r �l1!�I.palMaIT/Ml-WORMAI MKI 01 MFA WO' ' :• ��l."���� .'�i�l�® �►' �J 't1 ,. �5 . ►l�L' �iR,�ll ,��0 . 561—1 (C-1! -PHFS elx-ived at Temperatures Vialations Rotated to Foodbarne fitness Interventions and Risk Accoidia.,to Law Cooled to Factors(Items 1-4) (Cont) -11 W45'F Within 14 Hours 3-50IA5 Coolio-'Mcibe&for IIHFs PROTECTION FROM CHEMICALS L14 I Food or Color Additives PHF Hot and Cold Holding — I ---- Cold PHI Maintained at(w belefe, 202 12 4 1 ii/4511 F, — I protookull front Uro nappved Additives, 302 14 —4 -r-.- -es TsTmT(7,(i�F lint ME, Maintained at or above Poisonous orToldc Substanc I 140"R I I raitying Info; net - Original Ide �l-50 I.16(,v) 1 koasos Held at or tdsove 1 102.1 i Common Nanue T30"F� Colitaillersp, are as a putill,Health Control LZO 2-20112 Se ararron 3- 01'i 9 1 Tim,as a Public I lealdn ControV - I tora e 7 590.004(1-1) PiMtirezrrow 1-20111 Reqriction -Presence and Use* 7-202.12 Conditions of Use REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7203 1-1 �Ixlc Elnlamere...probibotoiWi POPULATIONS(HSP 7: J-204.VI' Sanitizery,Crrieria--Chemic Asii, �041 2 -7(7h-,-1ulCals for Washief?,Prodtafe,Ctiteria"i 21 '#-SMAJ(At Unpaiiern izcd Pic Packaged Juices alul 7-204,I±_ LDDrLjnv' A�L�catfi,Criteria� flevera2'es with Warning,I dols". _ ._ 3g0. lj,e of paqeo 1-205.31 1 Incidental FaxlZonaiict,lAtbitewils" 7-i06,i I Pesticides,criteltal 3-801 I I(D) Raw or Pailialh,Coolked Animal Food and Ray. 7-206.12 1 Rodent Boil StationsIfC) M6 13 'Ir sicking Prr��fl,r��Pf-s[(:antro! and CONSUMER ADVISORY 22 34 1 0 It f1trafail Jor Cowumption(41' TIME/TEMPERATURE CONTROLS 1 16 Proper Cooking Temperatures For— AwqiA Frxxhz'I'hraarc Rain, tJTndtqcxx)kcd ir! PHFs Net Othom ise lerocessed w Eluninatz r�11111�:fw; 3,101,11 A(l)12) Eggs 15i'F 15 Sol% 13 Pjsteflrlf"d Fl,, Suhsutuhe for Raw Shell � 7 401.1 1(02; Comminuted Fish,M"'(s&G11M - Ardwals- 1551-' 17 sec� " SPECIAL,REOUIREMENTS 7-40711(B)(1,1(2) flrakand]3cel`Roast 130'1I2I in, 3-40 LI I(A)(") Ratites, Iniekled Wilts - 155 F I —TT 'lin 5 Lll"E- I on�i7u I Seclitol 590.L09(1%)-(7D catering, mohi1c.ftxrdi,tempora Did 746i.11(Ah3) f`fnfltry'1�0dGalr,,,Stns eTf�iTs' reeidential kitchen opeiations!should be I ld he Stuffhug Containing Fish, Meat, debiled ander the 8pproprlitic sections Poultry or Ratites-165°F 15 sm. If abeflifo 11 related to foodborne illness 3-401 11,C)i(3; Intao BvJ Steaks intei vendons and risk Lactors, Other 1451590009 violations relating to hoodretail 2 Row Aiaff�[Foixts CvoCd ill a practices hould be debited under#29 - � Mictowave 16.51" Special tfeqtlirerncjrts- L1-401,11(A)(1 (b) Ali Othai PHI-s-- 1451, 15 sec, Lg Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES flhs 165'F 15 wo, (Items 23-30) 3-403.11(13) Microwave- 165'F 2 h9olaaStuduti, aidral err noft-cf,"wal viva! ons,11-hich r new r(fiare to the fialrdhorne diness filter Venliony'ald rink'factors lifted frbore, (an be 1 3-403.11(C) ConaftereWly Processed RTVFood found ill sel-tioriv oche Food Cade and 105 CMR 14WF1 3-401 11(Sc} Remaillin. uIrrileed Portions of Beef item otail Practices F 750,0W Mena smen an Persorinj FC 2 1 003 1 1--246 1 Foi-A and Food Proreetion Proper Cooling at PMFs 7 F -- - -�[� - _05 and FC 4--- "- I 501 140) Cooling Cooli PHFs fo, abtu3dante --------- -1-- 5 006 70"F Within 2 flour. and From 70'F 27, PhVsic,,l FacifilV to 4i }-145 F ills"ithin 4 How I FC-7 003 48) Coriling PHF�Made From Ambient --i-S p 2��a Tcurperatare firgredicius to 41�Fi(45�1, Other L_, Within 4 ljour� CITY OF SALEM, MASSAC H USE r-i S BOARD ON HEALTH 1 uCi lV"ASH INGT(7u STRFiI:�,I',4` Pi,,<:x�R TEL: (978)741-1800 KIMBE;RLEY DRISCOLI: FAX (978) 745-0343 MAYOR 7rmiLht, salem.com LA�L121'IL111II71 N,RS f}tI{415,L;}40,CP-t'5 FIVAlsi-i ACI;NT ThLc Fern wdll bs coIto c#ed during your nex Boars'of Health inspecCi n C' OUESTIONAIRE -GREASE TRAPS 2089 1. NAME OF ESTABLISHMENT: �a �eS{/uK e�erltt I�l 2. ADDRESS OF ESTABLISHMENT: 6c4l I 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? S 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?