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HAWTHORNE HOTEL - ESTABLISHMENTS ftNIVERSAL® UNV-12110 MADE IN USA �R EE MN.RECYCIID l IN111AtNF CONfBlf10M'® Cel"Fiber Soerehq �t'� www Nryrogrem mq Sl ul!Ai o CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 3 120 WASHINGTON STREET, 4TH FLOOR SALEM. MA O1970 TEL. 978-741-1800 Q FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to : Owner' s Name : Dorothy Harrington Name of Establishment : Hawthorne Hotel Address of Establishment : 18 Washington Square West Type of Establishment : FOOD SERVICE Application Date : 01/03/2003 Restrictions : Permit for Food Establishment 221-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 48-03 These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT l ` CITY OF SALEM, MASSACHUSETTS ej BOARD OF HEALTH 3 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01 970 TEL. 978-741 1 800 FAx 978-745-0343 STANLEY USOVIC7, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGFNT 2403 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Hawthorne Hotel TEL# (978) 744-4080 ADDRESS OF ESTABLISHMENT 18 Washington Square West , Salem, MA 01970 MAILING ADDRESS (if different) OWNER'S NAME Dorothv Harrington TEL# (978) 744-4080 ADDRESS 7 Bay View Avenue CITY Beverlv STATE MA ZIP 01915 CERTIFIED FOOD MANAGER'S NAME(S) Steven Nelson CERTIFICATE#(s) 714175 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Steven Nelson HOME TEL#(978) 922-7850 HOURS OF OPERATION: Mon. X Tue. X Wed. X Thu. X Fri. X Sat. X Sun. X "Ck-lzp �4-12Y (Qa-12V, CA-i2p to-i2p 2P TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than I0,000sq.ft. =$250 RESTAURANT 4YD NO �� �,( 3 less than 25 seats =$100 25-99 seats 150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO 5 TOBACCO VENDOR YES NO 4S''� $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGLapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my ZS no belief, have filed all stat t x returns and paid all state taxes required under the law, is!73,)e o1/-a9aS7Y'9 � Date Social Security or Federal Identification Number Revised 11126....../02 F2 `"F'"OODAP2.adm Check#6 Date R'HE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT, Tel: (978) 741-1800 Fax: (978) 745-0343 Name Da Tvnp of Oneration(s) T e of Inspection, }�(2 j Food Service Routine Address Risk Retail ❑ Re-inspection _' Level{M ❑ Residential Kitchen Previous Inspection Telephone C�(7��/�// 4-��-. f- J'� I ��� ❑ Mobile Date: Owner / f HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) / Q{�/,r Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector�c Out: Permit No. ❑ Other Each / violatcnhecked requires/an' exLplanation 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 fRed ItemsI. Anti-choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food-Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) El 4. Food and Water from Approved Source El16. Cooking Temperatures El 5. Receiving/Condition El 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/ HACCP Plans �❑ 118. Cooling Jul 1 PROTECTION FROM CONTAMINATION ❑ 9. Hot and Cold Holding 20. Time as a Public Health Control ❑ 8. Separation/,Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (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 fnr Onrrec i n: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR o Health. 590.000/Federal Food Code.This report, when signed below c N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 4 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: f Inspector's Signature: I Print���] Q - PIC's Signature: (� r /_ ,�' `„ I Print, I ; '_s f pr ) ao-j I Page 0(3Pages FORM 734A HOBBS&WARREN - BOSTON V Violations Related to Foodborne Illness ,n l Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination I FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw 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 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B)l Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces 4 Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency Surfaces ces and Utetion si Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Ho[Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating.Drinking or Using Tobacco* J 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* 6 I Tags/Records:Shellstock 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(1) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM .� `�B4O�AR1D OF HEALTH Establishment Name: u. ���_ NC�`L� Date: O Page: of e Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY , o aw l c�1 - �t� ��w, I I hJ s� I I-O S- _ I I `��:_ �� O� I A-t> �# S ue% 12 � a* Coke _ G �� tc2 • 1 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No ( ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all Li Voluntary Compliance Ll Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P El 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 .dour food permit. ❑ Voluntary Disposal ❑ Other: r r 3-501 14(C) PRFs Received at Temperatures Violations Rested to Foodborne illness Interventions and Risk Accla-din ,o I..w('+r)led tv Fsctors(Items 1.22) (Cont.) 11'Ft4517Pvithu:4Haurs. ' 3-SULK Ctmlirw Methods lin PH F: PROTECTION FROM CHEMICALS ' ' lq Food or Color Additives i � lY PfiF Hut and Cord Holding 7 3-SOI.16(ii) C1dd PIIF's:vlainuilned at nt helow 3-02.12 Additires^ ;ovm(k} F) 5' P 3-302.14 Protection trout(Inappioved Additkesr" ( - tlot n F 115 ' Poisonous or Toxic Substances 5`21'(6(11' 1Iot Pl-iPs Maintained at nr::bn,c 7-101.11 Identdpngtnformatiun-origins! ` 140°F. ''` 3-Sill 16(:1 Roast,,;Held allot above 73U'F Containers' I 1 70 j T)m?as a Public Health Control 7-102.1 1 Common Narne -W orkinr Containers" � . '01.11 Se mnien-Stora>e" 3-501J) Timea.:a Public Health C orilot" 7.20.'..11 R"triction-Presence and Use' j 59W'01(H i Var Inco Requueutam i 7-202.12 Conditions of Use" 7-2t)3. ! Toxic Containers-Prohibitionsr REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2_04.11 Sanifizeis.Criteria -C'hei neals POPULATIONS(HSP) 7- 7 L Chemicals for R'a�ehiut�k of ,.ocnccI ,CritenaT i 121 3-801.11(A) Unprstcuri7xd Prc-packagudluiccs and _GI Hereiage. with Warning Labels* j 7-204.14 Drtifny Aleuts.Criteria` j ! 3-W!.14(131 Use cf Past;ill ized Legs- j j 7 '_OS I 1 Incidental Food Contact,Lnbncant'" ( 3-801 1 I D) Ras:of Pani ih,Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria" 1 I Raw Seed Sprouts Not Served. 7-206J2 Rodent Batt Stations', j 3-801.1 I(C) Unopened Prod Package Not Re-served. " ! 7-206,13 "Cracking Povxier s,Pest Control and Monitoring" CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-60.11 Consurrter Advisory Posed for Consumption of 16 Proper Cooking Temperatures for Amoral Poods'I7rrt arc Raw. Undm'+ooked or PHFs Not Uthera:ae Processed to Eliminate Pathogen;.:.rQe<",.v:cm 3-401.1 I:A(i;(2J Eggs- 155"F 1.5See 3-302.1 Psteur xd E,,s Substitute for Raw Shell E,,.s- Immediate Set loco 145'F1 Isis_' °G' 3-401.11(A)(2) Comminuted Fish, Meats&Came Eg€sx Animals - 155T 15 sec. " SPECIAL.REQUIREMENTS 3-401.11(B)(1)('2) Pork and Beef Roast - 13UTI<1 min" I 5 3-401.11(A)(2) Ratitcs,Injected Mcau.- 155°F 15 90 009(A)-(l)) Violations of Section >40.O09(A)-.D} in sec. " catering, mobile food. temporary and 3-401.11(A)(3) Puoltry,Wild Came.Stuffed PfiFs, residential kitchen operations should be. ,Stuffing Cum:fining Fish, Ment, dchited under the appropriate scetions Poultry or Ratites-165'F 15 tics. * above if related to foodborne ilhtees 13-401.1 I(C)(3) Whole-muscle, Intact Beet Steaks I interventions and risk factors. Other j 145'F" 590.009 violations relating to good retail ,--ol,12 Raw Animal Foods Cooked in a practices Should be debited tattler 029 - Microwave 165`F* Special -Requirements. 3-401.11(A)(1)(b) All Otbet PHFs-- 1.15"F 15 see. * j try Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PF-IFz 165`F 15 sec. ?ltent¢23-30) 3-403.1 t(B) Microwave- 165-F 2 Minnie Standing Gitical rn:d son-enlica! ieulr.rions, which do not rr,''ate io the Time" Ioodhnrne illness iruerveutions and tok foams later[above can be 3-403.11(C) Commercially Processed RTE Food- I funnel in die olloning set tm,,., of fire Food Corte and 105 CATR i 1401,' 5r10000. 3-403.11(E) Remaining Unsliced Portions of Reef ', Item Good Retail Practices FC 590.000 23 Management and Personnel FC-2 .003 is Proper Cooling of PHFS 24 Food and Food Protection Fc- 3 Orifi 25. Equipment and Ute-si s FC-4 .005 3-5111,14(A) Cooling Cooked PHP+from 140`,to 26. I Water,Piumbinq and Waste FC-5 .006 7W I,Within 2 Hour and From 70`F 1 27. i Physical Facility FC--6 .007 I to 41'F'/45�F Within 4 Hours. t 28 Poisonous or Toxic Materials FC- .008 3-501.1,4(B) Cooliue PHFs Made Flom Ambient25. Speual Requirements .009 Temperature !ngiedie•nts to 41'Ff45`17 30. Othe: Within 4 Hours. . `Ilmllel c:0ical nrni in the to s,'A 1997 Food Cad.01 10�C\1It CITY OF SALEM �BO�AppRD OF HEALTH Establishment Name: e�rr� �3k-�cYr�F H_e' t X Date: /v/4>3 Page: of Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY - I I 1 - ,; ~' I W I . I �• I I I I _ [Discussion With Person in Charge: � Corrective Action Required: I ❑ No ( ❑ !es have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction i violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. s' ❑ Voluntary Disposal 0 Other: 3-501,14t(',) PHFS Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk .Accor Cine to Law Cooled to Factors(Items 1-22) (Cant.) j 41"Fk15"F WitL•in 4 t-loars. 3-5t)L!5 Co:r,'ine Methjis tar HFs PHF Hct and Cold Holding PROTECTION FROM CHEMICALS Food or Color Additives ( I`J 14 3.51'.1 16(9) !'old PI tF,,''Oaintz:ncd at or below 3-202.12 Additives* ?02.14 Protection from Unahpnand Rdditis�cs° ! 41''!4S- F*! 15 Poisonous or Toxic Substances .i-StiLlb(:1; IotP1IFs14[aintam.dutw'abal-e 140`1' 7-101.11 Identifyinc Information- Onginal 1 501.16(1) Roa:,ts Held at or above 30'F ' Containers- 7-102.11 Common Nmue-Working Containers" 20 ! Time as a Public Health Control 7-.Iol.11 Separation-5tora203-Sfrl.19 'rw, is n pu(-dic I-tealth Control" ,^-02.11 Re:ariction--Presence and Use'' 590,004(H) Variance Requiremere 7-202.12 Condiions of Ilse" 7-203.11 Toxic Container,--Piohibilious;, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizzrs.Criteria-Chzmicils^ POPULATIONS(HSP) '/2041 12 Chemical;for Washing P1'OdnCe.Criteria" 21 3-$01.1 L.A) Unpasteuuirtt Pre-Pach...;ed Juice.and Beverages, with Warning Labels* 7-204.13 Drying Aunts.Criteria* � 3-5(li.!I(Bt j Use of Pnr.trn�ized Ees` � 205 It ( Incidental Food Contact.Lubr!.ants„' ,1-801 11(D) Ras cr Pattia3ly C okei!Animal Food and 7-206.11 l R.cstrictzd Use F'esti6des,Criteria* i ! i\dw coed Sprattts IN"A 7-20u.!2 1 Rodent BaitSL,Bions* 7-2061.!3 i Tracking Po"de�, Pest Contort and I 3�i0).i I(C:) Uncap,ted Fexxl Paekape Ka+i Re,-sewed. " Momtorine' CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 2" -l-60',,11 Consdtaet Advta oiv Posted for Consumpttun a1' 16 Proper Cooking Temperatures for I Amir fl Food,That are Rave,, Undercooked or PHFS Not Otherwise Processed to Eliminate 3-401.11 Ali l(2) Eggs- 155-F 15 Sec PalLnr�rne/'F,;o�.,:.,.;.:nn� E,-,-Is- Immechate Service 14ic Fl5secr -'-3U2.I3 Ryaeurized E- Substituiv io.n Raw Shell Foss'. 3-401.L I(A)(2) Comminuted hrsit. Meals d Came Animals- 155`F 15 sec. SPECIAL REQUIREMENTS 3-4ULI IiA)(2) Ratites,Injected Meat: 3-401.11(9)(2)(2) Ruck and Beef Roast- 1- 15 155`'F 15 121 min"' 5g OOWAi(D) Violations of Section 590,009(A)-(D) in ctnerm,a, nu}hile foot, tempos anand 3-101.110)(3) Pouhiv,Wile,(Game.Stuffed PHFS, ! resulenti I kilohm operations should Fie Stuffing Containing Fish, Meat, dcLuted under the appropriate sections Poultry or Ranles-165°F 15 sec above if telatcd to foodborne illness 3=01.1 ItCi3) Whole-muscle, Intact Beet Steaks 4,1tervcn6tms and risk factors. Other 145'F s 590.009 violations relaHne to good retail 3-401.12 Raw Animal Foods Conked in a ( practice,;should be debited under#29- Microwane 165°F * Special Requirements. 3-401.1IW(I)(b) All Other P1if's-- 145°F 15 see. * I 17 Reheating for Hot Holding ( VIOLATIONS R--LA rED 770 GOOD RETAIL PRACTICES 3-403A 1(A)XetD) PIIFs 165'F 15 sec. * (items 23-30) 3-403.11(6) Microwave- 165°F 2 Minute Standing I Cetu al tied nor.-critical violations, which do no:n laie to the• Time* ,joodhorn,illness imerreeuions and risk faetms iisferl uhnrv, car he 3403.11(C) Commercially Processed RTE Fax)- ,/maid u:the('lava ir:S se(Jion s of tiro Food gado and 105 CRfX 1400 17, 590.000. 3-4U3.11(E) Remaining,Un.,licedPortions ofBeef Item I Good Retail Practices FC 590.000 Roasts" I 23. Managernent and Personnel , FC-2 .009 IS Proper Cooling of PHFS 24. Food and Foot Protection FC,- 3 .004 25. Equipment an^iltensrs I FC-4 '005 3-5i)1.t4(A) Cooling Conked PHFS from 140`F to 26. Water, P!ummnq arc Waste FC--5 .006 70'F'Within Homs and From 7iFF 27 P wsicai Facilay fC-6 007 u)41`Fid5'F Within 4 Hours. '° 28. Poisonous cr Toxic Matena!s FC--7 .005 3-501.14(B) Cooling PHFS Made From Ambient 29. 1 Special Reuuirernents .009 Tcmperaiwrc Ingredients to 41`F145"F 30 Otl er 1 Within 4 Hnurs* " hen,de+�riti:al;tem)n the federal I9'3o II,<)J Code o; I Oi C:MR�9u 000. �_ ^s'."'.^"___'^T'`...--.sr•".+.+Y•iP.-+iYran.l'+..v'4i1t'r.%S/�'i^'.-n7r+`L.�wh_.. .,... .. 'l'yalf-p,v•w",w•hm.rww��T....=^s'W"».Iw�...s+tisss....xe*+-._---. A • "THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPOR /" Tel: (978) 741-1800 Fax: (978) 745-0343 Name Dale�S ��7 jype of Oneration(M Tv a of Insoec i n !-�C,U Food Service Routine Address /ry- �,--� Risk U Retail Re-inspection ( (l �� �- ��C1• VVC-� Level ❑ Residential Kitchen Previous Inspection Telephone 9 //// T ❑ Mobile Date: OwnerHACCP Y/N ElTemporary ❑ Pre-operation 14 a-- L- C ,�-� ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ElBed&Breakfast ElGeneral Complaint In: El HAC Inspector f /�-. rY7/Y-t f�, i( Out: Permit No. ElO1heCP Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source El 16. Cooking Temperatures El 5. Receiving/Condition El 17. Reheating El6. Tags/ Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing El 10. Proper Adequate Handwashing ❑ 21• Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing X28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: 91 Print:�._._.� .c- Frfi� 42A Vy ) gt 0 ' PIC's Si ,1,gna _, l/ - Print: Page/of ages FORM K�.34A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 0 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 1590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw 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 Food Contac[with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 13-306.14(A)(B)I Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE � 9 Food Contact Surfaces 4 I Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 1 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Game and Wild Mushrooms Approved by 4 10 Proper,Adequate Handwashing Regulatory Authority 2-301.11 Clean Condition-Hands and Arms 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* Il Good Hygienic Practices 3-201.17 Game Animals* 12-401.11 I Eating,Drinking or Using Tobacco* I 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 I Location and Placement* I 590.004(1) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 I Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 I Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* 1 I I •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY of SALEM BOARD`_OF HEALTH I, Establishment Name: �����. �`3�-t�Q Dat e: / �/G�3 Page: <_ of Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R—Red Item PLEASE PRIW CLEARLY Verified I 1 � I v _ 1 I-�-��� �S�-,S .� Ir' - ITSr�i/-��� o�Cvz Gi•�� w�Sh Ar/r;nc��� 1 l 1 j 1 t I I 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / violations before the next inspection, to observe all conditions as described, and to comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled ❑ Emergency Suspension result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other f FORM 734B HOBBS &WARREN - BOSTON { Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 4I°F/45*F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives _ _� 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/450F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 ( Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* � 21 3-801.1 I(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* l 7-204.14 Drying Agents,Criteria* 3-801 1 l(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Hlecnve 11,1200, 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145*F 15 Sec.* 3-401.1l(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(6)(1)(2) Pork and Beef Roast- 130*F 121 Min.*1 catering,mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.*1 residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165*F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165*F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 f 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-_2 .003 J Roasts* 24. Food and Food Protection FC-3 .004 f 18 ( Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 f 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 f 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 f to 41°F/45*F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(8) Cooling PHFs Made From Ambient 29. Special Requirements .009 f Temperature Ingredients to 41°F/45*F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. i 4 � ( IMPORT1AW MESSAGE ) FOR 1 OCe�n�✓`-Q — G < A.M. DATE n < �) < O i TIME �D</S P.M. M OF fY- O LOKp" '- PHONE 97Jry O as ZOD AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBIi F AREA CODE / NUMBER TIME TO CALL/ TELEPHONED <PLEASE CALL CAME TO SEE YOU ( WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL/ WILL FAX TO YOU MESSAGE 2 l�'J 12-A-m� Z �bf1/9M SI EO FORM 4009 MARE IN U.S.A CITY OF SALEM BOARD OF HEALTH > Establishment Name: rl� ��t7 S1�X Dater Page: / of Item Code c-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I I mak- I I I I V J i27 � I - I I I I I I I I I I I I I I I I • , Discussion With Person in Charge: Corrective Action Required: I ❑ No ❑ fes 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 Emersion ❑ Re-inspection Scheduled Cl Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal 13 Other: 1 n • , 3-501.1 1(C) PHFs Received at Temperatures t' Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41°17(45-I=Within 4 Hours PROTECTION FROM CHEMICALS 3-50i.15 Cooling Mcdc'XISJos Plies Food or Color Additives 19 PHF Hot and Cold Holding 14 ( i-501.1 G(B I Cold PI-IFs Maintained at is below 3-202.12 Additives* ( 500,004CF1 4 "745^E,: -302,14 Protection front Unapproved Additives` i_50L16(A) Hot PHFs Maintained at of above 15 Poisonous or Toxic Substances ,4W " 7-10111 1 Identifying Information-Original ( 3-501.16(A) Roasts Held at ni above 30`F ' Containers ,'.0 7-102 it Common Name-Working Containers"' � Time as a Public Health Control 7-201.11 Sepanaiun-Storage'' 3-501 19 Tittle its a Public health Control' 7-202.11 Restriction-Presence and Use" S90004(H) Vaunter,Requirement 7=203 12 Conditions of User 7?03 11 'toxic Container,-Prohibition~^' REQUIREMENTSLATIO (FISP) HIGHLY SUSCEPTIBLE 7-204.11 Sanuizets.Criteria-Chemicals" POPULATIONS(FISP) 7-204.12 Chemicals for Wa�ehmg Pnwuce; Criteria' ( 2I 3-801.1 i(A'; l en esteuriwitzcd Fro-rning a iviccs and 7-204.14 Drvinc Agents,Criteria" Use with Warning Labels'' 3-801.tI(B) Use ofP,tslecariaerlE;,asM 7-205 11 htetdenial Fool Contact,Lubricant," 3-801 11CDt Raw of Pam'.11y Cooked Annual Food and 7-206.11 Restricted Use Pcsueade,.Cruet ia" Rain Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations'" 3-801.11(C) Unopened Food Package Not Re-ser cd. 7-206.13 Tracking Powders, Pest Control and Mumturine'' CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-003.11 e"onsuraer Advisory Posted for Consumption of • 16 Proper Cooking Temperatures for Animal Fools That re Raw, Undercooked or PHFs Not Otherwise Processed to Ebnnnnre 3-401.IIAtJ)(2) Eggs- l55`F15Sec ' Eggs- Immediate Service 145'1715sec' ;-302.I; Pasteunrcd Fgcs Substitute for Raw Shelf r 13-401.1 I(A)Q) Comminuted Fish.Knouts K Crunie Egger Animals- 155'F 15 sec. 4. 3-4(71.11(11)(1)(2) Pock and BnefRoast- 130°FI?I min'" SPECIAL REQUIREMENTS Seg0009(A)-0)iViol 3=4( 1 J l(A)(21 Rattles, Injected Meats- 15-TT 15 � ton::of Section 5)C}m00rary and see. in a cattm ering, obile R ods temporary and 3401.11(;1)(3) Poultry,Wald Game, Stuffed PHFs• residential kitchen operation, should be StufRm�Containing Fish, Meat, debited under the appropriate sections Poultry'or Ratites-i 65'F 15 SCL. above if related to foodborne.illness ' 3-401 11(003) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other I 145'F* 590.009 violations relating,to good retain 1 3-401.12 Raw Aniutal Food,Cooked in a practices should be debited under# 9-- C r I . Microwave )WF* Special Requirements. ` 3-4tL11(A)(I)(b) All OtherPHFs - 145,F 15 sec. 's t j 17 Reheating for Hot Holding VIOLATIONS WLATED TO GOOD RETAIL PRACTICES 3403 I l(A)&(U) PIIPs 165'F 15 sec. 4` (Items 2 .31)) 3--103.11(13) A1icn+wage- 165'F 2 A9mute Standing Crrlrcul sad non-(ritirdt violations, which de not re[nte to rhe Tune" foodhorne dhie>s interrerttioac tend risk factor\ listed abot c, can2be � 3403 1 t(C) Cnnmrercially Pioeessed RTE Food- found let the f,llotring da dorm o/the food Corte and IO$011)? _ 1-10°Fr =90.000. !t 3403.110E) Remaining Unsliced Portions of Beef' item I Good Retail Practices FC 590,000 a 23 t"1anaitement and Personnel FC-2 003 Ir Rua;ts ' 24 Food and Foal Pu+tertion FC--3 004 18 Proper Cooling of PHFs .- 25. '�, Equipment nt aa 'nd Utensils ( FC-4". ,,005 _ 3-501.14(A) Cooling Cooked PH Fs from 140"17 to ( 26. Water.Plumbinq and Waste FC--5 .006 . 70'F Within 2 Homs and From 70'F 27, Phvsica:Farlity FC-6 007 to 41"F145'F Within 4 Hours. * j 28 Poisonous or Toxic Materials FC -7 008 3-501.14(&) Cooling PHFs Made From Ambient 29 Special Requirements - 009 I : . {. u Temperature ingredients to 41'17745'F 30. then _-'=;---,---_----'' Within 4 Hours" 1 "Denote,:ridcal nem in the tedet at 1999 Fuud Cede es 105 C4tR 590 000. i CITY OF SALEM s BOARD OF HEALTH Establishment Name: rlC �` �2 Y Date: �'"� � Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN.'OF,CORRECTION Date No. Reference R-Red Item ," - Verified PLEASE PRINT CLEARLY -SCJSS�G 7 s.Z r- S CAIS - 1lr �n U /Cz3 Pte, -�� _2 I . I - I • I • I ry - I 'Discussion With Person in Charge: (l Corrective Action Required: $ o. + 4 I have read this report, have had the opportunity to ask questions and agree to correct all voluntary Compliance a Employ / Exclus n violations before the next inspection, to observe all conditions as described, and to - . p eanspection Scheduled Verg,.n pension comply with all mandates of the Mass/Federal Food Code. I understand that mprg�y noncompliance may result in daily fines of twenty-five dollars or suspension/revocation ofgo m ' C LIE •'.Y 'your food permit. u a As !O e . - '�1 I 1 3-SOl.I4({' PRFs Receioed at Temperatures ` Vtotarn:im Related to Foodborne Illness interventions and Risk Acordir ut I.:,w Cooled to i factors(Items 1.22) (Cont) 41'F745'F W dlop 4 Hours. *, ?-i0!.':5 Cu,!ini, Methods frr PfIFs PROTECTION FROM CHEMICALS j9 PHF Hot and Ca;C Holding 24 ( Food or Calor Additives I 3-5p':,16(W Cold Ph Fs ,\lviw' ined at or below 3-20112 ,Addittvec 590.00.F(F) .11',,;;,F:: 3-302.I4 Poisonou from Toxic Substances rkldidi-es 3-501.16(A) I-lot PI Nfamntimed at w above 1.S Poisonous or Toxic Substances � ;40`Fr 7-101.11 Identrfymg lnfolloation --Original I 3_,;01.;tr;+\�) Roost.;Held at or aixx-e i30'F' Containers' 7-102.11 Q:nnuou\once - AVorking Conauners' ( j 20 Time as a Public Health Control) - 7-201.11 Separation-Slot age 3-507.19 Tittle a,,a FuF,l "' :e I-'�xlth Coll!,oft 7-202.11 Restriction-Preseaco and Ilse" 59wJ04(H1 V anance Requiremcttt 7-202.12 Conditions of I lsc 7-2ZU3.11 Toric Containers- Prohibitions: REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-C'hcnucat," POPULATIONS(HSP) 7-204 12 Chemicals for Washing Produce,Critrtia* ! 121 ? 801 11(A) Unpa,.tuurized Pre-p:,ekaeed Juices and 6everases uvith %sarnim„(.,.!bels 7-205.11 Dninp talents. Criteria* ; s01.I IB) Use of Past-in zed Eggs^ 7-20 .11 incidental UseFooContact. Lubricants', ?_gpl I liD) Raw of Pm'tia0y Cooked Animal Faad and 7-206.11 Restricted Use Pestieidea,Criteria' - � Rai, Seed Sprouts Not SerYed. ". 7-206.12 Roden! BattStations" : 3-801.11(0 Unopened F(YA Package Not Re-sorted. " 7--206.13 Ttackinp Powders,Pest Control and Monitoring" CONSUMER ADVISORY 22 1-66.11 Consurne r Advisory Posttd for Consumption of TIME/TEMPEP.ATURE CONTROLS Ammar Fauis"ibat are Kae..Undcreo*>ked of lfi ( Proper Cooking Temperatures for tion Oflxr aiw Processed to hlinfinate PHFS w;�•n�...r;,�x- i-101.11A(1)(2) Eggs- 155'F 15 Ser. Pathogens.;: Ekgs-immediate Set vita NS°El Ssec, 3-3u'' 13 Pasteurized Eggs Substimic t1.!'Raw Shelf 3-401 I I(A)(Z) Comminuted Dish, Bleats&:CrWme Eggs""' Animals- 15.117 15 sec. "' SPECIAL REQUIREMENTS 3-40 Pork and BeefRnast- 13U'F t21 iron' 3-401.11(A)(2) Battles,Injected Mears- 155°f' IS 590,009(A)-(J) Violations of Section 590.009(A)-(D) in sec caterng,mobile food, temporary and 3-401.11(A)(3) Poultry, Wild Came. Staffed PHIls, residential kitchen operations should be Stuffing Containin;Fish, Meat, dehited under the approl,-late sections Poultry or Ratites-1tiS"f 15 sec " above if related Eo finiihoine illness 3-401.1 I(C (3) Whole-muscle, Intact Beef Stcak:. i Intervent:inn anti risk factors. Other 145`F"' 590 009 '.iolations relafins to good retail 3-401.12 Raw Animal Foods C(xwked in a ( practices should he debited under 1179- Miciowave las`U Special Reyu.rcmcnis. 3-401.11(A)(1)(b) All Other PH F,;-- 145'F 15 see. 17 Reheating for Hot Holding VIOLA T/ONS R. LATER TO GOOD RETAIL PRACTICES 3-403.11(A)K(D) PHFS 165'F 15 sec. " (Ite,`ns 23-31)) 3-403.1 1(B 1 Microwave- 165'F 2 bhnnle Standing Criv,ai and nos-crilh:;1 rirlutions, which dor not relate to the Time" foodborne i/Miss irrten,oa ons and nsf factor Itctrri acore, can be 3-403.1 1(C) Coninteraally Processed RTE Food- I fwund in the inlloning:.cr'lions(if flee f eod Code and f05 LAIR 41 1 "F* 560.00(). . I ?-4031I(E) Rtmaininq Unsbced Portions of Beef Item Good Retail Practices FC 590.000 1 Roasts" 23 lA nageenent and Persamel FC-2 .003- -- -- 18 I Proper Cooling of PHFS 24. Fan?and Food Prorrcticn FC -3 004 25 Egwpnieni and Utensil; FC-4 .005 3-501.14(A) Cooling Cooked PHFS rrotn 140"F to 26. Waren,Plumbwo,Ind Waste I FC-5 .006 7W F'1Vrthin 2 flouts and Front 70`Y 27 ; Physical Facility FG-6 OU? to 41'F/45'17 Within 4 Hours. * 28. Pofccnou=-or Toxic Melon& l FC -7 .006 1 3-501.19(6) Cooling PliFs Made From Ambient I 29. ' Special Requirements 009 'Temperature ingredicntn tool 'FJ9s"F' • '0 Other r Within 4 Hours- `Danole,rnhtat urn in she Icdrrat 1499 Fuad Code o, lou C:l9R 590.000, f }� CITY OF SALEM, MASSACHUSETTS BOARD OT HEALTH 120 WASHINGTON S i REET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741.1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Hawthorne Hotel Address of Establishment: 18 Washington Square West Owner's Name: Dorothy Harrington Restrictions: Application Date: 12/4/2003 Permit for Food Establishment 92-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 22-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS a BOARD OF HEALTH 1,20 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO t MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Hawthorne Hotel TEL# (978) 744-4080 ADDRESS OF ESTABLISHMENT 18 Washington Square West, Salem, MA 01970 MAILING ADDRESS (if different) OWNER'SNAME Dorothy L. Harrington TEL# (978) 744-4080 ADDRESS 7 Bay View Avenue CITY Beverly STATE MA ZIP '01915 CERTIFIED FOOD MANAGER'S NAME(S) Steven Nelson CERTIFICATE#(s)7J41 75__ (required in an establishment where potentially hazardous food is prepared.) .EMERGENCY RESPONSE PERSON Steven Nelson HOME TEL# (978) 922-7850 HOURS OF OPERATION: Mon. X Tue. X Wed. X Thu. X Fri. X Sal. X Sun. X TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO f less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =-$150 more than 99 seats 2 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS � MAKE(not just serve)ICE CREAM, YOGURT, SOFT SERVE YES a5 OBACCO VENDO( � C��r ALL 1VvI7-FHQF1 such as church kitchens} YE $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit.must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to M Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my bes o ge and belief, have filed all state tax returns and paid all state taxes required under the law. 12/03/03 04-2925769 tgnattlte Date Social Security or Federal Identification Number G----------- -- •-------------------------- Revised 11/03103 FOODAP2.adm Check#&Date �L'/�O ^ �o�"*..� -..3 mill f Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,41" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tvof Operation(s), Type of Insoection 1d19Wr74&4r& 140f'ZCI.. /aSr/d/ ng I Food Service E❑� Ro�utine AddressIq " r1owi r-opi d✓ Risk El Retail At4 e-inspection Telephone Level [I Residential Kitchen Previous Inspection '7,14`4V, yv pif 14 ❑ Mobile Date: Owner HACCP YM El Temporary E] Pre-operation 00"r" 1hWAIf4SM1,l I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC)f��NNBtt!f B'�C(SI�CL� Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector nAarO Arts t .rf✓icnu Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE _ ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION [119. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control �(]�9 Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 10. Proper Adequate Handwashing El 21. Food and Food Preparation for HSP ❑ El 11. ADVISORY 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofC earth. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (Fc-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 59016 pWfFo1m 44 d. Inspector's Signature: s'�� Q,•t, d4Ii Print: PIC'sSignature: ) , �--0A1,La I Print: Kennofh O'Atel`2 I Page of 9Pages C Violations Related to Foodborne Illness Interventions and Risk Factors(items 7-22) PROTFC7tON FROM CONTAMINATION FOOD PROTECTION MANAGEMENT { S ( Crrss-coarzminaion I 5^•0.003(4) I :4sugr,ment o112csponsibility' ( :,-30i.11(A):1) Raw Ardniai Foods Separated frv::? 590.003(Bl ; Demo.*:ctratton of Kvov:ledge` I Cyto'{ed and R'IT 2-103.l: Person in charge-duties I ?>oraamnra5crt from Rav,Ingredients i 3-302 I i(A)(?) Raw Auunal Fords Separated from Fach EMPLOYEE HEALTH Other 2 590.00310 Responsibility of the person m,Jim g:to i Gonramina7ett from?be Environment require repotting,by food ennployees and { 3-7-ii7 l It Ai Forxi Pro:e:lion' applicants'i I -31)2 15. W,v,rur.,Fruits and Vegetables 590.003(F) Responsibility 01 A Fo+xi lr,mp!oyee Or Ar. 3-30a,i 1 Fend CoataLi with Bqutpm_w and Applicant To ReportTo The Perwva ht Jten>nls": C'haruc Corits;minauo;I Nur„the Cerrsur?ar 590 003(G) Reporting•Ly Person in C?ar!_e' I 3-306.14i.4;(B) Returned Food and Rscrvlcr of Food* { 13 :i90.001(I)) Exclusions arid Restrictions* i Disposition ofgduJora'edorCoataminated 590.(103(1) Rentoi al of Exclusions and Restrictions, Food 3-70i,I I Discarding nr Recrndihor.:ng Unsafe FOOD FROM APPROVED SOURCE I 'd" 14 Food and Water From Regulated Snuroes 9 Food Contact Surfaces 590.0ig(A-B) Compliance with Food LaU* 5`1) 1 1 I I Manual 14;trewashmc-Hot'Water 3-20i.12 1 R<od in Hermeiwally SealedContamcr* { Sanitization Temperatures" { 3-301 13 { Fhrid Milk and bride Yutducts* { I d-501.11'_' Mechanical 4Parewashine Hot Water { 3-2-02.13 Shell Eggs` I S:nitfzatican Temper<uures� Eg 3-20 14 gs and'litk Produua.Pasteuriz.d> 445 1 1111 Chemical Sanitization-temp., pH, 3-202.16 Ice Made From Potable Drinking Watcr" { :.onceetndioii and hardness. 5.101. I Drinking Water frim an Approved Svstem" 4-601 1 I(At F+mipment Food Contact Surfaces and Utensils Ccan" igC.006(A) { Bottled Drink:ng Water* 590 006(8) Water Meets Standards in 310 CbIR'20" -I 60:...1 Cleaning Frquene} of I3quipment Food- 5910 Coutaa Surfa,,os .ad Utensils* Sholffish and Fish From an Approved Source 4-702.11 Frequency ui Sauaiz.?bort o;L'tettsils t,n�: 3-201.1+ Nish and Recreationally Caught M:;lluscan - Fo•.ri Contact Su faces of Fquipment` Shellfish" I Y-70311 Method,-i San!tizatinn-Hart Waterand 3-201 15 Molluscan Shellfivlt from NSSP lasted Che:?Beal"' Sources* ( IC Proper,Adequate Handwash:ng { { I Game and Wild Mushroom;Approved by Heguratory Authority ( 2.:()i.i! Clean Condition-Hand;and A:ms` 3-202.18 Shellstr,_k Identification Present" { 2-301.12 Cleaning Procedure' 59000-I(C) Wild Mushrooms^ { 2-i01.14 When to A nsh* 3-201.17 Game Animate.' 111 j Good Hygienic Practices ( g Receiving/C•ondrion 1401.1 Eatln„Drinklnz rr Using'reba�eo' 4U 1 12 Ldschar 13-202.11 Pill's Received at Proper"temperatures" es From the Eyes,Nose and 3-2,02,15 Packarre Integrity` I Mouth 3-101 11 Food Safe and Unadulterated "" 13 301.12 Pre++emiuY Cnntamimdion When Tasting" 6 Tags/Records:SheiistocA 112 Prevention of Contamination from Hands j 3-202.18 ShelistockIdenuft,.unon' I ( 590.004(6-) P[evsminzConia;iariatiunfront r 3-203.73 ( ShelL,ta::k Identification bF.inplwee� laintatned" ( 1 73 ( Handwash Facilities { Tags/Records:Fish products { ! Conveniently Located and A:cesslhfe -=402.11 Parasite Destruction" ! 3-<1U2.12 Records.Creation inti Retention:' j 15-303.II -Numbers pati C[ acitirs^ 590.004(7) Labeling of Ingredients' ( I ^ 20-4.1 i:rauou and Placement* 7 Conformance with Approved Procedures I i 5?0.`,.I I ?.cc:cs;bdity,Operation and'Maintenance { /IIACCP Plans Supplied wi8r.Svzp and Hand Drying I 1-502. Detdces 11 Snecialized Processing NIQfli ds" { 3-502 12 Reduced nx,,gcn packarnn;;.criteria* I 6-301.1; Handw--ShingCeanser Amuilabiliti, { 8-103.12 Conformance with Approved Procedmes'< ( 6-301.12 Hand Drying Provision Dei of s o itictl Nwm m th;.tcdtrJ 19'19 FeNx!Crile of 105 CNIR�94iL:0. CITY OF SALEM //JJ BOARD OF HEALTH � Establishment Name: N/4bintr�/*/e li6t�rf, Date: /v /� /aY Page: `Z- of Z Item ' Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 1 No. Reference R—Red Item Verified ' PLEASE PRINT CLEARLY " gqCA4-nN/. lguA"-r fV*1t4 0 i ff0 Qt.w-4cfJ sJCW PuTi'!t4& 0eMr/71 /�i112E 1 Ali_ aF7&r1 , rJ 911-071Uy R4eodW � IVej 1 1 I 1 1 I i I 1 ; I 1 _ 1 e Discussion With Person in Charge: Corrective Action Required: I ❑ No ( ❑ Yes Emloee I have read this report, have had the opportunity to ask questions and agree to correct all ° Voluntary Compliance ° Exclusion Restriction/ 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: n. L A A' w -VJ 14{0 ! PHFs P.ecen+ed at"I'empuratures Violations Related to Foodborne//iness Interventions and Risk 4ccn;line to 1 aw Coo!cd to Factors(items 1-22) (Cont.) -4!'!'F/45'F Within 4 Hour;. " PROTECTION FROM CHEMICALS 1 3-50 t.15 c'04:i_ ;btethods for PHFs I 114 Food or Color Additives 1 19 PHF Hot and Cold Holding i 16tB1 CDIdPiIF, ?Maintaincdatorbelow -i-202.1^ Additives-' 5,01 3-302.14 Protecton from llnatprwed A,duiceg+ 1540.!(-1P; 41 !!5" F^ 3-50!.16(?.) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 1 140'F7-107.11 klentifyurc to formatnap-Or:;inoil 5-501.i6(A) Roasts Held to,shove 130e17. Containers' 1 7-102.11 Comtnt»i Name -Workin;;Containers' 1 20 Tlme as a Public Health Control 1 7-201.11 Separation-Storaec^ t-- 1`t Time as a Public:Health ConhoP' 1 7-201II Re,trichon--Presence and Use'" 1 i '00.004( 1) I Variance Rrq:orement f 7-20:.12 Cundnions of IJ::c' 7-20-3 11 Toxic Containare-Prohihi;ions' � REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sairitirers.Criteria-Cipemicaf;^` i POPULATIONS{HSP) o ,r , , 121 3-601.1 it A) Unp::cteuiazea Pre-pa:.kaged Juices and 7-.04.12 Chemicals flit Washing 1.oduu:,C rttrria I l 1 Beve:rtges with W;n:tine(,,bels- 7-204.14 Drviug:Rents.Criteria' 3-n01,31(B) Useof Pasteurized hetsq* 1 7-205-11 hicidentA Fuud Contact. Labricanis 3.801.1 (D) Raw•.,;Partially Cot)ked Ariun.d Foodand 7-20611 Restricted Cie Pesticides.Criteriat Kaw Sced Sprouts tint Served. 7 206.12 Rodent Bao iters.Pce $01.11( iC) Unopened Food Packa a Not reed. 7 ?06.13 Trackine Powders.Fst Control and j t f, t Re-sc1 Monitcrmgx 1 CONSUMER ADVISORY _ TIME/TEMPERATURE CONTROLS 12 3-603.1 1 Consumer A(Wsory Posted Cor Co,mumption of 16 I Proper Cooking Temperatures for Animal F(akis 11hat are Raw, Undurcuoked or PHFs Not Otherwise Processed to h:innnate 3-301.11 A(1)(2) Eggs- 155°F 15 Sea 1),il, !t•ne *`"`"°°`"t), Eggs-LnmediatcJervis• 145`F15se,E i 303.13 A'!steuri:;ed I[j^.ie SubItuttne for Raw Shell 3-401.11(A1(2) Comminuted Fish, Meats&Game I Eggs` Annuals- 155'F 15:cec. 'r 3-401.11tii)(I)(2) Pork and Beef Roast- 130c'F 121 rhin' SPECIALREOREQUIREMENTS 3-401.11(A)(2) Ratites. Injected Meats- 155'F IS Sq{){)tP:�(A)-(Di Violations ons of Section 590.ui49(A)-(D) in sec. ' catering, mobile food,temporary and 3-401.11(A)(3) Poultry, Wild Game,SmtTed IIH[Fs, tentdential kitchen operations should be Stuffing Containing Fish,Meat, debited under the apptntidate.sections Poultry or Rautes-1654F I5 sec, above if re!a.ed to frxidbornc illness 3-101.11((70) W node-nnusele,Intact Beof S:eaks interventions and risk factors. Other 145-17 540.009 violations ielstime to good retail 3-401.1^_ Raw Animal Foods Cooked in a I pracuces should be debited under 6`29- Microt.ave 165'F* Special Requirements. 3-=10111(0)(1)(6) A110TherPHF;-- 145°F 15 ser_. 17 Reheating for Hot Holding 1 VIOLATIONS RcLATED To GOOD RETAIL PRACTICES 3-403.11(A')MD) PHFs 165`17 15 sec'. * I Uterus 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standine I Criti,ai and non-riiticrti tit&,tor„s. which do not relrrc to r@r Time" I lundborne illnrse ;trtcrv:nrion.) and,i-d factor, listed above, can be 3-403.1 I(C) Commercially Pr:xecsed RTL Food- I kuwd hi r4r juilougne scrtions'of rhe Feud Cole and 105 CXIR I i40'F' I 5`)I),IZO. 3-•303.1 i(E) Reniainmg Un,Iiced Portion:of Beef I 1l�m Good Retail Practices F^ 1590.000 Roasts' 23. F4laratie.: 2.ro Personnel FC - i ,003 - --- '24. Food and Food Pm'cctioo FC-3 1 004 18 Proper Cooling of PHFs I I 3-501.14(5) Comma Cooked PHFs from 140`F it) 25 Euulnment and Utensils_ � FC- 4 26, Water, P:umbiaq and Waste Ft;--5 . .005 J 70°F Within 2 1-Ioars and From 70'1 127. ohasical Pacillty ;-6 007 J to:};^F/4S^F Within4 Hours t 126. Posonous cr"folie Materials FC- .DCS J +-50L 14(B) Cooliog PHFs Made hronh Ambrent 123 Special Raqu,rements !J09 Tempe.an:reltzgredientsto4l`f'/45"F 30. Other j 1 Within 4lloursx ( s.•,o..+,:,:,o-:,,+ lienotcs Inial item ni tip(Fdeizl 1999 FuNl Code or IO:;CNIR S90000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4`" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name ,J�r Date jy of Ooeration(s) T_ypeof Insoection A,G1r1J,4ei.Ilt /Vm ,rL �OY Food Service Routine Address Risk ❑ Retail ❑ Re-inspection LevgI - ❑ Residential Kitchen Previous Inspection Telephone y(,R^ YA ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation /')0,e,%r74!j I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast El Complaint ^t�L,Gl In: [j HACCP InspectorOA-,Pl 6? Aj9ki+<M,&A4M I Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1 Prevention of Contamination from Hands [11. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities EMPLOYEE HEALTH El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS E] 3. Personnel with Infections Restricted/Excluded [:114.Approved Food or Color Additives ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [:118. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20. Time As a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizingar REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofc eaNh. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590 003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of ( )( ) the food establishment permit and cessation of food 2�6. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. ' 30. Other DATE OF RE-INSPECTION: 1616-16,0 S 50MVs lFo� 14 do Inspector's Signature /_ __;I� T. Print: \' ! I R PIC's Signature: /)(L(IY/ ' I Print: '/ie nn2tti y�eeC a JI Page�ot•`�Pages Violations Related to Foodborne Illness interventions and Risk Factors(items 9-22t PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-conram,;,ration I 590.003u Ail AssienrnentoTRrah(3n�ibility' ( iI ?- O'.ii(A)4 i) Rao:Animal i'etxls Jep.u'ated fno an 590.003(6) Dem•xtsnation of P,r:owled€;e" Cooked and RTP Fowls'0 2-103.11 Person in charge- duties ( Contamination from Raw!ngredients 3-302.1I(A;(2) R,w Animal Foods Separated frr•n?Edch EMP-O"EE HEALTH Orhzr' 12 590.003(C) Responsibility of the person in c??:n;�,e to Contaminanon!rom the Environment require reporting by food employees and 3-30.1..1 It A) Ford Prate:non' appLcatnts^' 3 302.15 Washing Fruits wnl Vegetattlet. 590,003(F) Responsibility Of A Food Employee Or An j :.'x,04.1 l Ford Co:dact with Equipir and Appli:.ant T�Rep,nt To The Ptrson In Utensils''` Charge" Contamination from the Consurnra 51)0.003(6) Reporting by Person in Charge* 3-306.14W(BI Remrged Fcotf and Reservice o Foo& j 3 590 003(Di Exclusions and Rest)icnons* j Cispositun o`Adutorated of Contaminaicd 590.003(L,) Removal of Exclusion..md Restriction:; i Fooa 1 3-701.11 Discarding ora Reconditioning Unsafe FOOD FROM APPROVED SOURCE ( Food: j 4 I Food and Warer From Regulated Sources 19 Food Contact Surfaces ! Curnphance with Fnod Lats'" 4 Sfl.l l l Manual W',trewashing-Rot'Water 59t).U04(A-6) I j 3-201.1' Food in a Hermetically Sealet.0 onamrr` 3-2U;.73 Fluid Milk and MilPgoducts* i4-501.112 SMuancihnazuaitcioanl Wani,elw:earashtuiruegs'C lot Water 3-202.1- i Sanitization Tempera!ures" Shell Eggs 3-202.14 hzgS and Milk Produc,5,Pasteurized" j -501.11.1 Chemical Saniti::attnn-tewp- pl-l. i 3-202.16 ice Msde From Potable Drinkinc Wa:ar^ d-6!11.i;(.1,) Equipment iuFood dContact S urfaces and 5-101.11 Drink Ise Water firm an Approved Syst.:mr 590 00l Bottled Drinking Water* ! I Utensils Cl.;.m' 4-602.11 Cleaning Puequency of Equi»gent Food- 1590,006(6) Water Meets Standard,,to 310 CMR 22 0" Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source I '1-702.11 F,cquencyc,,l'S�i: izancnofUtensils and 3-201.14 Fish and Recreationally C aught titollu>cae FukKl Contact Sud;crs of CsGuipmmnt" Shellfish" 14-103.11 .',•ethnds of Samuis: i 2 I S tiurJ-- Hot ti\'iter rtnt. _ 1.15 Molluscan Shellfish Crow N:i5P Listed Chcmi„tl^ l Sources" ;0 Propel,Adequate Handwashing Regulatory AuAut Game and m Mushrooms Approved by ( "_4(,�LI1 Ci;an Condit:m - HandF and Arms* 5-202.18 SheilvockIdentification I§esem` 2-301.i2 Cleaningl'roco,tore` 1590AXWC) Wild Mushnwms^ 2-301.!4 \Yhc:? to wash" j 3-201.:7 Came Animals* '-' Good Hygienic Practices 5 Receiving/Condition ( 2-401.11 Paring,Drinking or Using,Tobacco 3-202.11 PIIFs Received at Proper Temperatm ec" 2-401.12 lliach:rtgcs Hom the Eyes, \use and _i-20'_.15 Puckaee lntearlty". Mouth" 3.102.)) Food.Safe and L'nxduiterated;^ 3-30;.12 T'rc,eutirg QmatamillaU,m When lasting^ i ( I?, Prevent!cn of Contamination from Hands 6 Tags/Records:Shellstock 3-202J8 Sl,dismck Identification^ i S 0.004(E) Preventing Contamination from 3-203.12 1 Shellstock Identification DfamUrined* ( Employees" jTags/Records:Fish Products ' 13 Handwash Facilities Conveniently Located mrd Accessible ?-;02.11 Parasite Desltuction^ i I I Numbers end Capacities* 3-40112 Records.Creation find Reter.Tiun"' . i90.o0 o) i.abe(ingofIngredients' I 5-20111 1)carunmidPL:ct:ucnI* 7 Conformance with Approved Procedures 15-ZU5.1 i Aursibility,t)»er.:iror.and il9:ar,�cnattre /HACCP Plans I Sunprie^t wit:Soap and Herd Prying -;-502,11 Speciahzed Processing Metho_-s* Devices 6-30i.II ifxntlwashm€t Cleam.cr A�.a+.ilamlity j 3-502.12 Reduced oxygen paeka;nng,entero un' 5-10? 12 Conformance with Approved Procedure,„, 6-301 11 Hand D'rv,ng Proci,ion ''Denote,critical item 6)the if i&ral 1?:i9 Pond Co,",.t !05 Cbitt"00:)00 CITY OF SALEM BOARD OF HEALTH Establishment Name: �i wrAfvRrJ1c /don;4 Date: 9�17�ay Page: of 3 Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 1 rL '0XP,'r.r6- 1VrPOS*&jc Awffe. G a ew/ALLr Alco vvrwir ? I 4D,sed�re�?c� e'6gs0_' yvlaral..s A_Vr A—+, ,I „QI/.ds't� snJ�s ,w &tz rmia ' I I c ca rrto er A6.&t_a r B.a.o,_R/ JV'b#,WA d9 AAO rCAW400 A'rokove.6 1 I V7f& Pd r 6v QNAC 4/S'tV`"SWICE r,0".1f cr c,Lf s 'UA 13,1�a<KN "e, 9&PAA nt AcObar.9- .4cl l-,er.rr f0d-S. I I 9 r �- �v,vr^„r irr saa.�� �.r�a! Foun,/I t'JiR,i�l, c-�s,to✓dfs-y-i ccs..�rr w++> rl�,i—rF rNW AWere A" A" _ ,4 i✓JCWS' R4u/C y9dc�uQ,n4,t w.,nArrAN- .FnrV ArtodHu .4t t tea,, AAfill N�� /�', f6a�rf C�rcerrt4 Aft9 ,�n� AYf�.6 VW, -r OctscisG MV F4M,,1�_ 24- ,ems M*eAft. " A%,7 A4- r 0.10004 A"D &A'Na. r Discussion With Person in Charge: Corrective Action Required:❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ 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: 1 � -591 J+ Pf-IFs itecetved at'1'entperafuras Violations Related to Foodborne Illness interventions and Risk According to Liv. Cola to Factors(Benis 1-22) (Cont.) 41-F/4,`FWit!un41-toms. ` PROTECTION FROM CHEMICALS I 5x1.15 '"rxitin^i62cthods for PHl's ( 114 ?HF Hat rod Cold Holding I 14 I Food or Color Additives ! 3-5n 1.16(8) Cotd Ill IFs Maintawcd at or below j 3 202.12 Additi.ea'° I 990A04(F) 41`'11115° F- 3-3()2.!4 Protection from Uuappio%cd Addur;es' ( 13-501.16(A) Hu! PHFs Main"ned at or above v; Poisonous or Toxic Substances 141)'F, h 7-101.11 klentif,,amgInformation-Original A.16(A, Rua;ts I-ci�at of above I309 ` Contaiuerr' 120 Tune as a Publ@c Health Control j 7-10_.l L Common Name-Working Containers 13-501.19 'Time as.::'ubhc Health i_untr,,O j j 7-201.11 S,partition-Storage` 17-202.11 Restriction-Presene,and Use;: I ( 590.004,H) Vk,riance Requirement 7-202.12 Conditions of Use* j j 7-203.11 Toxic Containers-Prohibitions%' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Smiitizers,Criteria-CheinicAs," i POPULATIONS,HSP) 1-204.12 ( Cheinieals for Washirw Produ:c,Criteria'' I 121 3-:O L I 1(`i) Ut .;snsut7cd Pre-packaged Junes and 7-204.14 I Dreine.Agents.Cnteria"' I Beverq;ec with W'araine IaiheL;" .,, I 3-801.1 ((B) I'se.ofPastemiredEpgs- j 7-205.11 IincidentalFoot.Contact.Lrbricants' I3-30:.11{D) RawnrPatt;a'15Ca�ked.0nim�;1F.aadlaid 7-206.11 I Restricted Iise Pesticides.Criteria" Raw Seed Sprouts Not Setve•d. 7-200.12 R<xl.nt Bait Stations' 3-801.11(C) Unopened F,Kxi Package Not Pc-seri ed. ' 7 206 13 Tracking Powder,,Pest Control ana Monitoring* CONSUMER ADVISORY TIMEIPEMPERATURE CONTROLS 22 603.11 Consttvier.Advisor} Posted for Consumption of Animal Fools"Phar as Raw, Undercooked or 1ti Proper Cooking Temperatures for PHFs Not Otherwise Pnx.essed to Elinnnate 3401.11A(1)(2) Fl=gs- 155'F 15 Sec. Patho"ge:s."" Eggs-Inar edliateService 145`F15scc 3-302.13 F;ea ur,led E;tgS SubSaiutf for Raw Shell 3-401.11(Alt 21 Comminuted Fish, M.ats&Ganie I Egg&* Animals- 155`F 15 sec. :, SPECIAL REQUIREMENTS j 3-401.11(8)0)(2) Pork and Beef Roast 130"F 121 loin" i 590 t)(,9tA?-(II) Vioi,tions of Section 590.Ui19(A}-(p) in 3-401.11(A)(2) Ratites. Injected Bleats- 155'F IS sec, - cateri,!g, mobile fohrd, temporary and 3-401.11(A)(3) Poaitrv, Wild Game,Stuffed PHFs ' residential kio-acn operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Pouhry nr Ratite=-1ti5`P iS sec. '° above if'relatedlo foodborne illness 3-401.1 h0l'3) Whole-mtiscie,Intact Beet Steaks mterventions and risk factors. Other 145"F"' -590.009 Violations relating to good retail 3 401.12 Raw Animal Foods Cooked in a ( piactices should be dehited under#29- Mltruwaee 165`F '' Sp:uu1 R quireinctits. j 3-4OL1i(A)(I)(b) All Other PHF„- 145'F !5sec I 17 Reheating for Hot Holding VIOLATIONS RZLA TED TO GOOD RETAIL PRACTICES 0-403.1 t(A)R_(D) PHFs 165°F 15 ice. * (Ile-is 23-30) 3-403.11(8) Microwave- 165"F 2 Minute Stanchne Ci iLa rd and rem-erifh.ui notations, which do nor relate to o1w Time* foo•dbornc:Jnecs iurrrvenlions and ri,b Gators Baird above, ant be 3-403.1)(C) Comnicrcialls Pnacessed RTE Food- fiartd ill the foliotrbm see;inns rlf the Food CoA-and 105 CUR 140''FT -590.000 3-403.11(E) Remaining Unshced Portions of Beef ltd Good Retail Practices FC 1590.000 Rmistsa- 23. Iviarapatnent atvl Ferso�net FC-2 .003 18 I Proper Cooling of PHFs j 24 Food and Focxi Protection IFC-3 004 j 25. Equipnteni and Utensils FC -4 .005 i-501.i 4(A) Cooling Cooked PHF n front 140"F to ; 26. Water, PIt:mbi,q and Waste FG-5 .006 70'F W"i thin 2 1 fours and From 70'F 27 Physical Faeiliiv FC-6 .007 t.i4l'F1451 PJ,thm 4 Hours. * 28 Pissorgea;or Tnxic Matenals FC--7 1 .008 3-501.14(B) Cooling PHFs Matic From Ambien; 29 Sp:reed Renuirevnents .Ou9 -- j Temperature Ingredients to bi'llNn 30. Gther Within 4 floarc,z *Cenotas cancel item❑i Me toderd ;9vv oJ Code or 1(1,;C�4R 590 n00, CITY OF SALEM BOARD OF HEALTH Establishment Name: Acu r/ftliww Halnim Date: 9/9-7/by Page: � of Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I 2r7 r✓/r� ei014'��gS �N Oce rr -dr4� �lissrnr6 �°� ��e�i�� co��¢s I 1 I � 1 .,*Avr-D WA-rlwv a KTMO-M. # hA-FMW t 7 rr�f N� 0-41Ao-k-®QS m H eTe RA-r FoeD� t��9fi?iSoM� I k nsA,< IN C4Y*'4C, 1 I I . I I I � 1 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes FI have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion IF 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. 1 '� ❑ Voluntary Disposal ❑ Other: t : 3-i0i.i a:( P�-iFa I2ec.:.ed�t"1-enmcr:4urca Violations Related to Foodborne Illness Interverntions and Risk ;`occordiml to L,o, Coo7cd h) Factors(Items 1-22) (Cont.) ' �I' r45 F Wi Llan 4 How s. " j J-551.15 Cooling Method,Cur PHFs PROTECTION FROM CHEMICALS 19 i PHF Hot and Cold Holding 3-20L.7.". Additives*(; I Food or cc->Color Additives 3-501.tWb) Ccid PHFs Maimahrcd at of helaw 5wwo-.I(F) 41'147'M, 3-302.11 Praection from Fnappnwed kddi6vec7'. i i 3-501 16(A} lint Pl-IF:: Maintained at or ubmr 15 Poisonous or Toxic Substances 4n"F 7,Ifi1.11 klentitywgtnfinnaurot-Utiginal 3-:107.1 h(A) Roasts}field ur nr above 1300F. i Containers" -) 7-10111 Cotmnon N:voe-R4+rkina Conteirers I ' 20 Time as a Public Health Control 7-201.11 Separation-S:u+a>;c" ! 3-501.19 Time a.;a Public Health Control* 17-202.11 Restriction--Presence and User j 59C.U04(H; Variance Requirement j 7-202.12 C' -nditions of Use' j j 7 ?03.11 1()xie COrna nl't:i-Prohibitions j REOOIREMEN'TS POP. HIGHLY SUSCEPTIBLE 7-204.11 Smiitizets,Criten?.-Chemicals" I POPULATIONS(HSP) 7-204.12 Chemicals R+r Washing Produce,Criteria" i 21 3-8(1!.11(.3,1 1 Unpaateunred Pre-packaged Juice,,and i I7-204.1- IDt 'std dents.Critea Reveragt-s with 1t.;,nmz Labels- 7 20`.11 ncidental Food Coniact,Lubricants* 3-V)1,111 B; Use of Pasteurized Ewes* ! ?.801.1 I(U: I Raw or Pattiailp C000l,ed Animal Forel and 7-206,11 I Restricted Use Pesticides.Criteria" 7 206.12 Rodent Bpit Stations" ( kaw ScCd Sprouts Not Served. ` j 3-801.11(C) : Unopened Food PavUec Not Re-served. ` 7-206.13 Tracking Fowlers,Pest Control and j :bfonirorine* CONSUMER ADVISORY 22 3-603,11 t'onsumer Advisory Postsd f,,,,C'orsumption of TIMEREMPERATURE CONTROLS utimat Foocc::'fiat ate Ram,,Undercooked of J6 Proper Cooking iemperaturas for I N-ca.Otherok mr Processed to Eliminate PHFs kers:=r,.rrz 1-401.11A(i)(2) Eggs- I55'F15Sec. Paleivens I E;rl;,: Inariediate Scrnce 145°1715sec* ! 3-302.1 i P.+steurvcd Eggs Substitute Cor Raw Sheil 3-401.11(A)l2) Comminuted Fish, Meats 8c G.w:r EF-s" Animals- 155'F 15 sec. 'k SPECIAL REQUIREMENTS 3-401.11(B)1,1)(2) Pork and Beet'Roast- 1305 121 ruin* I ?y000u( 3-401.11(:\)"2) Ratites, Injected Meats- 155-'F 15 A)-(G! Violations o: Secfior. 590.009(A)-(D) In see, catering. mobile food,temporary and 3-40t.I I(A)(3) Poultry,Wild Game Stuffed PHP,, ( residential kitchen oper,tions should be Stuffing Containing Fish, Meat, debited umler use appropriate sections Pouitry rm Ratite,-165'F 15 sec. " above if related to Roixiborne illuess 3-401 l hC)(3) Whole-muscle,intact Beef Steaks I interventions and risk factors. Other 145°F* :190.009 Volations gelatins-to good retail 3-401.12 Raw Animal Foods Cooked in a ( practices should he debited under 1129-- AT+erourtve 105`5'* Special Requiterrents. 3-401.11(Ali,I)(b) Alt Other PHFs- 145'F 15 j 17 Reheating for Hot Holding j WOLAT/ONS R- LA TED TO GOOD RETAIL PRACTICES 3-403.1 I(,,)StD) MIN 165'F 15 sec. ' j (Tteins 23-30) 3-403.11($) Microwave- 165'F 2 Minnie Standing, Critical and+:un-c-rdtiral vwfinwms. ovhtrh do not relate to the Timc* 6aadberr,e d;neev inner entions and rise;jnc'tors U ted above, can he 3-103.11(Ct Comtnontally Pi ocessed RTE Food- found it rhefultou0 see rinns q/the'Fond Code nerd.'05 CSt1X 140'F` -5."0.000. 3-403.11(5) Rei taimng Unsliced Portions of ReefI Item Good Retail Practices FC 5.9QOt70 Roast:* 23. Management and Personae! FC-2 .003 Proper Cooling of PHFs1 24 Foad and Food Pro+ection FG--3 .004 25. Fquipmeni and Utensils FC-4 .005 3-501 14(A) Coniine Cooked PHFs from ki to - -- ----� �26 ,Vater P!umbino ie:d Waste FC--S .00ti 70'F Withia 2 Moore and From 70T 1 27. Physical FaeiNy FC-6 007 to 41°F/45"14 Within 4 How s. " 128. Poisonous or Toxic Materials FC--7 1 .008 f 3-501 Wolf) Coohng PIIFs Made From Ambient 1 29. Special Pectu+rements ; 009 1 Temperature ingredients to 4l`F/4`F 130. ()that - --1 Within 4Hours = Denotes enocdl ituu m the fatoral 1099 Food Code or t 05 CbIR 590(100. PORTANT MESSAGE FOR X101:2- vim_ / A M AT_ 7. `� TIM �e- 2MF � _ _ Q� • ��r OF n / �s-L/3va PHONE 7 d��7 } Y�.3 AREA CODE NUMBER -EkTENSION bn=1111F q7F— AREA CDOE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU I I WILL CALL AGAIN WANTS TO SEE YOU I RUSH RETURNED YOUR CALL WILL FAX ILLFAX TO YOU MESSAGE SIGNEjO (�� p� FOR �N 0009 a R<vr+ ~ o.. � � � \� � m � ` ', \ \ � '. � Massachusetts Department of Public Health Salem Board of Health w 120 Washington Street, 4th Floor, Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name // L Date Tyne of Ooeration(sl Tyue of Insoection &I"")"A Al e Ak'k l _ ,'>'-�-�i�1 [XFood Service ®JJ��outine Address Risk ❑ Retail We-inspection Telephone p� /ti�74 Level El Residential Kitchen Previous Inspection p 7U U �lASfO ❑ Mobile Date: 3--/-O/f Owner HACCP Y/N ❑ Temporary ❑ Pre-operation P(Y747 an r i/V y1 ElCaterer ElSuspect Illness Person in Charge(PIC) Time ElBed&Breakfast [I General Complaint Sf-cj/? In: ❑ HACCP Inspector Poa� ai �i7 n ��7y/ � X < Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT [112. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ' ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate El 21. Food and Food Preparation for HSP Handwashing ��.,❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as dQfermined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofCeaNh 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-a)(sso.00s) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s 5901nsp ctFor iJ em 1 .fI cto' rgrrgfE�<re._ /,. _ �I,iund. 'L0. Print: PIC's Si ature��Ftdrl j 4 /�--�i-tu� Print: J CL��S K kx .,� Page of ZPages Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 00.1ss contam+nation j j I 590.0M(A) Assranment of Responsibility- 3-30211 Raw.-'smn'al Fvodls Separated from 790.003(11) Demonstration of Knon led get' h � Cooked and RTE Fords* j 2-103.1 1 Person in charge-duties i j Cnn'anu++etroo fns,Par,ingedrorts � 3-302 1 l(A)(2) Rwr Amoral Foods Separated froth Each EMPLOYEE HEALTH Other, 2 590.003(C) Responsibility of the person in charge to Conraminanon.,oro the Enmonment require reporting b} fond enrplo.wec and 3-302.11,A) !nod Protection" j applicants* I 3-302.15 Washing Fruit,and Vegetables j 590.003(F) Responsibility Of A Food Employee Or An 3-304.1! Food or.•;.adtmtr Fo.;r ,ment :md ,�,plic:mt'(oReport To The Persue In I Utensas* Cnat tie", j ConEmina'ion from the Consumer ;90.003(G) Reportine by Person in Chanel j j 3-306.14(A)(13) ?eturned food and Reset-,ice of Food" j 31 590.003!13) Lxchotons aha Restrictions* j Disposition ofAduiterated of Contanninated j 590.003(F) Renimal of Exclusions and Restrictions Fooa 3-701.11 Discarain;;ur Reconditioning Unsafe FOOD FROM APPROVED SOURCE F00d4 4 food and Water From Roguiated Sources i j 9 Food Cortact Surface= � < ;• -;501.111 Pdmtuai W'arewashim_-Hot W"atcr 1 �)U.00,CA-t3) Compliance with Food Law" j 3""201.12 Food in a I-Ennetically Scaled Cantam:r' j Sao, lizal,nn'I'er.!peramres" I ?-Nd 13 Fluid Milk and Milk Products* j '"`)1.1 12 Mechanical Wmev aahia- Hot Water-- - j 3-202.13 Shell E--s- I $arntizati;:n'1'owperaturr,`: J 1-20? 14 Fggs and Milk Products.Pasteurized;; ' 5",1.114 Chemic:.: Smadz"llion-temp.. pit. j 3-202.1~ Ice Made From Potable Drinking Water" j I y I cuncen+ration dna nafdaess. j 5-101.1 I i Drinking Water i'rom an ApprnveU Jysteut"' 1.01 1 I(A) Equipment Food Contact Sw;ace�and i 1 Rensils Clean" JXiolxn AI j Rouled Drinking Water* j e,-007 1 I Craning Fre mmn y of Ecu!7meni Food- 590.0:,6(Ri Water Yleets Standards in 31 ii CMR 22 (i` Contact Sm iagi.t and Urensil(s` Shellfish and Fish From an Approved Source • Inv 11 Frequesy ut Sanitization of Utensils and 3=20?.it fish and Recreationally(':night Molluscan I I Food Contact$urfac-s of Lyn:p'Water ( Shellfish* 1 4-703.11 Methode of San;rizati(:n-Hot and 3-201.15 Molluscan Shellfish from NSSP Listed i I I Chemical* arcus* G j IO I j Proper,Adequate Handwashing j ! same and Wdd Mus+++'ncros Apprrved By ! 2 3eanon .n-?lands and Arms' 01.11 ClCdit: ' Regulatory Authority ( j 3-202.18 Shellstock Idem iticatinn Present* 12-301.12 Cleaning Proc. dur.* j 590.0041,C) Wild lbluahrdwnrs* 1 2-30].14 Wbi.en to Wnsh� j 1 3-201.17 Gam, Animals* l I Gond ilyglamc Practices g , Receiving/Condition j <-a01.II I Eating.DrinkingorUsingTobacco", j ?_bi2 11 PHFs Received m Prop-r Temperattncc* j 2-41101 1? Discharges From the byes. Nose;nd j 3-20213 j Package Integrity, j I ( ivlouth.: 3-IOLii Food j 4 01.12 Preventing Contamination Wben'fastin- j ' � _ i b Tags/Records:Shellstock ( 12 j Prevention of Contamination from Hands j 3-30'_.1:. Shellstock Idcnti8:then* ( 590.0-'Af E Presenting Contamination fru~: j 3-203"12 Shellstock Identification Maintained"' ( mpioyccsx Tags/Records:Fish Products j I I3 Handwash Facilities j 3402.1; Parasite Destruction" Conveniently Located and Accessible 13-402.12 Records.Creation and Retention* j 203,1': Nu:nbeta and Capacities* 1590.0040) Labeling of Ingredients' 5-204.1 i Location and Placemcnr* ? 5-205.with Approved Procedures 5-2'05. i Accessibility, :peration and:biaintenaoce /HACCP Plans i Supplied wIN,.Scall and Hand Drying ice Dev ;; ,502.1 l Spreialized Processing Niethtxls°' j j 3-502.13 Reduced osvern packzing,criteria" j !i-iUl.t I I9.nidwashing C•lcatser, Availability S-::01.12 ! Hand I)r.ing Provision ' 8-103.1'2 Conr"nrmance with Approved Procedures'^ j -Denotes cna:rol man in the frdetal 1099 Food C,ic of 105 t'MR 5a0 x100 CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: _-Q_ ./ Page: of , Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY { �.�/) ) I M/AT /. Jw iA/J i/ //A (_ /Z ` Lric . ri� � „311u{wrt / n��0n / -r,�f l/, ✓ A �_./ 3 �i/ s./�:lJ nio-f" !� /v Irt., /t ,rJQ,�✓., _a 1 f � 1 k` 1 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/ 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 Y noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of LI Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 1 q� s 3-5i)1 l4tC" PHFn Re,,ri,,d it Tcsperdurer VJalations Retared to Foodhorne dlness Interventions and Risk At cording t,F;::v Coded u, Factors(ttems 1-22) (Cont.) j iIp,iy.4 i . • AYT WitHoms PROTECTION FROM CHEMICALS � i 3-`61.1.5 Cadhw,R1ethcxh ,•r PH='i j 19 PHF Hae and Cold Hording 1J Food or Color Additives j i 3-202,12 Addurves `-61.1 (F) 41 hl P'' Fs Maintain::! .0 rr he(nw 3-s02.i4 Protection foto (ht:q>p;oved ldd;ate:.' j ! '96,044(1") 41 '1'45' h i 1S Poisonous or Toxic Substances 13-'VL16t A: fiat FHl's T.I,n rtainrd at of above 140'}•, x i-101.1 1 Idcnnfymg Inforroation-Ortgiml Containe:.s- i:Llb(A7 Rot,'ts F:.:a at :;r+rho 1301 7-1 LC.t 1 Common Nance - N4rzhing{:mu;finer," j j `tl i Time as a Public Health Control z.<i 119 Time of it Public Fi;alth Control, j j 7-2-01.11 Separation-Stotm-c j j 7-202.11 Restriction-Presence and Use" j ? Stxmtwt(H) Vandnco Reyun"cmral 7-702.1;'- Conditions of 1Jcc- j 7-263 ! I 'Toxic Containers-Prohibitions': REQUiREMENTS FOR MGh'L Y SUSCEPTIBLE j 7-204.1 1 S:mirizers.Crrtens-C'h>micah" j POPULATIONS(HSP) ! ( 121 3-s61.i i(.i) ( O:paseijrized Pic- �ckaecd lmces and i 7-2,04.12 Chemicals for Nasi,ii,_, Produce, Criteria;. }3e't:::ger arid: 1Varniny- Labels` � 7-204,14 Drninl�Meats.Critreda* j i 7-2Irdenta!Food Co :et,Labars" 3-561.:!(B) CseofFe cteurized Lgs' + g ! 7-206.11 Restricted Use Pesticide..Crnrrnr' j 3-861.:i(1); Raw or Par'nally Crooked Animal Fort"and I 7-206.12 Rodent Bait Stations' j Raw Seed Sprott:Not Served. " j -SOLi1(C) (;nopercet":x.dPa&aieNotRe-set%ed 7-206.(3 Frackiug Puwdtcrs,Fest Control and ( - Monttarinr' CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 1-663.1 1 Co paitu :Adt-iaury Poeted for Con;umption 0f Alum::! r.wdr. Thad arc Raw.Un&'.-tt OLed 0r lb Proper Cooking Temperatures for ( Not O;hery iso Processed to Eliminate PHFs {(11.I1A(1)(2) Eels- 155'F I:i Sec Pad op"".' ' e;!s-Immediate Servide 145'1 15sec 3-362.!3 pastern':'redEgg, SdUstituteL,rRaw She]] ?-461.11t A)(2) Comminuted F61h. Meals f;;.{fame Animids- 155'F a s:.c. " SPECIAL REQUIREMENTS i-401.11(6)(1)(2) Park and Beei'RoaA - 130"F 121 min" 1 3-90LI1(0.1t2) Rah[c,,Injected treats - 155'F I? 590Mf)9(A)-(i); Violatin)r.of SeC1,1011 590.009(A)-(D) in sec. � catering.;oiibile food, temporarq and 3 401.11(A)(3) Poultry,Wild Game. Stuffed PHPs- residential i.uchen operations should be l Stuffing Containin,z Fish. Mea 1 debit-d tinderthe appropriate sections ' Poultry of kahtes-IfiS'F i]i sec above n rclaleo to lbodborne i1ln8ss i 1-401 11(001 Whole-muscle, Intact Reef Steaks interventions and risk Factor:.. Other 45`1`' 590.009 vic,,a:ion;r retia-to adx+d toted I 1-401.12 Raw AnuoA Food,Cooked in u i practic,c shcnid be debited under It?9- Microwave 165`F . Sp.,;en:i Requirements. ' 1(A)(1)(b) ,%IfOther PHF; - 145^F !5.cc. '•` 17 I Reheating for Hot Holding j VIOLATIONS R3ATED TO GOOD RETAII. PR4CT.ICES j 3-403A It A)&tD) PFIFs 165:'F 15 sec.. (Items 23=317) 3403.11(6) Microwave- 165` F 2 `•tirade Standin:, frit,;r:;ung:nrrr-�rrricnl +<,;::::frac,, :c!:icF,.10 riot r<Irrte to Ike 1.11110 1 foodborne illness irrterre„r,c•s and i;ok fern++:7 hoc,"abo:r, can be 3-103 11(Ct Commercially Ptocenaed RTF,Fund b,tind ie the J),flmr;o;;x tion; q(the Food Code aord R)5 0i6 I.40"F°" 5YO.000. 3-40311(E) Remrinin,_l tn4wcd Portions of Beef item Good Retail Practices FC 590,000 Roasts" ,-23,--_--{'-[v_iaragement and Personnel FC"- 2 003 ; lg Proper Cooling of PRFs 2'{" Food aur:+�ood'rotectl-n FG"" 3 004 25. Equ!cment and Uluic;ils FC-4 005 3-5(}1.!4(A) Cooling Cooked PFlFs from l 3(i"F to 26. i vi;,ter.Plumbino and'.Vaie FG-s .006 70'F Within 2 Hours and Frnm 70'1: ' 27, Kvs:ca:Far ddv FC"-"6 07 I to al 9;145'F Within 4 Fiouri. " i 28 Poisorous or Toxic Materials FC-7 .008 3-501.13(B) Cozlmg PHFs Made Fran AmrientI '2. Special Requ!ramxas 003 Temperature Ingredients to 41'F,1-15'F 30 Other � Within 4 Hnurs" Wrong,aural new in the ledej 1999 1-und Code 01 1115 CYiR 3'4+.00q. Massachusetts�iDepartment of Public Health Salem Board of Health Division of Food and Druy's. 120 Washington Street, 4 Floor Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name DateTvoe of Operation(s) TylSe of Insoection sf �r/�ryPive �/SPL 3- / 0� I Food Servicep outine Address Risk 6 Retail [�Re-inspection �AS7- Level ❑ Residential Kitchen Previous Inspection Telephone /�rn 1 yG1 y X01 ❑ Mobile Date: a -/q-01f Owner HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint S1Ed¢ iUpL.cmn In: ❑ HACCP Inspector_,�)G,e �a� �//� S�4(tIUS Out: Permit No. E]Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties y/ l�13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS - El2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives [:13. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE _ ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 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 Z9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing El 21. Food and Food Preparation for HSP i ❑ 11. Good Hygienic Practices CONSUMER ADVISORY " ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions �° d immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, signed below, when C_ N P 23. Management and Personnel (FC-2)(590 003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations V 25. Equipment and Utensils (Fc-a)(sso.00s) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you V 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590 008)- and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 59901�n�p�pC'llFor 14 dw ` l.i •�na 'iPll , '� �//�!./.r„%L,�'LLc�i Print: / PIC's Si ��A Print:S�z°v,'h /)/p/s� fi Page/of Z Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PHOTECTEON FROM CONTAMINATION FOOD PROTECTION MANAGEMENT ( S Crc.^s:cnta+n;itatirn I ! 590.003(A) Assignment of Responsibility' 3-302.1i.(A}(11 Raw Anil»al 1'ootls Separated from j 590.003(8) Demonstratum of Knowledge°' I C(x>ked:incl RTE.F:v.xls" 2-103.11 i :iron in:harge-duties G?ntnmir;afior tmm Raw ing+edents 3 "rut 11,+1e2) Raw Aw in.:: Foods Sepia-c: from Each EMPLOYEE HEALTH Other' ! 3 590.0031 C, Responsibility of flit pee;un in chnree to Corraminatkn rrom the En✓,ronment rcquirc repotvna by food erop!oyees and 3-302.11 tA) r'oed Prorectiowc j applicants" ; ';-302.!5 Washing Fruits and Vegetable: 59t 0O4(F) Responsibility Of A Fcxid'rmnlovee Or An j 3-104.1 Fvk d Con!:.ct with Enwpmem and Applicant To Report To The Pcrson in ! IJnatstl�* Charge Cont3.mm3.,on ftor r Ore Consumer 59.0 003((3 i Reporting b)Petsoa in('harle* I I -3i)5.14t ti;;B! Returned Food an,:: Kesetvtce of F'taxP` I3 S90.003rI31 Exciu>eo s and RestridwrisDisposition of Adulimated of Contaminated 590.0O3(E) kemoval of Eralusions and Restrtcti+}ns I Food .3 701.1: ! Discarding otReconditioningUnsafe FOOD FROM APPROVED SOURCE rood" 4 i Food and Water From Regulaied Sources ( 19 rood Contact Surfaces 590.004(A-B) Comp:ante�.vitb Food law" 4-501.11 I fdmmai ti':uewa'shmg-Hot crater -.'.01.1'_ Food ;n a Hermetically Sealed Container" Sanifiz�non Temperatures" ., 'ri.i '.? ! Medhaaical'rvzretynshin< IfutN+ater 3-20!.1-3 Fluid Milk and Milk Piodaas* I ri j + 20213 Shell Eggs* I ( S,mitization Temperatures* ! 501 I ld Chei ne.al Smit:ration-temp.,pit, 02.14 E;tgs and Milk Products.Pasteurized'' 4-501 , trance:,:ra:ion and hardness. " X02.16 I Ice M:de From potable (harking Water' 4-6C;.t i(A) Equipment Food Contact Smfacec and 5-1W.i I Drinking Water from in AAproerP•Svstam'� � Uteri's;;;Clean': 590.006(A) Bottled Drinking Water* 602.11 leis:nr'rreaaencyofF•,quiptuentFood- Water Meets Standards in, 310 C;y1R 22 0* Contact Surfaces and Utensils'° Shelifish sad Fish From an Approved Source ( i 4-702.11 Frequency of Sanitizat:,n of L'tcrvsi(s and 3-2OL7- Fish and Recreationally Caught Molluscan PoaJ Gmta:r acfaces ofPquip:merit"' i Shellfish' I 4-703.: i ' bleQxwds of S:a:,uzati� n-;-tot`A'atcr and 13-201.15 Moitusom Shellfish front NSSP Listed I i Chemical" Sources' it) I Proper,Adequate Han!washing Game and Wild Mushrooms Approved by ,, �, Regulatory AuthorilV ! 2-301.1 l Clean C ridition--Hands anti Acini, -202.18 SheOstock Identification Pre:.enl" j 2-301.12 C}eanut};Procedure` 590.004(C) Wild h-Sushrtwnns 2-30!.J.4 When to�r ash 3 207.17 Cisme 4uimas* 1 ! I? ! Good Hygienic Practices ' e Recsiving/Condition j 2-01 11 Eating„Drinkino,„!r Using Tobacco -,-202.11 PHFs Received at Propet Temperattnec r ( 2-401.1= D:acYc.:rco5 From the Eyes, Nose and 3-202 15 Packeye llttcgrity" IA4h* . 3-101.11 Cood Sate and Unadulterated* j :-301 12 Presenting Cuntamination Alien'loling,_ j 6 Tags/Records,Sheifstock I 112 Prevention of Contamination from Hands i-202.18 Shellstcek Identif=.carton 590.004&) Prv�enting Contamination from I3-203.12 ShellstockhicnhttcationP4aintained` I ; Empk,�ees" i 13 Tags/Records:Fish Products : Csh Facii!ties o ven; I Co��+en;rnt/,,1.ocsred apo Access;bfe -v02 i l Parasite Destruction' 5 1 t `lumbers end Capaciuvs* 3-+402.12 Records,CreatL.m and Retention* 15-20-.11 Lcx,ation and Pta.emra* 590.0040) I Labeling of ingredients' )� i g Conformance with Approved Procedures ( ! -' `)- ll Acce<s,bdity.Opa.:r'nn and Y1:.t,nten;nta /HACCP Plans i SuppBed with.Soap and Hand Drying i)ev,ces 3-:i02.11 SpecJized Pnu;essing Method'* 3-502.12 Reduced oxygen packaging,t•rrteaa" 5-301.11 kandn'a;hing(leunser. Availability; 6-"3(lt.' Hard ilr}nr!Prociston I t;-103,12 Cnnfot2nancn with Approved Procedures' Duih';sin.a'nem i:�tl:.ieden• ,i 1999 Coal Code o: 105 C\9R 590 000. Ju� y� CITY OF SALEM BOARD OF HEALTH l 4' FEstablishment Name: /,Z. "L Date: 3/��< f Page:a of 2 Item Code c-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date ANo. -Reference R-Red Item - Verified ( PLEASE PRINT CLEARLY - P !!�, p I 'i,_4r� t �l ZSr - �_i n.,/d it n;o AA VWC L-; ' / ✓ ' f,C-'P-P->r o LAa.P A r.n P/OC //Z 7 /�-� O /l /_ p./�./iOC >mm . w>..r r/e A,& /!C 0/L.�(,(iI?/n,o/.(Ay 417- 7^r 1Z7.^r - /���.R 77/r Cry t 7Y7.,}��r` .:r,PiF A412t / _ 7.RfaPGL1L /�)Y,l�n!/.� r7.Ca/iin�c <<ier�c 1/�77�L GC_itrnS/7�.v/�G mr /,r{ Uuast�rvc/ �7n �r.f q, 2ooz1 1 I' 1 ; Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ les 11 I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension = comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars orsusp�n/revocation of ❑ Embargo ❑ Emergency Closure your food permit. Z)/.�)/f�-� �// Voluntary Disposal ❑ Other: r 3-fi01,l HC'. PRt e le�eiyed:a Temperatures triafabuns Rela!ed to Foodborne i(hrese interventions end Risk Arco;diro,to Lone Cowled to Factors(Items 1-22) ,Cont.) PROTECTION FROM CHEMICALS j 5V1.I5 Cta ling Methvtis hn °IiFs t 9 Food or Calor Additives to PHF Ha;stud<uo:d Ho?ding ! 7-501.Vill) C,ad i;hs Mainto:ned ator bclorw b-202.12 Additives" acs^ -) :il'/4,5'h•: _302.11 Protection front Unapproved 9dJitise•:' + r5 Poisonous or Toxic Substances I i-5;IL U,('\1 Hut ;'HFs Maintained at of above 7 1 O L I 1 Idrnitfpn,L In lnrmza:nn-Qrigi nal 1 10'h ' -5ii 1.16(1` Roasts Held,u .v ano^�+e l 3u'F - Containers' Time as a Public Health Control 7-1 U2.t l Common Name-\4workitrg CanGtiurr.' j I ' i-201 I1 Separation-Sloragen ? 501 1'i Tint.a:aPublic tL:alih C.nt!tt,i" ! 2(al I Restriction-Prrsrn�c and Use' ( 590.004(E-1) V:ntanca Reyuuemc:+t 7-2(12,12 Ccmf tions at l k.c" REOt ?Rr'.6alENTS FOR HIGHLY Safi,.^.EPT'sB!E 7-203.I1 Toxic Cuntainera-Prohibitions' j POPULATIONS(1#SP) -"LOd.I I Sauitizer,.C'rite.+ia -ChetnmatsT 72i1a12 Chemicals lot WashingPf0JUCe,Cia,-6n^ 21 ? cOLil(a; Beveotic"eswili're-pzckag.d.tuteesand 7-204.14 Dtyima.Agents.Criteria` Severaees with knnung Lane Ls' 7-205 11 Incidental Food Contact. Lubricants* 3-SOLI IQ, Use o Pasteurized d oke 3?UI 11(J, Raw nr Partially Cooked Amoral Fnrxt.md 7-206.11 Restricted Use IsCi,Mides,CIt!et':a* Raw Se-.,!Sprouts Not Scr.cd. ` -206 12 Rodent Bait Stations 1.1 (C) ['...upene;t F , i Packai;c Not Re-sot ved 7-2o6.13 Tracking Powders; Pest Control and I . Monitunne" CONSUMER ADVISORY 22 3.603.11 Consutn.r Advisoty Puscd for Consumption of TIME/TEMPERATURE CONTROLS Alarm' F.t:,ds that are R:w, llndcre.xr�ed of 14 I Proper Cooking Temperatures for ( Not O:Itarw .,x Processed to Elinnnate PHFS ?401.1IA(1)(2) EIg;s- 155=F15See 3.302.,3 FkstrwPatels ivns.ed: Ee1's-Immediate Service 145'171 5w," Fg;>.. Substitute :L:'R;a•.v Shell 3-401.11(A)(2) Comminuted Fish, lytcdlA K Game Animals- 155'F 15 sec. ,; SPECIAL REOUIREMENYS 3-401.1 I(R)(1)(2) Por},and Reel Roast - I30'F 121 mm" 3-401.1I(A)(2) Ratites,Injected hL:a[s- 155"F li 5oi0.0U9;:a)-(D, Violation,of Sectira; 590.009(A)-i U) tit ;ec * I .atertng, mobile iitod, temporary and 401 11(A)(3) Poultry,Wild Game.Staffed PHF,. res:den:iai kitchen operatizfac should he Stuffing Cont:unmg Fish,,bleat. ( debited under lire appropriate sections Poultry or Ratites-165'F 15 i,ec. ` nho %e ifreia:_.': to foodbom.,, il)ncs ?401 I UcC (3) Whole-muscle.Intact Reef 5tenki. interventions and -ii;k factors. Other 145"F"' 59i11.0M09 violating s relating to �100d retail 1 3-401.12 Ram Animal Fmids Cooked in a I practices dn"Ad be debited under k2)- R4iC!'OwavC. 165'F special Roquir2;aCnts. 3-401.11(.)0 tib? All Other PHF:-- 14511 15 see. " 17 Reheating for Hat Holding VIOLATIONS R:LATER TO GOOD RETAIL.PRACTICES 3-403.1 t(A)&(D) Pt1F:; 165'F 15 sec. ^' :Items 23-30) 3-403.11(8) Microwave- 165'F 2 Minute Standing C%:!+cu!w:;?r:mrerilwal violations, which 'A an telate In the 'lime* ,(ovdimn;e itlress inic,ve,rrions and risk:facior., iiste:'abote, carr he 3-403.1 1(C Commercially Processed RTE Food- /;rend ill the foliutrin,e se(rinrr;qJ Me Fond Code and 105 CCR 1401:" `')0.lAi0, 3-403.11(E) Rernainow Unsbced Portions of R-e( I Item good Retail Practices rC 590.000 Runtis" 1 l?. Marlacerneni and Pe+sonnel FC-2 .008 lg Proper Cooling o!PHFS 24. Food orad Farxt Prate-?ion IFC--3 00= Cooling CookcJ PI1Fs from I40'F to 25 EmIpment and Utensils FC-4 ODg 501.14(.4) - -I, 126. i 'Jv%ate+. Flmn7atp and Waste � �C;--; Oi�S 7(11 Within 2 Hama and From"70'F1 1 77. Physical raciLty i FC-o .ODI I, to 41"F7-lj'F S4 ithin 4 Hours * j PR ! po-sonous or i cxc Micena!s PC-7 .00c 3-501.1a(R) Couliug k HFs Made brim Anthant � i Special(-;eeuirs:cents .009 i 111 Tcn,neraturr Ingredient.to 4('1145`, 30 Other Witnm 4 Hours. �,..",,%.,... ' Den.xo.rritleol item in the federal 1009 Food Cole vt 10j UNIR 590.000. x� Massachusetts Department of Public Health Salem Board of Health 1' 120 Washington Street,4�h Floor Division of Food and Drugs Salem,MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978)745-0343 Name Date Type of Operation(sl TY6 of Inspection '�2-19-e L� I [61 Food Service © Routine Address Risk ❑ Retail ❑ Re-inspection Level I ❑ Residential Kitchen Previous Inspection Telephonef ElMobile Date:9,-/r'e3-�'vr-a3 lh ❑ Temporary ❑ Pre-operation Owner Q J _ HACCP Y/N , ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast, ❑General Complaint 7Jli /./lP_ NaLsm7.,C�,nv�UlSax /vO.N.0 (ilii/ir/�.���n,z /rPT'1 In: ❑HACCP Inapecto r7d" '-e N j1 } £,{,tom fc[s Out: Permit No. Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded [115.Toxic Chemicals FOOD FROM APPROVED SOURCE TIMENEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 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 ��,[.:..�1,11�8. Cooling PROTECTION FROM CONTAMINATION l 19. Hot and Cold Holding A 8,Separation/Segregation!Protection ❑20.Time As a Public Health Control till. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Q 21. Food and Food Preparation for HSP ❑ 10.Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions C immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations --T7'24, Food and Food Protection (Fc-3)(590.004) cited in this report may result in suspension or revocation of p 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.Do6) 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 REINSPECTION: S S•9'UJIn,dhMr -14 doc Print: 1"IC's SignaturePrint: Page of�_Pages t'A.i.�,e Page 1 J � J j Violations Belated to Foodborne Illness Interventions and Risk Factors(items i-22) PROTECTION FROM CONTAMHATION FOOD PROTECTION MANAGEMENT S Cress co,:tamiration R S90.003(A) Ass!gume-r ni ResPcros;hi!aF'" I 3-307.1 i(A`(l) R;iw snm:,,l ^oat:: Se^aimedfnm 590.003(B) Dcmonstaunn of Knov ledgc* ! (:.,.oked and RTE F,xxls* 2-11 1 3.t 1 Person in charge-duties C.;nrun;i;aficr:from Have Ingreo'rents 3 11(A):,2) Paw Amus! P uds Sepirttecf t u::,Each EMPLOYEE HEALTH Oth,r" 2 590.003(C) Responsibility of the person in charge:o I Co,,ram6vaNer,from the F,^virorr.^ent require repnrhng by forst employees and 3-302.11:A.) Ford Plotectio!r' appli_dntr' 13 302.15 Washing Fmits and Vegetables 59010.)'{F) Responsibility Of A P,xxl EmploWe (?t An 13-304.1 i Fkttrlau-:Ii and Applicant Tu Kcpnn '{'o The Fersoa hr Utensils' Charge" Contam,,n2','nrumin'.':e Censunrer 59U 063(G) Reporting by Person to Charge' ! 1-308.14(Aj13) Retnrn,-d Yizud:•nd Re=.et e^ce of Frx,d^ I 3 1590.0031D) Esclus,ous and Restrictions I D;eposit+nn ufAduderated or Contaminated j 590.003(E; Removal ut Exeiusions and Restrictions I I Food 3-701.11 Discardirg or Reconditiomng Unsafe FOOD FROM APPROVED SOURCE 4 1Food and tNater From Henuiatra Snurcos ( 19 Focd Contact surfaces 590.004(A-B) Congpluince wttb Food Low,. -t-50I 111 Mauuai Watewashmg- Hot Water 3201.12 Fund inaFlermnccallyScaled Container* I Sanitiz.,tile`Peropent:::es' 3-201.13 Fluid Milk and Milk Pr,,ducr. ! 4-50'.112 Mechanical WarrtNastunn Brei? \Pater I3-202.;3 ShellE,gps* I Sutitizationsenmoratures* 3 202.14 Eggs and Mill, Prtx!acts.Pasteurized- I d 301.1:14 Chemical Sanitization-temp.,fill, conccnt!ation and hardness. * :02.10 I fec NIMe From Por;thle Drink:r,Water- 5-0 4-1)01 I I(A1 Equipnx:d Food Contact.S'w faces mid S-101 11 UrurkfaeNaterfrom;:nApproved System' L1teitsil%{:ican- 590.006(A) 'Bottled Dunking Water* 445)11 I Clrannte Frequency of Equipment Footl- 590 own) W4;-r Meat;Standards;n 310 CMR,.,_^ ' Contact Surfa_cs and Utensiis'b Shellfsh and Fish From ar.Approved Source I.io t t, Frequency of Utensils and 3201 ld Fish and Recreationally Caught fvTollu;c:!n Fo.sJ Contact Surfaces of Equipment' - shellf'10' 4-7J3.11 Methods of Sanitization-1-{or Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chrmica Soumcs' i j lU I Pi aper,Adequate Handwashing Game and Wild Mushrooms Approved G}' ­301.11 Clean Hands and Arms" Reguratory Authonty ; I ? 202.18 Sh,11!;to:k Identification Present" ( ' ! 301.:2 Cleantag Pp.,cedurc` 5'a0004(C) Wild Mushrooms" I 2-=01.i4 When to Wash 1-201.17 Game Animals* I ! I1 I Good riygierie Practices I S ! RecelvinglCondition I 12-401.11 Eating,Drinking or Usi,,'Tobacco* ' - -- --- _ ( 2-40 t.i 2 Discharges From:he Even. Nose and j 3-202.11 PHF,Received at Proper Temskperaturej Youth' J-202 1 I Package eIntegrity'nn `_01 12- Precenti.,P Cot:tar�iosti,m When Tasting* 3-'(11.11 I Fcad Safe and Unadulterated* I Tags/fiecards-Shellstock 12 Prevention of Contamination from Hands 3-?02JS Shellstock Ideaiu icanon* :i90.U.)-'(EI ; Pr;-,tinting Contamination hom i Fa,;,iup•ri" j 3-263 13 ( ;hellstock Tdenhlic.rtion Maintained- 13 Handwash Fa-o ties Tags/Records:Fish Products Canvan;errt!y Located and Ac:essin;e 3-402 11 Parasite Creation an � S 203 11 Nunn.ers and(,'aIncioes* 3-403.12 Records.Creahun and Retention* rLabeling : ? .'-0:).11 1;:c:aior.and P!ac:anent' 5)O.UO4tJ) I of In Ingredients' r Conformance with Approved Procedures 5-105.i l Accessibiht\.Operation and Maintenance ,. /HACCP Plans ( I Supe!ied whir Soap ana Hano D; rnq 3502.11 Sptmalized Process:t:p;M,athods" ( Devioes Reduced ox,-Ren pdcl:aging.cnier,a" ! 6-301.11 Hamiwashiae Clc�nscr,Acailabilov S 103.12 ( ::'0nform ncc•.vith Atprovrd Procedures;` j 16-365.:? !-laud "rorsmn *Gecatca crick;d itew in the lvde:,d 190,Pond C:x{c of M C.MR 590.0W, L CITY OF SALEM BOARD OF HEALTH i Establishment Name: Date: Page: of .3 t Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified y PLEASE PRINT CLEARLY A � /f"/1/i n/y %/�c �!!p///(/2_ /A/i S/7 F/�l/f» /U/1 540.x/ � 6'�/ _� • —/?,/, Y�-r �,/n ✓Soil L1�.�C ,S}'//P.O.��S-.�1J/n/O.A — /�f,J'l Bey jf /J.P /11�,�/A/� P_ r . . NJ OQZ if '-FN/ir IY/ AYQC� 1cS/AZ _ YYI/.CC/nr� �//rU PG ii��r - .l/o.e��c I . fid• C' /3 F In/1//N.5 5' Ahr e A/4pia /41/ / /o L_ 7 _j7 �r�n,�'✓-..n�/_�.vav H Q �, / - 7/,,r7/ ! Glias -iv GFrm�P� /, 0 �� , rzr, � csr�� rv� r — 61 I 1 r Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ lea I { .r I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance El Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion I" � P L] 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 k your food permit. d1_11 i f 0 N 1711 A(� r ❑ Voluntary Disposal ❑ Other: `I J -50114iC) Pf{F: Received at Tercperatwes j Violation-Related to Focanorne illness:ntarventions and Risk i Acc.rdm�t•,E-sur•Costed to j ✓=actors(teems 1.22) (Cont.) {I'Fr{-i'-'R%ithi:e 4 Haw;: PROTECTION FROM CHEMICALS l vicl 13 Couime:l1ietiaals tim PEiP; � j 14 Food or Color.'additive, ( 1 19 PHF Hot and Cold Holeinel ' j ' 3-i(1!.I On") Cal.] PI lFS,M2c rlained a(of bchm I 2 20_1.12 Additites'^ J90.00Y,F� 41;-�5 h :. 3-302.14 Protection Iruw Unaum oN ed Audita-es' ( ,3.5(1:.;0(.1) i-Ic,t PF Fs\5.�iataiued at or-hoc•: 15 Poisonous or Toxic Substances 40'i 7-101.11 Identt!wtg information-Ori l;n l Cuntairers;` 3-50..16 i,) R,>a;.:.Hrd .:t of ai;uve 30'F ' 7-102.1 1 Common yxrue-Working C'owdioerc* � ' 20 Time ss a Public Health Control ( '7-201.11 Sepacuiou-S?uutve=' .i9 Tiat :u a Public HealihCwn.roP' j Gill j 7-20,..11 Re,friction-Presence andUsa'' Va II :,l' H(-oo:- ment 7-202.12 Cnndniors of l:-sc` 7-203,11 'ToxicContainers-Prohibitions^" R QUIREMEWS FOR HIGHLY SUSCEPTIBLE � ',-204-.11 Sanitizert„ C'nteria--Chemic:ds; POPULATIONS (HSP) Produce!+ ( 21 ''.."M II(Ai (h:nasteurn l:,i Prc-p-.ckacrd h"ices:nd _U' 1.,_ Clmnuc:d;for Washing nxhr'e,Criteria* j 7-204.14 Ut vine Agrias.Critei ia'r Beveiaeet with W wrung Lzbels'. 3 tii:L1i(i;j Frizz j"_05.1 I Inc:denial Food Canhci, Lubri. Use of ants* j � - ) Urised F.e;';:' i 1(Di Raw or Parti.i' Cooped Amoral Food and 7-206.11 Restrivtrd Us, Pesundae.Cr,rrn v* Y Ra«:Seed Sprouts Not Set wed. ^. 7-'06.12 Rodent Bait Soitwnsr Pe j 1'•(C) Unopened F<vid Package 'hut Ra-screed ( 7-206.13 Tracking Powders, Pest Control and Monitorme' CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-6t)t.I I Cunsutner?.d,,;sury Post d li,r Consumption of 16 Proper Cooking Temperatures for I Anim,:l F,;ads That are Ra;,. Undcrc.wked nr PHFs Not{)(!lel'\;se Processed to Eliminate 3-40].IIA(1)(2) Eggs- 155`F 15 See Pathos,ens. ' m: eas-Immcd:ate Service 145`F15set' 5-W2.i 3 Pasteur ized F;>g <Substitute Ra Raw Shell 3-401 1 I,,A)(2) Comminuted Yi::h. Yir,lis r"g" 5J' K Game ( e Arnmals- 1F 13:,ec. " 3PEG,AL REQUIREMENTS 3-401 I1(B)(1)(2) Puck and Bert d Xle - 00"17121_ 5 n" St)0.0'.li(At_(0) Violations of Section 590.00'9 1 E) in li-dOLi11,A)(2) Rahtcs,Lijededtt-]eats.- I55`'Fl5 (% )-i ) sec. a catering,mobile iol)d- temporaryanti ?-4V 1.1 I(A)(3) Poultry,Wild Game.Stuffed PFIFa, re;idc-imal kitchen operation, should be Stulfmg Containing Fish, h4ear debited uudei the appropriate sections j PoultryorRantee-i(iSFlSsec aboveilrelatedtofoodhorneillness ! 3-40:1 11(C)(3) W'hele-muscle. Intact Seel Steaks ( mterventi-.nu•altd risk facttmn. Other 145`F i 1 590.009 violations relating to geed retail 3-401.12 Raw Awtr:al Foods Cooked in a ( prnt'tice3 shetYd be debited under ff29- Mictowme 10511- 'F i Sac cml Retioirements.3-401.E 1(A)(1)(b) All Other PlP=s - 14;"F L`i ce( * 17 Reheating for Hot Golding ( VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-103 1 t(A)6:(D) PEIFs, 165'F 15 sec. i (items 23-30) 3-103.1 I(B) Microwave I65' F 7 %minute Standing Crri rr u/ued nor--rr;Ncui ,-redo;mos, rriilerr ria not rete;u ru rhe Tnu;:�` krorlLoru, ilhrese hv.rntnrhnts n.^.a';r... ;rift:r�tistert ubuvr. run he 3-403.11tC) Cownteici:dly Bice. sed RTE Food- Imn:d in the Jed/o:<tng su tions fi;rel Code un.i 105 C,rydlf 140'F" 500,000. 3-403.11(E) Itrmaitnng U',lslked Portions of Beef I Item Good Retail Practices FC .5.90AOO Rosts': li 23 Vianaaemvand Pwsrnnel I FC- 2 .003 1g Proper Cooling of PHFs 124. _ Poco and Fad Protection j FC -3 .004 25. Fqu:pntert and Utensil FC-4 .005 ,1-50 L 14:,A) Cooling Cooked PI-117l, Crum 140'F:u ' ,>g j water.F!.nnbSrc and Waste ( FC-5 .00P,'()'F 7()'F W'ithm 2 Hours and Front"104-F 27. Phvsicai Facil'v FC-U .007 to1l'F/45FP'iihw9 Hoar.; * 2& Poisonous o'Totic Rla?esctls FC--7 .001 3-501.14(S) Cooling PHFs Mace rrom Antbtcnt 20. Specia Re4uimmentc Temperature Ingredients to"I 'F/45 ,F U Ulher - Wi?hin 4 Flours^ _ *Denmu"critical item in the(adoral 1999 f•cctu Cade m loj CbtR`.•'U.GOiI CITY OF SALEM BOARD OF HEALTH Establishment Name: we- RFs / Date: Page: 3 of 3 Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY �»_ A- i1.r/n /.n A'1. x? 1/ O Z-/. &/r/1!r ,C fir-s„r-n c I I I I 4� I lix ///,/Lag Q E `� I vl EvYfRor7� .rin//.rn. —_/I/�GY�,ivr� �_ ',LivimiraGS — .CJi- 7Y�C�� T�tLI/ � ✓ Lem�i f .21a'7� F��r� —�/�>J/eS �fi�,Q �J n ,F 2/�i�v/S/�s 2f.C-e�. 1�,vU /fir Cl7.P V 7/d/I��P.P 1'1v r I I I c r A�9-fled- ter n I I I I I Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion 'S p ❑ Re-inspection Scheduled ❑ Emergency Suspension Oomply 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. (^gyp —��}/`( ' `'dhAe A A)1 ( �t ,�A6A 0 Voluntary Disposal 0 Other: I'l(C) i PHI-s Rece:wdnt TemlyeTatVi"', Violations Related to Foodborrm Illness Interventions and Rask Acwj di n�-,to Law C oolcd to Factor.,,111c."s 1-2g) "Cont.) 41"F!4i'FVV:thin4Kw;q 3-�)()i,i 5 C.),on--,Mli�.)& ior PI[Fs PROTECTION FROM CHEMICALS 14 Food or Colot Additives 19 PHF Hot rod Cold Holdinri 3-50 .If5,8) C,,,],- PlIf i."laintaincul oi bul.)w 3-202,12 Additiies,' io:0,0041F) Ili F 3-302.14 14 Protcetion from Unapproved Additives` 3. -50i.I t,�A) 1101 PHF�Maintained at or aboc 15 Poisonous or Toxic Substances 1 1 12(1'F.'1-101.'1 Identif),lng Information-Original -5 0 1.1 N A) Rinjqt; K-ld at of above 130'F ContoinerSl' 20 Tim as a PttbE�X-,alth Control 7-101 i I Comment Name-Working Containers 3-`til le, Tim::+a a liunll;�, I-Itnail (,ojitr(,[ 7-201.11 Separation-S101',wc'� 7-20111 RLstriction-Presence and t.'se" q0.004(H; Vaijame Rccpuirellleot 7-20112 Condition:;ot 7-20', I I 'toxic Contaim-s-Prohibjtious� REQUIREI-41ENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 sanitizcls�critella-Chemicals' POPULAT?ONS(HSP) 7204,12 Chemicals for Washint PrOdclCe,CrilCril` 21 ?803.;1(.4) Bcnxpearqcunwid Prea-trnnAac-d jan.es ami nzes d Wn 7-204.14 Drying Agents.Cfitei ia* -1-80 (B) Use of Pastemized Eg.,, 7-205 11 Incidental Food Contact Lubi wanto* 7-206.11 Rc,trictrd Use Pesticides,Crv�i:a" 3-801. Raw m Partially C,,(,ked Animal Poor,!aid 7-206 12 Rodent Bail SlahonO' 1-1130 i Raw Seed Sproms,No:Servc A. I 7-206.1 Tracking;Powders, Pest Control and - ..I (C) Unopened Food Packdee M,� Re-scrv- CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-003.11 COTISMUCT Ad%-I;,01 F Posted for Consumption of Animal Food, That :ire Raw, Undercooked'or 16 Proper Cooking Temperatures for PHFs ;'lot()fl)vrv,,Se Proces.svd to Elimmate 2ens, -'001 34 ,*01.11 At 1)(2) Eggs- J55'F 15 SeP-!ho! Eggs-Immediate Set 3 3-302.1 s P:ist,-vriz,�d Eg�s Substitute for Racy Shell I vice 14-ScFl�,wc� 3-401 11(A)(2) Comminuted Pish. Mc.its&Giarne E I Animals- 155'F 15 sc,. - 3-40 1.11(B (1)(1) Pujk and beefltoarL - I`iOT I?I SPECIAL REQUIREMENTS 3-401.1 I(A;(2) Ratites,Injected Bleats- 155'F 15 590 009iA)-(D) Violations of Section 590.009(A)-(D)in see. * j catering,motile food, temporary and 3-401.11(A)(3) Poulhy,Wild Unite.Stuffed PHFs, rcsidero;al kitcnei, operations should rie stulfiln,Cont,flon,Fish,Meat, debited trader the appropriate iections Poultry or Patitcs-165F 15 s '"ec ibov,, if related to foodborne if less 340I.1ItC)(3) Whole-muscle,Intact Beef Steal,: intervc-itioms and Fsk factors. Ottisti 145"F I 590.009 violattoa, i elating to good retell 3-401.12 Raw,Annual Foods Cwke.d in u Practices should be debited under#29- Microwave 165'1- * Special Requirements. 3-401.11(A)(I)(I)) All Other PHFs-- 149'F i5 sec. 17 Reheating for Hot Holding VIOL 4TIONS R-LATED TO GOOD RETAIL PRACTICES 3-403.1 t(A)&(D) Pil"S 165'F 15 se, (Items 23-3(i) 3-403.11(B) Mici ov,ave- 165'F 2 Minute Standinl! Opilical and wit ,rawid violations, Aich do nor relate to the Tine lolCt-.enrionsand risk lucious lisret!abate, Can be 3-40" 11(C) Comwercialiv Pt ocesstd R-1 F Food- Jovial in the)honing se,t;,m, o(the the bood Cod,,and 105 CtIR I l0iF1 590.000. 3-403.1 !(E) Remnorling Unshced P,,nions of Beef Item Good Retall Practice&, Fc- 590.000 i Roasts* 23 Ma-aqe:qcnI aqd Pors,^rcl FC 2 .003 Proper Cooling of PHFs 24, Food and 7ocd Protection I-C - 3 004 25 Equipment q;"d Uten0i, FC- 41 '005 3-501.14(A) Cooling Cooked PHFs from 14W F n, ?6. Weter. Plunrt;jnq Pact Waste FC-5 006 7WIF Within 2 Hours and Fron17(rF 1 i 27 pilys!'ail Facility FG , 007 to 41'F/45+Within 4 Hoary, * 1Pow,ousel-roxir,Matenpis FC--7 008 20 3-501.14(B) Cooling PHFs Made From Amb�eat Special Retluimnlen!5 Tempen,,tw Ingredient.:to-11'R-l5l-, 30. other Within 4 Hour;:` m. DQnow, ritmil item in the Lu&ral 19119 F-mill Cii,le of 11111 CMR 590'iltl(). n", 11�t-q. PA� W SALEM, MASSACHUSETTS CITY OF ETT BOARD OF,,,HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 0 1970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Hawthorne Hotel Address of Establishment: 18 Washington Square West Owner's Name: Dorothy Harrington Restrictions: Application Date: 12/2/2004 Permit for Food Establishment 120-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 29-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. q"--x HEMTH AGAENTvt � — CITY OF SALEM, MASSACHUS BOARD-OF TALTH u' 120 WASHINGTONSALEM, MA 01970TH FLOOR 3 0 2084 TEL. 978-741-1800 NOVN FAX 978-745-0343 CITY OF SALEM STANLEY J. LISOV ICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Hawthorne Hotel TEL#978-744-4080 ADDRESS OF ESTABLISHMENT 18 Washington Square West , Salem, MA 01970 MAILING ADDRESS (if different) OWNER'S NAME H&C Service Corporation TEL#978-744-4080 ADDRESS 18 Washington Square West CITY Salem STATE ma ZIP 617 7 6 CERTIFIED FOOD MANAGER'S NAME(S) StpvP NPT Gon CERTIFICATE#(s)71417 9 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON .Yuji T.pAarhana HOME TEL#q7&740-0540 HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun. 7 days 6am - 12 midnight-------------------- TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES ( NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO n D.O� less than 25 seats =$100 d 25-99 seats =$150 more than 99 seats =$20 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YESNO $5 TOBACCO VENDOR ICL- ES O $50 ALL NON-PROFIT(such as church, k;tche^s) Nd Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my bes"ure lief have filed all state tax returns and paid all state taxes required under the law. � 11 /24/04 04-2925769 Si Date Social Security or Federal Identification Number Revised l l/03/03 FOODAP2 adm Check#&Date 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 744-4080 Non-compliance with: Not Done Owner: Anti-Choking PASS ❑ Dorothy Herriligton Tobacco PASS ❑ PIC. FOOD PROTECTION MANAGEMENT Not Done Inspector:_ PIC Assigned/Knowledgeable/Duties PASSd❑ RED David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED 3/29/2005 Personnel with Infections Restricted/Excluded PASS ❑/ RED Risk Level:' FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASS ❑ RED BHP-2005-0203 Receiving/Condition PASS /❑ RED Status: Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED VIOLATION Conformance with Approved Procedures/HACCP PASS ❑d RED #of Critical Violations:. Plans 1 I PROTECTION FROM CONTAMINATION Not Done Time IN. I Time OUT: Separation/Segregation/Protection PASS �/❑ RED Notes: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ./❑ RED All cutting boards are stained and scored. 52. - Resurface or replace all cutting boards Proper Adequate Handwashing PASS ❑d RED Urgency Description(s): Good Hygienic Practices PASS ❑J RED BLUE:, Violations Related to Good Prevention of Contamination from Hands PASS ❑/ RED Retail Practices (Critical Handwash Facilities PASSd❑ RED violations must be corrected immediately or within 10 days)(Non-critical violations GeoTMS®2005 Des Lauriers Municipal Solutions, Inc ( Rev. Mar 30,2005 ) Page 1 o!3 0018 WASHINGTON SQUARE WE Hawthorne Hotel must be corrected immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) Approved Food or Color Additives PASS Q RED RED: Violations Related to Toxic chemicals PASS ❑Q RED Foodborne Illness Interventions TIMEtTEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASS ❑d RED immediate corrective action) Reheating PASS ❑d RED Cooling PASS ❑d RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS Q RED 11 GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Mar 30,2005 ) Page 2 of 0018 WASHINGTON SQUARE WE Hawthorne Hotel_ Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE v Tray of peppers in walkin freezer uncovered. All food in storage must be covered. Equipment and Utensils FAIL Non-Critical ❑ BLUE - Side of fryolator has an accumulation of grease and grime Thoroughly clean fryolator ✓Coke cooling unit needs a thorough cleaning. Light fixture in hall with the ice maker needs protective covers. ✓Small refrigerator in employees lounge needs a visible, accurate thermometer. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non-Critical ❑ BLUE Floors in basement walkin and dry storage area need to be repainted. Flooring in the kitchen needs a thorough cleaning including under and around all equipment. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE GeoTMS®2005 Des Laurlers Municipal Solutions, Inc. ( Rev. Mar 30,2005 ) Page 3 of 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE REINSPECTION Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 744-4080 Non-compliance with: Not Done Owner: Anti-Choking PASS ❑ Dorothy Harrington Tobacco PASS ❑ PIC: Steven Nelson FOOD PROTECTION MANAGEMENT Not Done InspectorPIC Assigned/Knowledgeable/Duties PASS Q RED David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: Correct By Reporting of Diseases by Food Employee and PIC PASS RED 4/12/2005 Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level: FOOD FROM APPROVED SOURCE Not Done Permit Number: - Food and Water from Approved Source PASSd❑ RED BHP-2005-0203. Receiving/Condition PASSJ❑ RED Status. Tags/Records/Accuracy of Ingredient Statements PASS J❑ RED SIGNED OFF #of Critical Violations: Conformance with Approved Procedures/HACCP PASS Q RED Plans PROTECTION FROM CONTAMINATION Not Done Time IN: (Time OUT Separation/Segregation/Protection PASS ❑d RED Notes: Food Contact Surfaces Cleaning and Sanitizing PASS ❑J RED 84. Proper Adequate Handwashing PASS ❑J RED Urgency Description(s): Good Hygienic Practices PASS ❑J RED BLUE: Prevention of Contamination from Hands PASS ❑J RED Violations Related to Good Retail Practices (Critical Handwash Facilities PASS ❑J RED violations must be corrected . immediately or within 10 ` days)(Non-critical violations GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 13,2005 ) Page 1 oft 0018 WASHINGTON SQUARE WE Hawthorne Hotel must be corrected immediately PROTECTION FROM CHEMICALS Not Done of within 90 days) Approved Food or Color Additives PASS ❑d RED RED: Toxic Chemicals PASS ❑d RED Violations Related to Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASS RED immediate corrective action) Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS 0 RED Time As a Public Health Control PASS ❑d RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS d❑ RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils FAIL Non-Critical ❑ BLUE Side of Vulcan oven encrusted with grease. Thoroughly clean unit. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non-Critical ❑ BLUE Basement floors to be painted by next routine inspection in six months. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE A'ft'VA" GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 13,2005 ) Page 2 o!2 4 � � ( IMP13RTJ%NT MESSAGE ) FOR I&J.ew DATES -1�Ls TIME "�mS�P�IDIh M �/ OF PHONE 97g• ai Ti- yi 3.t� AREA CODE NUMBER EXTENSION O FAX ❑ MOEIII F AREA CODE -NUMBER TIME TO CALL /- TELEPHONED PLEASE CALL vi CAME TO SEE YOU �I WILL CALL AGAIN WANTS TO SEE YOU I ` RUSH I RETURNED YOUR CALL I WILL FAX TO YOU MESSAGE Pn 1 / 0 SIGNED 4 + �ps MARE IN FORM 4009 LLS AA z 0 i m [n y P a J "I Memo Date: 5/19/2005 To: File Cc: From: David Greenbaum RE: Hawthorne Hotel Claire from the Hawthorne Hotel called to report that a woman dining in Nathaniel's had become ill after eating about 3/. of a grilled chicken meal An investigation was conducted on 5/9/05, the following was noted: the chicken breast comes from Sysco and is received frozen. Upon receiving the chicken is put directly into the walk-in freezer that had a temperature of—25 degrees Fahrenheit. The chicken is then moved from the basement walk-in freezer to the kitchen walk-in freezer one case at a time the kitchen walk-in freezer had a temperature of 10 degrees Fahrenheit. The chicken is thawed in the kitchen walk-in at a temperature of 38 degrees Fahrenheit. Once the chicken is thawed it is prepared with spices and held in a cooling unit by the cook line. The temperature of this unit was 40 degrees Fahrenheit. Five to six servings of the chicken are prepared at a time and it is cooked only when ordered. I did not see any food safety violations at this time. I recommended that all soap and chemicals stored under the end prep table be stored in covered containers or removed from this area. ( IMPORTANT Ni5SSAOE ) FOR )u' DATE e- d s TIME -4W M �/��// al a4 r L/ OF PHONI=' / ARLACODE NUMBER EXTENSION D FAX O MOBII F AREA CODE NPMBER TIME TO CALL TELEPHONED ,/✓PLEASE CALL CAME TO SEE YOU 1 WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOURCALLWILL FAX TO YOU MESSAGE �n A'i�A; 4.✓�,�. Q /7- 73 /�07 /LS LiG a�GY r�C f'i v SIGNED f:.ajj, �--p �0lk FOMAGREMIN 400U.S.A. r vnc nd_ - Aesh12,4-s_s_o-e-77N 4-9em Ir _...--- ,,,_..,, I .." � ___--- ISI _. �,,,,,,,.....-- ...--- ' -- -- �--. „'�. �,---."' ,.,.,,, ,Jr.., _--- �.- .-- _-----'' .�-----' .---- I .�^� r+"" it _,... ��, `�._,,,_._.----- i.. �, s' __---�-� CI1"Y OF SALEM, MASSACHUSE'I"I'S BOARD OF HEALTH 120 WASHINGTON STREET 4p.FLOOR PublicHt.aith STREET, Prevent Promote_Protect TEL. (978) 741-1800 FAx(978) 745-0343 KIMBERLEY DRISCOLL )ramdin(&saletn.com MAYORL.\RKl'R,\NIDIN,RS/RI;I I5,CI 10,(T-FS MAYOR A(il?Nt August 14, 2014 Hawthorne Hotel 18 Washington Square Salem, MA 01970 Dear Owner: On Monday,July 21, 2014 at 11:41 am personnel from the North Shore Cape Ann Tobacco and Alcohol Policy Program conducted a Smoke Free Workplace Law(SFWL) Inspection based on 2 complaints forwarded from the Massachusetts 1-800-compliant call in line. During this visit a violation of the Salem Board of Health Regulation#22`Workplace Smoking Ban"was issued. Documentation is now on file at the Board of Health regarding that violation. The Hawthorne Hotel is in violation of section D. 2. "It shall be unlawful for any employer or other person having control of the premises upon which smoking is prohibited by this regulation, or the business agent or designee of such person,to permit a violation of this regulation."A Hundred Dollar fine($100.00)for the first offense has been issued for this violation. In the case of three(3)or more violations within 24 months of the current violation, including the current violation, a fine of three hundred dollars($300.00). The North Shore Cape Ann Tobacco and Alcohol Policy Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street, 4th floor,within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 978-741-1800. Sincerely yours, Larry Ramdin Health Agent LR/hlp CERTIFIED MAIL: 70121640 0002 3312 0225 cc: North Shore Cape Ann Tobacco and Alcohol Policy Program Barbara Poremba, Board of Health Chairperson and Members 9' Memo FEC�REIVE® JUl `Z y 2014 Date:July24,lou} p N pF 6A�EM H To:Larry Ramdin,Health Agent BOARD OF HEA From:Joyce Redford,Director RE:Workplace Smoking Inspection On Monday July 21,2oi4 the North Shore/Cape Ann Tobacco Alcohol Policy Program conducted a Smoke Free Workplace Law(SFWL)Inspection based on two(2)complaints forwarded from the Massachusetts 1-800 complaint call in line.During this visit a violation of the"SALEM BOARD OF HEALTH REGULATION#22 WORKPLACE SMOKING BAN"was issued. Establishment Address Violation Fine Hawthorne Hotel 18 Washington St ist Smoking in a workplace $ioo.00 Narrative: Upon entering the Hotel we took the elevator to the second floor this floor is comprised of business offices,conference rooms and guest rooms.Peter King,Inspector and I noted a strong odor of tobacco and cigar smoke. As we investigated the areas of the floor it was clear that the odor was strongest in the office area. We asked an employee about the occupants of the office where the cigar smoke was the strongest,we were told that this level(second floor)was for smoking guests and confirmed that the owner smokes in his office. We were escorted down to the Hotel Managers office and were introduced to Ms.Ledorhaus,we discussed why we were there and our findings,she too confirmed that the owner smokes in his office and asked"how this was different from a guest smoking on that floor"we explained the difference between guest verses employee and we issued a violation She stated that she was sure that the owner would likely want to come before the Board of Health to discuss on this issue. Should you have any questions please do not hesitate to contact me at 781-586-6821 n Violation Notice ` • City/=Town `> ; Board of Health PablicHegUl Prevent. Promote. Protect. - This notice is to inform you that your establishment violated the Board of Health Sale of Tobacco Products &Nicotine Delivery Products and/or Environmental Tobacco Smoke(ETS)Regulation. � 5 Name of establishment Address 1 Date df violation 5 Time of violation Minor's.age/gender Minor's ID# (Ordinance,Section,Regulation) (Act Constituting Violation) Narrative information: I affirm,under the pains and penalties of perjury,that the above report is true to the best of my knowledge and belief. y Inspector(Signature) (Print name) s VENDOR'STATEMENT: I acknowledge I received this ViolatiokNotice on _? c: A 20 at 1 y tAM/PM and I am being given a carbon copy of this notice.I also acknowledge that I have been informed that the Peabody Board of Health will provide additional,follow-up information to this violation notice. Owner/Manager/Clerk(Signature) (Print name) If vendor refuses this Notice or if the inspector feels unsafe in delivering it,an explanation must be written on a note attached hereto.Mailing of this Notice is thus required. Contact the North Shore/Cape Ann Tobacco Alcohol Policy Program at 781-586.6821 with questions r� Estabiishmem-white $'NSTCP-yellow Board of Health-pink COMPLAINT REFERRAL Complaint Information Complaint Number 1215 Complaint received via: Live Phone Cali Date of call: 7/17/2014 Time of call: 2:00 PM Workplace information Name of workplace Hawthorne Hotel I Street Address: 18 Washington Square West City: Salem Zip: 01970 Incident Details Date of the Incident: ongoing Approximate time of incident: ongoing Type of workplace: Hotel Location of the incident within the workplace: Primaty work area Comments about the location of incident: Either a guest or a person attending a meeting complained that someone was smoking in the 1 onference rooms or a private office located on the second floor of the hotel. Apparently the I( caller could smell smoke throughout the second floor area and esp in the office located there. Person seen smoking: Customer ❑ Employee 0 Unknown 0 Other smoking indicators: ashtrays present El cig stubs present 0 Additional Information: ris is the second compliant I've received about smoking at this hotel. t also noticed that people m have written reviews about staying at the hotel have complained about the smell of cigarette mole kt the hallways and conference rooms on the 2nd floor. Friday,July 18,2014 r Page 1139 of 1139 Larry Ramdin From: Juli Lederhaus <juli@hawthornehotel.com> Sent: Monday, April 01, 2013 4:23 PM To: Larry Ramdin Cc: Claire Kallelis;James Gilliss Subject: Hawthorne Hotel Hi Mr. Ramdin: Yesterday, Easter Sunday, we had a problem with the separate water heater that provides supplemental hot water to our lobby public restrooms. Our building maintenance chief was on duty, and he determined that the heating element for that xunit was going bad. We placed sanitizing hand cleaner in each of the two restrooms. We ordered a new heating element today. In the meantime he was able to reset the unit, which seems to be working for the time being. I am bringing this to your attention because there was one guest here for the Easter Brunch who was quite upset, and said that if that water wasn't hot in the rest rooms, we must not have hot water anywhere else in the building, and he felt that was a health hazard and said that he would be reporting this to the"health department" today. I can assure you that we were not without hot water anywhere else in the building, and that we believe we dealt with this in an appropriate manner. Please let me know your thoughts. Thank you. Juli Juli Lederhaus General Manager 978-744-4080 Hawthorne Hotel Est. 1925 A Proud Member of Historic Hotels of America, a program of the National Trust for Historic Preservation Click here to see our$45 Wedding "ODDortunity Date" Packages Click here for Hawthorne Hotel Virtual Tour t I 1 r ` Commonwealth of Massachusetts` ro ` e = v City of Salem 1 7 #s s - F Board of Health . Kimberley bris'00 u< 3 4 : a or - .120 Washington Street,4th Floor:e= Y SALEM,MA `:01970= Food/Retail Establishment Permlt y „ § DATE PRINTED: 01/03/2013 " h ESTABLISHMENT NAME:' Hawthorne Hotel ' ='' ' V ir File Number:BtiF-20oa 0001st a£ = 18 W_asbington Square West s - Salem - a MA 01970 ` LOCATED AT: '6019 WASHINGTON SQUARE WE ' =Y. SALEM,-MA 01970'. Permit Type ' Permit No.- Permit Issued3 Permit Expires ;. Fee Restrictions'/Notes-'t f+ "' 4 FOOD SERVICE r BHP-2013-0313 'Jan 1;2013 Dec 31,.2013 ':$420.00,, ESTABLISHMENT �> 2 Total Fees: $420.00 v 4 Y PERMIT EXPIRESv IDecemher 31, 2013 . _ Y x Board of Health a4" This Permit is not transferable and must be reissued upon change of ownership or location."The.peimit must be posted `_ V 11 in a prominent location in the Establishment:; s `. z t In accordance with the State Sanitary Code beofre any revonations,improvements,or equipment changes are mad_e, v all plans for such must be submitted to and approved by the Salem Board of Health. 'E. page 1' '. :. °- CITY OF SALEM, MASSACHUSETTS ��I CC t�wl�xeattn GCEIit�" Bo,\auOFHFAIM-1 ..........m... .,..., 120'WASI IINGPON SIRFI'1',4111 F1S)0R ICINIBERLEY DRISCOIJ rr(r� q Jo%JFi-(978)741-1800 FAN(978)745-0343 LARRY RANIDIN,RS/RI C1 IS,(1110,CP-FS MAYOR �CU 1 Irimclitina salem.com Hi%Al.m A(ii',N'P ( OOF H��i H '*ood Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: NQ\nl (lr Y1P ti/q ' ' 1 - 2) Establishment Address: ® (�G�h , j7 G(j tA Q-CT 3) Establishment Mailing Address(if different): 'f 4) Establishment Telephone No: q q O, - 9 L41-4 U O Rh n 5) Applicant Name&Title: 6) Applicant Address: I } i 17) Applicant Telephone No:ghR-.nj�G.l) �(�24 Hour Emergency No: Email: j lid i C7i h(11n1 nC n , cu 6) Owner Name&Title(if different from applicant): ,-n n f-n-�k l I N a rr 1 C) ' I 9) Owner Address(if different from applicant):' Rn I ��/ i P k/\.) A V.1 P PPV P_Y-t j l.� I I A 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. tion Name Title Home Address A corporation AWtffdMdMr A partnership � n Prete SSP AhnvP Other legal entitv 12) Person Directly Responsible For Daily Operations(Owner, Person in Charge, Supervisor,Manager,etc.) I Name&Title: ,Tti11 L2AP(-h(ll I M n Address: �� \ nn �' �!11P,W1 MA OtA'1d Telephone No: Q`I S . Li(L n F 1 n Fax: Email I e I Emergency Telephone No: 9rl R- R q 5 - U inn 13) District or Regional Supervisor(if applicable) Name&Title: Address: 1� Telephone No: Fax: Email: Check#: Date: /`' /U///ate Amount ' �7 Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: GO M- I Q(Irj) M-�;a! 17) No. of Food Employees: 80 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) q-�PU P_ 19) Person Trained in Anti-Choking Procedures( if 25 seats or more): )(Yes No Cl CL\( e I'1(�� P. 1 < 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑ Caterer Permanent Structure M Food Service-( qSq 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________________________ (check one) RETAIL STORE RESTAURANT Annual X ❑ 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 ❑25-99 seats $28 N More than 99 seats •�. - TemporarylDates/Time: ---------- ❑ Bed &Breakfast/Childcare Services/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: PAF-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-eat 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 1/ 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✓ v Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be Completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other 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 Applicant: Pursuant to MGL Ch. 62C, sec. 49 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: r) 26) Signature of Individual or Corporate Name: E`Commonwealth of Massachusetts z X - s`- A - City of Salem � � � �- ` �� s s y �. � Board of Health" ° 9, Kimberley Dnscoil .120 Washington Street,4th Floor - z payorlk =n E .SALEM,MA, 01970 -a V Hotel - Motel Permit >.= DATE PRINTED: A 01/03/2013- }± w ESTABLISHMENT,NAME: _' Hawthorne Hotel File Number sHF-zooa-000tsi ' ' - - 18 Washington Square West, Salem MA .01970 LOCATED AT: . 0018 WASHINGTON SQUARE.WE - y> '� SALEM;IMA 01970 ' Permit Type '" Permit No: Permit Issued Permit Expires 4 Fee Restrictions/Notes Vic' Jan 1,2013 Dec 31;'2013 - $200.00 Operations Permit Hotel/Motel - BHP-2013-0351 e r., wzl 3- Total Fees:- $200.00 F 4. PERMIT EXPIRES (December 31,2013 Board of Health ¢° e ,. Page 1 _ 4 10k, orf* RE ;OFSALEM, MASSACHUSETTS r 101 BOARD OF HEALTH DCi� 3 120 WASHINGTON STREET,4°1 FLOORVpI1bI1CHP.81t1 GIl r SA- (,1 (978) 741-1800 FAX(978) 745-0343 KIMBERLEY DRISCOAIDARD JF H bamilinna saler.cotn LARRY RAMI)IN,R.0/RVIIS,CI R),CP-IS MAYOR HI±.,\I;l i I Ac.C?NT Application to Operate a Hotel / Motel $200.00 Name of Establishment: H o w A ' n f-n P. TCr.I Address of Establishment: I � ws b qq 1 cl ce V,1� Mailing Address (if different): J Tel#: R18' `ILA q- uORn Fax#: CM_ qL( Business Email: 1` �( 1.) 1�n rn P_� ��n .M1y�_Website:W vy� 1(j(����F �n�lt�Q l f)�c . or)m (1 Owner's Name: n fC1'4-N 1 I Tel# q9R q`QQ - gi 1 �IAddress: la�[Lew R VP_ Jfi-)r\ Pup ,rlrt i 'MA C1 I_ q 1 ,15 City I I State Zip Emergency Response Person(s):,T >_ I t I P(7 P Y 'nl 1�i Tel#: q 9�R •(Iq 0 -o Ci 9 f) How many rooms are reserved for guests? �q Is food served in the Establishment? \IPc,�i Are animals allowed on the premises (other than service animals)? *Please make check payable to the City of Salem. (Pay by check or money order only) This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the establishment. Pursuant to MGL Chapter 62C Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. 'Signat a Date Social Security or Federal Identification Number ------------------- --------------------------------------------- 523/1 hotel-motel appl.doc Check#&Date $�p� iC -/(0/ Commonwealth of Massachusetts City of SalemBoard of Health 120 Washington Street,4th Floor Kimberley Driscoll4: p l MAW SALEM,MA 01970 Mayor Food/Retail Establishment Permit DATE PRINTED: 12/29/2011 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Hotel/Motel BHP-2012-0141 Jan 1,2012 ' Dec 31,2012 $200.00 Operations Permit Total Fees: $200.00 PERMIT EXPIRES December 31, 2012 Board of Health' m /J s' . This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance mith the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. page 1 Commonwealth of Massachusetts City of Salem k Board of Health 120 Washington Street,4th Floor Kimberley Driscoll SALEM,MA 01970 Mayor Food/Retail Establishment Permit DATE PRINTED: 12/29/2011 ESTABLISHMENT NAME: Hawthorne Hotel File Number BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2012-0134 Jan 1,2012 Dec 31,2012 $420.00 ESTABLISHMENT Total Fees: $420.00 PERMIT EXPIRESDecember 31, 2012 . Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 �• pp CITY OF SALEM, MASSACHUSETTS P / BOARD OF HEALTH 120 WASHINGTON STREET,4p. FLOUR To_ (978) 741-1800 KINIBERLEY DRISCOLL FAX(978) 745-0343 A-iiYOR ltamdinOsalem.com LARRY RAMI)IN,RS/RFI IS,Cl 10,01-1,S Fir V:1'1 I A(i kNI' II 201_APPLICATIONFORPERMIT TO OPERAiTE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT�cmji+)arne_ u(��P_11.1 I TEL# "IrI8 " rI14L4 - L4(�r:5C ) ADDRESS OF ESTABLISHMENT Q�'fl t C1(1� tr, Sa UV Q 5� FAX# MAILING ADDRESS(if different) J `h EMAIL- Business': 'IC &�IaW�-�nornohallz -f�Website: VVWaAj OWNER'S NAME_)QH/ kt j �7 TEL# ADDRESS 1 PV)% I 1 P u 1 A\i P Pun)P H( M A STREET, - CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) ared) r-A CERTIFICATE#(S) 9 I L4 17 � (Required in an establishment where potentially hazardous foo is prep - EMERGENCY RESPONSE PERSON.TI) 1 P��r h(1 1 A HOME TEL# a_12- 9L4 0 -Or]ll - (� I DAYS OFOPERATION Monday, ' > Tuesday Wednesday -=Thursday °'';: ;"Friday- Saturday Sunday i HOURS OF OPERATION I t t Please write in time of day. (� ^ t t r' it (Forexampletlam-11pm) TYPE OF ESTABLISHMENT FEE (check oniv) RETAIL STORE YES ( NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - - ----- ---- - - - ---- RESTAURANT ES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210 25-99 seats =$280 more than 99 seats =$420 - - ---------------------------------- ----------------------- ------ -------- ----------- BED/BREAKFAST! YES NO $100 CHILDCARE SERVICESlNURSING HOME - ADDITIONAL PERMITS - - MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES ( 09 $$25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,1 certify under the pains and penalties of perjurythat I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. nn A - �� I � ► 1 *ture&4(1C _ ,_1„n l I P r ` Date Social Security or Federal Identification Number U ted 523/11 FOODAP2011adm Check#&Date $ a Massachusetts Department of Public Health Salem Board of Health Division Of Food and Drugs 120 Washington Street,4s' Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax (978) 745-0343 Name, 1 ate Tvpe-of Operation(s). T_vpe of Insoectlon M� roa t (ZJ MP �1 1 PJ. �, c7,-� ( 12] Food Service lutine Address II Risk El Retail ElRe-inspectionI ICS I )rl A�-Pn11. 0 A AA O Level ❑ Residential Kitchen Previous Inspection Telephonev � ')C,/ -I(�4_ L+d�o 'j ❑ Mobile Date: ❑ Temporary ❑ Pre-operation Owner �p CiIPAAWP 0o- rQ(J Y 1 (AA HACCP YMrI ❑ Caterer ❑ Suspect Illness Person in Charge(PIC)- l .j��\ ` t 1 Time I��'❑ Bed&Breakfast ❑ General Complaint �-�� )Pn II ) r�/�SQM I IRU ❑ HACCP Inspector � 1j, c � I Out: } Permit No. El Other Each violation checked requires an gxplanatlon on the narrative pige(s)and a citation of specific provision(s)violated. �J Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking- Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 690.009(E) 590.009(F) ,gam action as determined by the Board of Health. / [FOOD PROTECTION MANAGEMENT . ,�� El12. Prevention of Contamination from OS 1. PIC Assigned/Knowledgeable/Duties � �k,, ( .--_____ 13. Handwash Facilities ,':EMPLOYEE HEALTH-` ,..- ❑ 2. Reporting of Diseases by Food Employee and PIC )PROTECTION FROM CHEMICALS El 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded �'15.Toxic Chemicals LFOOD FROM APPROVED SOURCE . - ' ° ❑ 4. Food and Water from Approved Source , IME/TEMPERATURE CONTROLS(Potemiafly 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 l 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 EREOUIRENI TS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices I._ ONSUMER ADVISORY 00122. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR cf Health. 590.000/federal Food Code. This report,when signed below T_ N by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-z)(sso.0 order of the Board of Health. Failure to correct violations v� 24. Food and Food Protection (FC-3)(990..0044))) 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you (3 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7)(590.008) and submitted to the Board of Health at the above address 41 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S svo�nspectFomb-�a dx � �,` / Ut0 �0 �� 1C1nP.t.� tr,n� ( Inspector's Signature: � � nj/�1ViAr: Print: '�f PIC, e., /���/ Print: s/� � �,�"U.�,� I Page of?Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(.0) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge` Contamination from Raw Ingredients 2-103.11 Person in charge -duties 3-302.1 I(A)(2) Raw Animd Foods Separated from Each Other' EMPLOvEE 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 li Washing Fruits and Vegetables applicants* 1 590.003(F) Responsibility Of A Fotxl Employee Or An 3-304.11 Food Contact with Equipment and Utensils Applicant To Report To The Person In I Contamination from the Consumer Charge* 3-306.14(.\)(B) Returned Food and Resen�ice of Food* 590.003(G) Reporting by Person in Charge* I Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* - Food 590.003(E) Removal of Exclusions and Restrictions f 13-701,1 t Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 1 4 Food and Water From R.Rgulated Sources 19 Food Contact Surfaces 590A04(A-B) Compliance with Food law* 1 4-501.11 I Manual Warewashing-Hot Water 3-201.12 Ftxxt in a Hermetically Scaled Contamer* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* � 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* _ Sanitization Temperatures* 3-202 14 Eggs and Milk Products. Pasteurized" 4-501.114 ( Chettncal Sanitization-temp.,pH, 3-202.16 fee Made From Potable Drinking Water" concentration and hardness. " 5-101.11 Drinking Water from an Approved System" 14-601.11(.4) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* ( Utensils Clean" 590.(Hi6(B) Water Meets Standards in.3I0 CMR 22.0' 4-602.11 Cleaning Frequency of Equipment Food- ShelNlsh and Fish From an Approved Source Contact Surfaces and Utensils" J 4-702.1 I Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Fond Contact Surfaces of Equipment* Shellfish" ( 4-103.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shell risk from NSSP listed Chemical* Sources* I i I0 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 12.3(p.11 Clean Condition-Hands and Arens* f 3-202.18 Shellsiock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms^ 12-301.1.1 When to Wash* 3-203.17 Game Animals* I1 Good Hygienic Practices g Receiving/Condition 12-401.11 Eating,Drinking or Using Tobacco* f 3-202.11 PHFs Received at Proper Temperatures* 12-301.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity" Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* I 590.(H)4(E) Preventing Contamination from- 3-203,12 Shellstock Identification Maintained' I Employees* Tags/Records:Fish Products ! 13 Handwash Facilities _ 3-402.11 Parasitt Destruction.* Conveniently Located and Accessible 3-402.125-203.11 Creation and Retention* 5-203.11 I Numbers and Capacities* 590.004(1) Labeling of ingredlenW i 5-204.11 I Location and Placement* Conformance with Approved Procedures 15-205.11 Accessibility,Operation and Maintenance /HACCP Plans I Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* ( Devices 3-502.12 Reduced oxygen packaging, criteria* 6-301.11 Handwashing Cleanser,Availability I 8-103.12 Conformance with Approved Procedures` 6-301.12 Hand Drying Provision *Denoles critical item in the federal 1999 Fond Code of 105 CMR 590.000. x CITY OF SALEM � � l 1 BOARD OF HEALTH Establishment NamefA((��nP.A" .,)4" "nn e h� A.OQ_._ Date: -1 a_ —Il Page: 1_ of Rem Code C-CrIII cal It m (I DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Ra If I�/gyl �y'�7B,tl n • 9 - �¢nM t��S y� � iV4'°6 p.. l/(� �G�11AA L,.S�I� PLpEASE PR NT C,L'E/A LV- ,,, _ Verified .�"' X 1 t J,/ Ilf�U�'� n , .9. o, I i�At D r n/1 r- ! AA 1-4 C/JIB—.aj(a/Vl fir 71n n, Ell P( n o.l Pal t it4)(-Y -A 0/1 - Il 1( I /��//�/1� � `Jn�� '\\ ,0�_�.0 /A ASIV\� �' �.T�/I 17 l-/1 '� \MO JI 1Lt�_l�f l� \/ �I VI \l,tfi ,/11 -iV X .(9 v �l'.�;Je,�n�' , ,nD � ���`.�,.�- -\n�r_r II)�,.,�-�;.�.�,�x�1n� -g.� 5� I��IAe7 L'_F�I��n.i/„� ,, f•,L( , ,,,_n-. 1'J{ ,'� ) ,� t'n11n_ I� ton�,)., �1� '"il� o, ; � .Q ,��Illr�— jir�ia.;. �� II%� T �.()Q _�-�/Y(•bA,�P) /)� o i-i/i�_ �/n .U�i_� "�)� �- � t fiLtO U` R �,n DI f61-1 A,2A1,. �1n ,.� - !l� o 1l 11�o DI On � �1 A e P In r�, D� o i A �- itY��/ 1 i JNf ,K .PI? ✓! �I/ /J�t�K/YJ�/ /�2.__1_'_LX/l��_11"\I'fhY � l(( 1�1 �C�� I __� Discussion With Person 1h Charge: v Corrective Action Required: I ❑ No 0-rYes I I I have read this report, have had the opportunity to ask questions and agree to correct all b-' Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and toRe-inspection Scheduled ❑ Emergency Suspension Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines ofi wen lars si/ sion/revocation of o Embargo Ll Emergency Closure your food permit. /,,�n \, ❑ 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(Items 1-22) (Cont.) I 4l'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS I 3-501.15 Cooling Methods for PHFs I 14 Food or Color Additives I 119 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 1 Additives* 590,004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 115 Poisonous or Toxic Substances 13-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original I 1400 F x ( 3-501.16(A) I Roasts Held at or above 130°F. Containers* 7-102.11 I Common Name-Working Containers* I 120 I I Time as a Public Health Control 17-201.11 I Separation-Storage* I 13-501.19 1 Time as a Public Health Control* 17-202.11 I Restriction-Presence and Use* 1590.004(H) I Variance Requirement 17-202.12 I Conditions of Use* I REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 I Toxic Containers-Prohibitions* I POPULATIONS(HSP) � 7-204.11 I Sanirizers.Criteria-Chemicals* � 7-204.12 i Chemicals for Washing Produce,Criteria* I 121 13-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 I Drying Agents.Criteria* Beverages with Warning Labels* 7-205.11 ( Incidental Food Contact,Lubricants* I 3-801.11(B) Use of Pasteurized Eggs* 7-206.11 I Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * 17-206.12 ( Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. " 7-206.13 ( Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for I Animal Foods That are Raw,Undercooked or PRFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 Sec. I Pathogens. Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-461.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(13)(1)(2) Pork and Beef Roast-130°F 121 rein* I 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 3-401.1,1(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 we. * above if related to foodborne ilhiess 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(6) I All Other PHFs- 145°F 15 sec. 117 I Reheating for Hot Holding VIOLATIONS R LATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) + PHFs 165F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3403.11(E) I Remaining Unsliced Portions of Beef I Nem I Good Retail Preattees .FC 590.000 Roasts*` 123. : Manaoemern and Personnel FC-2 .003 I 18 I I Proper Cooling of PHFs I i 24. I Foci and Food Protection FC-3 .004 j y I 3-501.14(A) Cooling Cooked PHFs from 140°F to 25. Eauioment and Utensils FC-4 .00526. Water.Piumbinq and Waste FC-5 .006 70°F Within 2 Hours and From 70"F 27. Phvsical Fact* FC-6 .007 I to 41°F/45°F Within 4 Hours. * 1 28. Poisonous or Toxic Materials ! FC-7 1 .008 3-501.14(B) Cooling PHFs Made From Ambient 1 29. Special Requirements Temperature Ingredients to 41017/45017 I I X Other ! I I Within 4 Hours* s.wr:m„w4znx *Ihnou s critical item in the federal 1999 Foal Code a 105 CMR 590.000. w CITY OF SALEM BOARD OF HEALTH, — Date: 5 —( - 1 I Page: 3 of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, No. Reference R—Red ItemI verified PLEASE PRINT CLEARLY -- �7 r1 NO - J�-a.e I�(>!.(� x/11 ��l)119,1 4011.e . , A- IVN i D„ 1-�- F </ r,.._�r � ' 9✓A,{/._]l Y 47) I }E,�/,T r �. a�e- rl./ ,4 %n..�1✓ i �icn . . � _IA � ) � I rJ(i➢e n O-l` L�i Zvi c2 !/r� �.�� 6�Y� �� � (fir'� A0_0 InOo/) V ) 14A' JA.11 �'�f�, v b_ Q_ Cir Al . a f i1 til !7. UIA01 f �O //�� 0 . 1K, r 11f'04 I v /1 U)/V�' (\ !lull e �v I\/T) �- k '4 _ l Discussion With Person in Charge: I Corrective Action Required: I ❑ No I aYVes I have read this report, have had the opportunity to ask questions and agree to correct all 6-/Voluntary Compliance ❑ Employee Resiriction/ P PP Y 4 9 Exclusion violations before the next inspection, to observe all conditions as described, and to _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 -f die dol r7or t;"'e sion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. V� ' ❑ Voluntary Disposal ❑ Other: r 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions ano Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'F145'F Within 4 Hairs. PROTECTION FROM CHEMICALS ] 3-501.15 Cooling Methods for PHFs ] ] 14 ( Food or Color Additives ] 119 P'HF Not and Cold Holding 3-501-16(B) ] 3-202.12 Additives* ] Cold PIFs Maintained at or below 590.004{F) 410145°F* 3-302.14 Protection from Unapproved Additives" S ] 3.501.16(.0) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°P. 7-101.11 identifying Information-Original Contaimer* 3-501.16(A) Roasts Held at or above 130'F." J ] 20 Time as a Public Health Control ] 7-102.11 Common Name-Working Containers* ] 3-501.14 Time as,a Public Health Control* l ] 7-201.11 Separation-Storage* ( 590,004(H) Variance Requirement 7-202.11 Restriction-Presence and Use* ] 7-202.12 Conditions of Use+ ] 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ] 7-204.11 Sanitizers,Criteria-Chemicals'* � 21 � 3-801.1](.A) Unpastetanzed Pre-packaged Juices and t 7-204.12 Chemicals fire Produce,Washing Produ ,Criteria" I Beverages with Fvanting labels" 7-204.14 Drying Agents.Criteria" I ] 7-205.21 Incidental Food Contact.Lubricants* ] 3-801,11(B) Use of Pasteurized Eggs* ] ] 3-803.11{D} Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides.Criteria* Raw Seed 7-206.12 [rodent Bait Stations* ] 7-206.13 Tracking Powder, Pest Control and ( ] 3-801.11(C) Unopened Food ood Sprains Not Served.Package Not Re-served. " I Monitoring* CONSUMER ADVISORY TIMEtPEMPERATURE CONTROLS 22 3-603.I1 Consumer:advisory Posted for Consumption of i 16 Proper Cooking Temperatures far Animal Foods That are Raw,undercooked or f PHPo Not Otherwise Processed to Eliminate 3401.11A(L)(2) Eggs- 155`F 15 See. Pathogens.* Eggs-Immediate Service 145`Fi5see. 3302.13 Pasteurized Eggs Substitute for Raw Sheil 3401.11(A)(2) Comminuted Fish.Meats&Game 1 Eggs* Animals-155°P 15 sec- ] SPECIAL REQUIREMENTS 3401.11(B)(1)(2) Pork and Bed Roast- 130'F 121 rain* j 3-401.11(A)(2) Ratite Injected Meats-153`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and 3-401.1 I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Mteat, debited udder the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(00) 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. 3301.11(A)(1)(b) All Other PHFs- 145'F 15 sec.* ] ! 17 Reheating for Not Holding ] VIOLA77ONS R LATER TO GOOD RETAIL PRACTICES 3-403AI(,A)&(D) PHFs 165°F 15 see.* I (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 facrors listed above, can be 3403.11(C) Commercially Processed RTE Foal- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 1 3-403.11(E) Remaining Unsliced Portions of Beef item Goad Retail Practices 1 FC 530.000 Roasts* 1 23. i Management and Personnel I FC-2 .003 ! 118 Proper Cooling of PRFs 1 24. ! Food and Food Protection I FC-3 .004 I 25. ( Equipment and Utensils I FC-4 '005 3-501.14(A) Cooling Cooked PHFs from 140`F to ! 2g, Water.Piumbinq and Waste FC-5 .ow 70'1`Within 2 Hours and From 70°F 27. 1 Physical Facility FC-6 .007 to 410FJ450F Within 4 Hours. * 1 28. ' Pasonous or Toxic Materials ! FC=7 .008 i 3-501.14(B) Cooling PHFs Made From Ambient 129. Special Requirements .009 ; Temperature Ingredients to 41`F45°F ! i Other ! 1 Within 4 Hours"' 'Denotes aitical rwm in the federal 1999 F+ 'J Cade or 105 CMR X90.000, . s �' `+. '. P-M �. -.ra'°.rir.... ,.-�Ytt...^l„QrvF.M'rl++.r?vwn9+rr i„..i ,w-r, -" "�.++ .. ...eµs �T4a. P�4ue•i'""1,:�r¢lr .P'ny�.N• ~"^-- ...,q Massachusetts Department of Public Health Salem Board Health DiJiSal 9 Salof Food and Drugs 120 Washington S Street,4'h Floor em, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name1� n 11 ''^. � � ` n Dae ! 3ype of ODeration(sTyee of Inspection C Y1�A�i N 11 t fA W1M P r iT(��1. ( -tet'., f❑, Food Service r,91 Routine Address Risk 9 ❑ Retail 0 Re-inspection N, \ P AI JAn Vn" -ups Level ❑ Residential Kitchen Previous Inspection E]Tele hone Mobile Date: P HACCP Y/N El Temporary E] Pre-operationOwner a {7�� ❑ Caterer E] Suspect Illness Person in Charge(PIC) `` // (� / ,,,>> Time. ❑ Bed&Breakfast ❑General Complaint t _V� 4AAA�J�Y/f ��e� C P In: ) �U� ❑ HACCP I inspector \0 eMV] (2 C � I Out:l�,�'h on Permit No. ❑Other Each violation checked requires an`e Ianation on the narrative pages) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking / Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E)•❑ 590.009(F)0 action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT Y ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El'. _-•. , ..-• 13. Handwash Facilities EMPLOYEE HEALTH - ... � "PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC 1-114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded „ ❑ 15.Toxic Chemicals -FOOD FROM APPROVED SOURCE . . El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures + ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION --•` '" " ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing Advisories'01 - ElCONSUMER ADVISORY 11. Good Hygienic Practices 2. Posting of Consumer s Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR r`F 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 500.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FFC-3)(C-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007)' have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other ' l) DATE OF RE-INSPECTION: 7t� (�/}; sssainspecrFomis-ra eon � V l(/t(l. (/,,L'1,'� eVi - 1 ' W���,)eAA✓t� `�.._u Inspector's Signature: IQ Print: c ^ I +J P-�ne ,h _ I 1 PIC's Signature: Page of agesPrint: G Violations Related to Foodborne Illness ` Interventions and Risk Factors(Hems 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT ( 8 Cross-contamination I 590.003(A) Assignment of Responsibility* ( 3-30'2'.11(A)0) Raw Animal Foots Separated from 590.003(B) Demonstration of Knowledge* ( Cooked and RTE Foods* 2-103.1 t Person in charge--duties ( Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH OtherT 2 590.00C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1 t(A) Food Protection- - ---- applicants* 13-302.15 Washing Fruits and Vegetables _ f 590,003(F) Responsibility-Of A Fool Emp!oyee Or An ( 3-304.11 Food Contact with Equipment and Applicam'I'o Report To The Person In Utensils* Charge* ( I Contamination from the Consumor 1590.003(6) ( Reporting by Person in Charge* I ( 3-306.14(A)(B) I Returned Food and Rescrcice of Food* ( 3 1590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions I ( I Food 3-701.11 Di.earding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources I 19 Food Contact Surfaces 590A04(A-B) Compliance with Ft ,d Law* 4.501 111 Manual Warewashing- Hot Water 3-201.12 Foodin a HermeticallyilProducts*Scaled Container" Sanitization Temperatures" 3-201,13 FimuMilkandMilk ( 4 501 ,12 Mechanical Warewashinr Hot Water 1 I 3-202.13 Shell Eggs* I Sanitization Temperatures* - ' 401-'14 Chemical Sanitization-tem H, 13-_.,02.14 Eggs and Milk Products.Pasteurized* I 4-_ { p" P l 13-202.16 I Iee Made From Potable Drinking Water- I concentration and hardness. 'G 5-101.11 I Drinking Water from an Approved Sys tem^ 14-60i.1 I(A) Equipment Food Contact Surfaces and 590.006(A) I Bottled Drinking Water* ! Utensils Clean- 4-6(j2.1 t Cleaning Frequency of E ui ment Food- 590.006(13) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and Utensils* SheiBish and Fish From an Approved Source I 4-702.1 i Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan I Food Contact Surfaces of Equipment* Shellfish* I 1-703 11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed I I Chemical* Sources* - -10 ProperAdequate Handwash.i ...9 ...............� Game and Wild Mushrooms Approved by ( I ( , n Regulatory Authority I 2-301.11 Clean Condition-Hands and Arms" f 3-202.18 I Shc(lsto:k Identification Present* 1 12-301.12 ( Cleaning Procedure* 590.004(C) Wild Mushrooms"` ( 2-301.14 1 When to Wash* 13-201.17 Game Animals* I I it Good Hygienic Practices 15 I Receiving/Condition 12401.11 I Eating,Drinking or Using Tobacco* _ 3-202.11 PH Fs Received at Proper Temperatures* 12 401,12 I Discharges From the Eyes.Nose and 3-202.15 Package Integritv'* ( Mouth* 3-101.11 Food Safe and Unadulterated* I 3-30;.12 I Preventing Contamination When Tasting* 16 Tags/Records:Sheiistock I 12 Prevention of Contamination from Hands 3-202.1$ Shellstock Identification* 590A)04(E) I Preventing Contamination from 3-203.12 Shellstock Identification Maintained'' I ( Employees* 113 ( Handwash Facilities Tarasite estr Fish Products I ( Conveniently I-orated and Accessible 13-102.11 Parasite Destruction' ( 3-402.12 Records.Creation and Retention" ( 15-203.11 I Numbers and Capacities* 590.0040) ( Labeling of Ingredients' ( 15-204.11 I Location and Placement* 7 Conformance with Approved Procedures 5-205,11 I Accessibility.Operation and Maintenance /HACCP Plans ( I Supplied with Soap and Hand DryingI 3-502.11 I Specialized Processing Metiu+ds* I Devices J 1 6-301.1 t Himdwashing Cleanser,Availability 3-502.12 Reduced oxygen pucka�ng;criteria' ( _-- 15-103.12 Conformance with Approved Proedares* I 16-301.12 Hand Drying Provision ' I Denotes critical nem in the federal 1099 Food Code or 105 CMR 590.006. r 1i tt CITY OF SALEM BOARD OF HEALTH 4 Establishment Name: SSP An 14 eo R.roA �e Date: C � —�-1j1 Page: .� of - - — Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item � verified PLEASE PRINT CLEA+RLYr I 1 �YVYt (M/,_ I I / . aIdl�ci �Ilo��K �IbtJ)rAr.t,,K,�_r hP1sn,1 v1 pn- Ln tw/l d r} I �1'�1 �_ Sn„�1:��',,� �C,Ut_.�-k��do ����_,�. /y -Jh�,✓�,: ���� g1�a+�° I�' O� VCPAi .�, ��M� f1ll O LIh/feuPM u A,( n AA44 Ski, rt n Y I (l L�d VAI L?,\ n,, .,rn (All 110 0 ,4 \ r ' ,cJn (I r;VI14 o it Q1 1 (n()� I! 1".chi 1 SCGI v �_�,A)Y C�A� �_ O„Ann J I C4 I tl[,1 1F)r ori ),can(— � Q)n lJ ✓ �t • nn Dn)n I v YL 1N(1J17 �y�) Yrf1f A/AV \_e( �V r r� \! n,b, 1 !V� (_/AVN � r .r6 n..'�' I/1n„ 1\/J A /V -, �9_n/-,>� !_9 4- U0,I fA ,^,, n vyPA \A 0 / ` ` y� \ Discussion With Person in Ora`rge:- - Corrective Action Required: I ❑ No I (3 Yes ❑ Voluntary Compliance ❑ Employee Restriction/ l.have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twe y-five dQ)Iars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. / X (j ❑ Voluntary Disposal ❑ Other: 3-711)1.14((') PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk ( Aaxlydi ng to Fau Cooled to Factors(Ite1»s l-22) (Cont) j 41 145°F Within 4 Hows. * PROTECTION FROM CHEMICALS 3-5OL15 Ctnling Method for PIFs ' 14 Food or Color Additives ( 19 PHF Hot and Cold Holding ) 3-501.16(B) Cnld PHFs Mwntained at or below 3-202.12 Addiutes* 590(l(i�(F) -11`/45°};` 15 Poisonous or Toxic Substances 3-302.14 I Protection (tont Unappro"ed Additives, j i 3-51" NA) Hnt PF}Fs Mainfaiued at or above + I(il.li id<anlfymg Iniin'mauon -Original � 14U'P. ` . 1 j 2.51)1.16(A) Roosts Hr!d at of above 130°F, I t oni.uu"r,` w 'll { Time as a Public Health Control j 7 102 l i_ ' C„rn •n ::'1 S:m +tiapmm.ti.ion- Sana}_e` —--”�{ i_=, ;{- 1'''_-- _j (itn•ss a!'ubtic l te,ilth Conh'al" 7-202,11 1-3tent;ic6on -Pirsene.nnJ F.,,•' _ -------- 7-202.12 .-_r-:7-'02.12 Cendnion,of 1'tc" 1 7-.',03 11 Toxic Containcl''-Pro!nhi::un,,. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE T"'A,I I Sann1�et..CYuetin -C'hrnriaJs' — POPULATIONS(NSP) „ � , 3d� �-Sttt.I it,1) Gnpacicurr/rd F'm-pnciat.,cd Jtncg::mid 7 -,k1.i.. ('h:•nnrait t<<i t'--hn:It t`„dnr,C rites rt _^ 7-10-4 44 Or}lii„Arents.Cnm:ia` — -- E3eleiares milli 1+'arnink labols° - �-- -------------- • St,; I ltl;) { L:::o: Pa.tr+nizcd Est,' I _205 11 __ hE.id••mr.! F-:uxl r'.•rVaa, l.nhuranfr _ r ------ — ' !,(;! Ilii)} ' K.:c. or l'aivaEL Clutl.rd 9oimstl Ftx,d and 1 _106.11 t.r dnr+ed t'ce Pr,nudee (•nteua' 7-20h.l2-- ie r: B:^.R.x „ -.-�-. la.1 v:\c:•d r ,uuet, tat Sc.ar•i. � (3dr i':'.:<_outr,d and j ! arnilr:ia9 ---- -''--_-- CON5UEdER ADVISORY TIME/TEMPERATURE CONTROLS 2,' i 3'i 7 ; ! ,:,;.t,.1:,•, ,1x=. :,.:1 Pov(d 1,1r<(reolli bon:,t i _, j ! :1:d+n'i !.e>•i, alar :irt• 4.,ti. (adc•.v<x,l.eii r. y6 ( Praptr Cooking Temperatures tot PHFs j •„t r)•ii,' F'n+'tv rd i:!nalnarr. Al 1+i.: F : =,:d- }ii• nui:cdlatr =:cr•.ru' 1-;.5'P1?:.e Vi or; F',zg. 4uhst•into Fr R w Sheri 'Ac.r,F. i i--i11.1!(I4ti}•';r f'vt a_+d !_::_-R.,. , ?'3' 1; 5:in' -- - - -4F-- tkC i3E: J.__r'..-.i'--.'_ _-'_ __"__'__'-'_' U1. 1('4a ~4:oft , 7:qr ' !w its i< ., 4fdG1} (iij;ft ! I :itwriilf .idyl',' 1.k x!. iclopUrai_ and I 1 t+.!.1 i(At t'+ P"ttit., R 116 r#xnu;. 4n:{t a'ic t'ntlCs s:r,,FisF.. !a1: .:. ' ,;r?:nl u:?ilci ?.'t=: .a4 'euios1 . , .. :'t:.. :.'ti ,..,. 'e: ,...'tit;:.'.• ..... tL'.. .. ...... .. ... :i,.. -,.,. .ii`t.,., ' i .•.•n4 7 RFA Fi C . : 42chctat:ng 4o: Hvl t, • is `... `';1ni' '7<LAl TC1i. i.� 'r'RL! -lc:'.1 Utt; I t.t 1,r,.t.a+`t l+-S P;. 4Lmr. b'ea,lt a;, t:"'.'ir . . '•r.. . : f'uf«.: "r,+<,rif..,,,. ,:f:rrh. :::,=:a: •+'fea'::,. . I I;i1-C' .,- ,'ir. rt'' ;fF:, rrt.JV, ,,,1f` : 1, 10,i.va inti,!:jCr,11 +rft't iY .�3.ii+r•} i ( :n+n i t i,I'i 11•4 I'!'c„.riJ.l i:l F•- ti- ,,:r:,. ' . :/), "i+.Ri' �Y,':P.' : rJ✓fi{.Llf v14a)'ijffiiii __e ._ _. _ _ __.-.-_ _- _ R,Ioi; > 2 ftam _ ;ars Fter<'.ft Pracsices _ FC ✓9().pOt) :-91f? 3iih � ❑otic, lr,�horrl l.�•a:�.ni l.ct•1 - -- ----- -�------ - ---- - ---'--- -- ---- - + ^: :la'ta t'm:,;.f ttaC Persnr,n,;=i ._ _ _ ._ _ - _. E8 I Proper Cooling of PHFS 1 '_G•; PC'Xl::nn PaXI P:a,::tion _. Ff. -`i _OC.a _1 i 211 _C�i➢y_^.+int aeitl UtPPSfis f !_i(t1} ( C'r><dut2 Cfe,!,,d PF{1=5 hnm 1 :(Ft ti• i ( •iC FC-i__ .' ;u } 1#'111tH .:' !fawr'.„rd From ru't frcd;! c(,_ (167 ----- 7 .04; -t .,r T^aC 0.sfgfrfa Fi:�-l;' 8Ci8 f ^J(71.id(fii Coniir PI IF,'vin,Jt From Arnbi,mt _ - ,_`-i)"�-+IR:a:drorng, 1 3i; r)lpt,r . 1 Tcmla'rdulrc [11:41-CC li,a;i,I, vt'F/...<. !- .- -- -- ' ¢Lvit'�.unc.ii f:ML in i',• „U.ur r.'I,,qi. ,�. .. :,:', ',,..�';(.,a:P 4 CITY OF SALEM BOARD OF HEALTH Establishment Namd:4J- L ,_7_/1 ,A A Date: i 4 -r-) Page: Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item : .VerMled (/ 'rm• �() � fin/ J��^ PLEASE PRINT CLEARLY `: titI �t - ACOS Ct4 '(a iV i N _`YU\0/-")/1 iIIDC�>t_nn cnn .� Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes 0 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 f comply with all mandates of the Mass/Federal Food Code. I understand that ! noncompliance may result in daily fines of twenty-five dollar, o suspension/revocation of ❑ Embargo Ll Emergency Closure your food permit. I / ❑ Voluntary Disposal ❑ Other: r . E 3-5111 W(C) PHFs Received at Temperatures i Violations Related to Foodborne Illness Interventions and RiskI I Aamrding to Law Cooled to Factors(IteYtts 1-22) (Cont.) 41"F/45`F Within 4 Hours. ' PROTECTION FROM CHEMICALS 1 3-51)1.15 Ct*linn Methods for PHFs ) 14 Food or Color Additives 19 PHF Hot and Cold Holding � t 501.16(B) Cold PHFs Maintained at or below 3-262.12 AdditiNes" 590 i)(WI-) 41`/45°F- 3-302.14 Protection front tlnappro%ed Adddtvey' 16i.%) I Int PHPc Alaintained at or above IS Poisonous or Toxic Substances i 140,1., ; I 1(}1.11 Identifying Information -Ouginai ! f '3-5€t} it o) Rt'ai,ts Held at or above 13091, t nnl.uuen L'_fi Time as a Public Health Control ! 7 102.11 C,»nroon`ami - N'nrki*{e� owam r," yri -- T' i,'jr,a Public Ilralth Conivut' _ - '-?.ot.II Jr?a xuan-SdnaJ:c` F-G--- ------- i-,.-. I V;7tarcc Rednir•.'ntc•i?l '7?02.11 I:c>[tiau»t -i'r:•uncc and i,>c^ � }_:.___.._-._—._- - 7-02.12 Gwd}tion,of Uu" j 7-263.t l Toxic Coniamet: -Proh;bi::on," REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-264.11 Samucerc,Criteria -Chc_m_ic;',c' POPULATIONS(HSP) 7-204.1'_' Ch<mical.for VLt' h"' f:ndncc,(:rites' ;- Till !it,3) i i:n1;::,trurtxcd Pre-patJul �tti 7 204.14 Or,inh Arrenta.C rilcriu' _--'------� ' r i'eizvazes with Warmnk 1,abeW` - 1 7 '05.}i Intidimial I-;oyl('umait Luhrrants- . : SU! I liR) L.e of Pa>trmized i.:¢tti' I i(i.)) ' i<,:w or P.unal1% CookM Animal Ftx,d and 7-206_1 t Rr.uu.l ed 'S' P_e,ri:,den.Cntet se" Ilam St:d?prout,\,it N' d. � '-sOG.I� ! Rtxien: I:.r: :Ysuort,' , NC: I or,i t l ;. t�_acd F,xv1 Pb:::aFr N't _05 13 ir.:Ckiiig P,IiN&'r'+ 11:'I:(:ontrol and 7 - - t,h+non„im'� -- — - — CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS t.an, ncr:?m:x;r ?oars,; ,r Mat dre Ra,.. UndC1"XX)kCd r. r 16 t Proper Cooking Temperatures for i ( i PHFs E ::nt O;4r,a i.e Psu::csx.d a,litit;t,nau: . 1.,,, - s t .___ .. .- `- cit. tC11 )]-%111(1 L.? !`5.;, ...._ l:n Raw Shill -- - ! �6l.i,iHr(!;,a, ! ,r; .rd f, i iter;::t ._'0 I' I:'i atir;� _ SSPECIAL ----- � EttfiEPdTS k �'';. :t: D; St-Iw9I .`>JI I,tN}4f:'tt-{t.)1 :: -01 V}IIA,; a R3•ita., f,lrt'.:d `<tt ch I i4 r i° I ::;ak,ry w. ti R,!HI: toot}, Letup Vint valid ! ':ItCriCn OICC�?i0i5 �itvp€( hi ate, j u. eti 1'11F,,� �t::'::,,r•L',nlnm,ni.}ash Pte.:: ! t:"?tire ,.. d:t L:c ap,'to?zr:.ttc; +er:lt,uv _ -'t( Floor"ling tot clot riolc',n9 i'rC•LA _. iCrRETAIL 1-4-03.1 1,A).c:itr Pill , ,r•5'-1: ; .c' ; .W3.11(h) `,hu,a*atz Ira' i 2191mer St md!n:: C,;;r.•; .,:.i,,.,:, :r vn:-i: .,t,. .0:n ft d. 'IW .,.:u;c: i;�t'•” .__ ;o.,t'}g rPf ';!%n}. ,•Pan,vL,yL, ,,^,::"C�:JU<I,vo(n%,'ct a.',,,. „qt" 3:403.I Ii C7 -� t „n:'na tsaRti th tn,...'d "'H'1••.+1 ii,;r,(i'r n.e , ..,. i tt, )=' :''ti-Ori:. 1140' :I& Rc!":untnz Lt;iwcd F'.•:=,tt„?.I)i bm: 7terrr -i;cra:'Ferad Prariice. Ft' S9G f,G,i a:...Pec.,n:.,,i_ PC . ' "nt?: . - i PCnIX',r_d F,xxt P:D:c tiG_ - FL { y 011 (g Proper Cooling of PHFs ---,-- ! ; 501 I VA) t C'o thane co,kid Pill-'s i not I ttt'F to tnpnit-nt and ti",,rs -----� -• F-^-4 - -.C - - - -. FC-5 7.;-F\b'nhrn 2ltow::,=.al Fn an"Ti' pny.p;:v:Pac,iitg FC-r'- i>r' - ;'.t5 Pl4ithmxN,vi . I 2b ?:*.;r. Ylx,^ `nom::r,l;:.-.,.,, -^ ?-FC- _ '"*C.f 501,HMI C','oi u:,fIIF. Wrie Front Aut!-tent .. ".- Si`vc+i �-- Tem€oi attire lrgrediem<,t,41'1./a51' t-----'----�-\blv:rn.11ltnn.� S -ter EXAM FORM NO. 4344 Student Name ---_-- -- Class Number C E R T I P I C A T E NO. 5791200 Exam DateExpiration Date Type of Training _r Hours of Trainin p Instructor Name Sponsor Name Exam Location Exam Form Nan c Overall Point S _ Overall%Soon - Passing%Saw ServSafe®R Certification Status Domain Idamai Foods CieaNSanifizelN KENNETH G OKEEFE Personnel for successfully completing the standards set forth by the National Restaurant Asaociavon Educational Foundation Temp.Maasudn for the ServSafem Food Protection Manager Certification Examination,which is accredited by the American National Allergens High-Risk Pop-Ula _ Standards Institute SANSI!-Conference for Food Protectior (CFP). Legal/Regulatory Facility Layout/D Training Employ( 3/11/2008 Toe a Web ha 1gcaavww,5 _n DATE OF EXAMINATION , wncnai tlenauma >. 3/11/2013 te( e _ nr /1 .r!1/2 V!/'��1 3 E4tILATi9NAL K0{{ 3 Qj I ®bt06 Nitlanat Revuvn Y I � I dradrat CID • • DATE OF EXI ATIDFI sir N �r16 ( Local lows apply.Check with)ro�r',^.cdregulatory aagngy for recerti!'saVon ra4ulremrnts C USe1e L $� 4 5 fl NATIONAL ServSafi f / - "' - RESTAURANT TO o N ionai ttesiaurant Assoclatton_ M.,yM Adolf ASSOCIATION b.war,wN�,l�:y iaa„a Rsgan sldent&COO,Produrs d Sorv!ces D;vuon rtl,aemr..xso.saaArar. cc EDUCATIONAL FOUN[?ATiON o + Natiunal Restaurant nssocianon solutions S o t L' T i p N S "I nate at 31 r"_ 9zW8 Naeunvl Reaiemvul Asene!grwn;dumVorar rm'cdat "'e'eiii'm sErvSora`and the Sr,Sare iogo am ragisteed vadnmar)s at lie Navooal Rcstuurem Assoda iun Fduoavonal Fnundallan, ngta o{Exgspnv ` and vsec under license M1y Naeanai Restnurant Assochrmn solutions LLC,awhu!Ivarvned sunPdiary of NO Naowu!Reseaurait AsscaiaCaa. ori: n '� un¢nnonnt rounn.+ tp cumoT cannm be repmdurnd nr aVared. 0601 _ Q OJg6W0i vpfia3 tv i 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: 744-4080 Owner. , HSC Service Corporation !PIC: , Steven Nelson Inspector: Elizabeth Salandrea Date Inspected:Correct By: 4/30/2009 Risk Level: Permit Number: BHP-2009-0066 Status: SIGNED OFF ,#of Critical Violations: t0 :Time IN: Time OUT: Urgency Description(s): BLUE: All violations noted in the 4/23/09 inspection report have been corrected. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 04,2009 ) Page 1 oft Noe i Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors(Require immediate corrective action) I City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 04,2449 ) Page 2 of'2 s f 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT- FOOD SERVICE Inspection HACCP: Item Status Violation Critical Urgency r Telepttone: PROTECTION FROM CONTAMINATION 7"-4080', Separation/Segregation/Pr ction / FAIL ,,//Critical I] RED Owner: keomment:Vict fridge,True fridge,both deli units in middle prep area,and TrauiSen fridge had potentially hazardous foods H&C Service Corporation stored abovelnext to ready to eat foods.Organize fridges to properly separate PHFs from RTE items. &PIC: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical 9j RED ISteven Nelson YCntomment:Sanitizer in bucket of utensils at cookline found too weak.Provide sanitizer of proper concentration(200ppm)In ;Inspector: j� . buckets at all times. I Elizabeth Salandrea I b'FIo bottles or buckets of sanitizer were available at cookiine.Sanitizer of proper concentration must be available at all workstations Date Inspected,ICorrect By: at all times. ? I TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) t 4/23/2009 Hot and Cold Hotdip IRisk Level: g FAIL Critical `JI RED 1( "O"'mment Sanyo fridge at bar In the Tavern at 48°F.Turn down to maintain temperature of 41°F or below. Permit Number: BHP-2009-0066 Status: VIOLATION 4 of Critical Violations: 1 14, jime IN: I Time OUT: Urgency Description(s): BLUE:: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 d bays)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GegTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 30.2009 } Page 1 of ! Item Status Violation Critical Urgency RED: _ f Violations Related to Good Retail Practices (Blue Items) Violations Related to t Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions V-Kmment: Both deli units at cookline had uncovered food in drawers.Cover all food in storage to prevent cross contamination. and Risk Factors (Require immediate corrective action) �4ccoop at ice machine upstairs broken.Provide new scoop for ice machine. Aingredient bags left open and had plastic container used as a scoop.Provide proper scoops with handle for dry ingredients and do not leave uncovered. Valk-in freezer upstairs had food stored on racks covered with frost.Do not allow food in storage to accumulate frost; move food to area where frost will not build up. Equipment and Utensils FAIL Non-Critical BLUE #,ileomment: Hood filters above charcoal grill have accumulation of grease.Thoroughly clean&de-grease filters.PIC states it is being done tonight(4/23/09). We storage rack above stove has accumulation of grease on it.Clean&de-grease rack. L, eating element above shelving in middle of prep area has accumulation of grease.Clean&de-grease heating element. VXce cream freezer needs general cleaning. volven above breakfast griddle has accumulation of grease.Clean and de-grease oven. rowers next to fryolator need cleaning. ,,/Iodgett oven in back prep area needs general cleaning. C/teamer needs general cleaning. Volator in back prep area needs cleaning&de-greasing. `hook and hold top compartment needs general cleaning. �iv�ir conditioning return vent has grime build up.Thoroughly clean vent. stairs walk-in freezer has significant frost accumulation on racks,floor and ceiling.Clean&de-frost freezer and repair to stay frost free. LAagic chef condiment fridge in Tavern had broken thermometer.Provide new visible,accurate thermometer for this fridge. Physical Facility FAIL Non-Critical BLUE 110"domment:Two lights in back prep area have broken covers.Repair light covers. r Exit door from ballroom to outdoors has a gap at the bottom.Seal gap to aid in prevention of entrance of pests. 7q Meas Reinspection in one week, all violations to be corrected. • . City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 30,2009 ) Page 2 of Item Status Violation Critical Urgency '. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 _ GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 30,2009 ) Page 3 of Commonwealth of Massachusetts sr City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Hotel - Motel Permit DATE PRINTED: 12/28/2011 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Hotel/Motel BHP-2012-0141 Jan 1,2011 Dec 31,2011 $200.00 Operations Permit Total Fees: $200.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health Page 1 CITY OF SALEM, N ASSACHUSETTS B0 ARD of HE,u,'n j 120 WASHINGIY)N STREF'r 4n.1' ,00li 77�i...(978)741-18W KIM13F.RI-EY DRISCOL L FkX (978)745-0343 MAYOR lramdinnsalent.com L UZRY R\MDIN,RS/Rlil IS,CI I(I,(:14S I TVAJ;n-1 AGISN'1' Application to Operate a Motel / Motel $200.00 Name of Establishment:,- RaW-4I nr-YAP- 0-Te - t Address of Establishment: --W nS`11 Yl()►�T� - .(fit' P �nl Q_S Mailing Address(if differentY. J Tel#: �9 9� - rIL4L4 - L4oAn Business Email ��jpCY1QCiV,1. tv( Website: WW1l�! �1(1\.Z�tlQ � .CU(t(l Owner's Name: "A rA-A (1-6 r) -Cel#� —g as g-t L-�_ Address:`]_�1 1ti1_�jl1Q- 1�_ PDQ �.i M/ Q-i-iq 15 City i State Zip Emergency Response Person(s): �t1� 1 ` PdP(-v 0 t B �, Tc1#:�g '�y () -0- t! t-I O How many rooms are reserved for guests? o q Is food served in the Establishment? e,c; Are animals allowed on the premises (other than service animals)? YP� *Please make check payable to the City of Salem. (Pay by check or money order only) This Permit is not transferable and must be reissued upon change of ownership, The Permit must be posted in a prominent location in the establishment. Pursuant to MGL Chapter 62C Section 49A,I certify undo,the pains and penalties of perjury that 1,to my best knowledge and belie£have filed all state tax returns and paid all state taxes required under the law. �0 1212tI I I I aq - Qgrl�� Gq Si tature 4 II Date - Social Security or Federal Identification Namba' 5 3/11 hotel-motel appl.doc Chec;ktk&Dates fir. $� Commonwealth of Massachusetts ° City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Hotel - Motel Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Hotel/Motel BHP-2011-0172 Jan 1,2011 Dec 31,2011 $200.00 Operations Permit Total Fees: $200.00 PERMIT EXPIRES December 31, 2011 Board of Health 1 Page 1 r ,10 r CITY OF SALEM, MASSACHUSETTS • • BOARD OF HEALTH 120 WASHINGTON STREET,4.°FLOOR TEL. (978) 741-1800 IUNIBERLEY DRISCOLL Fax(978) 745-0343 MAYOR UGRF BNIIiW M0,SAl,HM.0061 DAVID G'REENII ACTING HEALTH AGENT 2010 Awlication to Overate a Hotel / Mq el $200.00 Name of Establishment: 9AU I t4xx . 4m-1%L, Address of Establishment: Mailing Address (if different): p� Tel#: � Fax#: �W�IW/� - 25_ Business Email: rYj Owner's Name: .�� \f Tel# Address: "\ If1 W ANF_ � I"lA - �Cti�ty�- �1(' ' State p'7c Zip / Emergency Response Person(s):!-, t t r L 1�@'.IC�f FFNA� TelyI I O -dS How many rooms are reserved for guests? . Is food served in the Establishment? � Are animals allowed on the premises (other than service animals)? 014,1 *Please make check payable to the City of Salem. (Pay by check or money order only) � � This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in promin los tion in the establishment. Pursuant to MGL Chapter 62C section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required and the law. ignature / Dat Social Security or Federal Identification Number -------------'---'----------------------------------------'----- -------- - - - ----- ---------- ---- ------------- ------------------------------- -----'-'-'-'------------------- 11/30/07 hotel-motel appl.doc Check#&Date $ Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0171 Jan 1, 2011 Dec 31,2011 $420.00 ESTABLISHMENT Total Fees: $420.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health Lao This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 C a CITY OF SALEM, MASSACHUSETTS ` BOARD OF HE.#LTH {�^ 120 WASHINGTON SrRFL.T,4...FLOOR TF,L. (978) 741-1800 KINIBERLEY DR1SCOLJ. F-1S(978)745-0343 TNN. YOR uc;RE,I;NBAU41 aSAI.l a1.COM D.WID GRE;FNBAU\f,RS ACTING HFALTH AGE,'\FI 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT t1'1QW 111709 kAP A TEL# ql-9 - 7 H L1 ' LI OR 0 ADDRESS OF ESTABLISHMENTn h 1 no Z(1 "�(1� FAX# MAILING ADDRESS(if different) i y EMAIL-Business':}(�Q.`p & Q1ni^�hn(T P_YIAQ{I . CIM Website: W VV hlltw iTl^,rt�(ZP (k�j� i�(1 ryx OWNER'S NAME b(1Y()-� k% { uAV- V-% rCl Lf7t`l TEL# ADDRESS 1 R�� V??� 2�1 Ave �� M A STREET 11 CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) Skye- we-lei n CERTIFICATE#(S) � I `� y � 1 (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON J U-11 L�(I�ir Vl4 l�rJ HOME TEL#_q]� rIq n C�_O DAYS,OF;OPERATION- : ,` �Mdndayi;...1,,,:l:Tuesday r; 1 "•Wednesday.-:-[,,:.Thursday `: L:: ",Fridayr:.,;i;, ( . —Saturday;_ -.Sunday - I HOURS OF OPERATION j Please write in time of day. ^ , t` V r t t r t o ' t t t t (For example IIam-11 pm) I TYPE OF ESTABLISHMENT FEE (check only► RETAIL STORE YESNO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 - - ... -- .-•-- --- - ----- ----------- .......... RESTAURANT YES NO less than 25 seats =$140 ;Outdoor Stationary Food Cart$21 25-99 seats =$28 more than 99 seats $420 _.... ... ... ................•----...-----..-.-.-------------------.....------ ----...-----..-----..........................---ii,6--••--- 3ED/BREAKFAST/ YES NO $100 :HIIOCARE SERV(CESINUR51NG HOME .... -------------- ---------- .......... ....-..... ........._-------------•............ 4DDITIONAL PERMITS OAKE (not just serve)ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ILL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location n the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for uch must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of er'u that 1,to my best knowledge and belief,have filed all state tax alums and paid all a taxes req ed u�r t law. %.< �v �v 04- A D 57 �I°t ignature Date Social Security or Federal Identification Number evised 1017/11 FOODAP201 I adm Check#&Date�� S I Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0096 Jan 4,2010 Dec 31,2010 $420.00 ESTABLISHMENT Total Fees: $420.00 PERMIT EXPIRES December 31,2010 94 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS + I + BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUM(0)SALEM.COLI DAVID GREENBAUAI, > ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT,TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Hn,w+horne t'10- Cl + TEL# 9l8 - lUy - y08 ADDRESS OF ESTABLISHMENT�VgaG n eS+ FAX# qqS - 'ILII MAILING ADDRESS(if different) EMAIL-Business'jdel1 h(S(IIF�O�Q�.( L)(Y1 Website: )NWW V/11A1fl::tnf(1P_hrAeA. row OWNER'S NAME l)nrn+A-i1 , Nn rr I In inn TEL# ADDRESS 9 gcgvieui .Ave- J ReuPrll� MA STRE$T t CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) STe V P_ N d` or) CERTIFICATE#(S) 2 ) I-•I I rf (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSONJILII �_P( IP.rI1r11J� HOME TEL# LIMB' rlyn — O5,4n ©AXSOF ORERAIQN { Mp Stay Tijestlayl Nldni sdayjThursd"ay 'x' Fiday"^ Satrdaj: ?. WSynday` ' I HOURS OF OPERATION I Please write in time of day. 6OLM ! l t t (For example 11 am-ttpm) i TYPE OF ESTABLISHMENT FEE (check only). RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ----------------------- ------------------------------------------------------less-------th--an-----2-5---s-ea--t----------------_$140-- -- ----- RESTAURANT s (Outdoor Stationary Food Cart$21YES NO 25-99 seats =$$Q more than 99 seats (T20 BED/BREAKFAST/ YES NO $100 H CHILDCARE SERVICESINURSING HOME NO----------------------------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 POSHO ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and aid all state axes eq fired under the law. , ,� -ay oy- aga5r7Gq Signature// Date�p, yam— Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008.adm Check#&Date v��I+D 1,],,�{�- $ `7-`�'�, --- Commonwealth of Massachusetts � f City of Salem Kimberley Driscoll Board of Health Mayor 120 Washington Street,4th Floor SALEM,MA 01970 Hotel - Motel Permit DATE PRINTED: 01/12/2010 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Hotel/Motel BHP-2010-0283 Jan 11,2010 Dec 31,2010 $200.00 Operations Permit Total Fees: $200.00 PERMIT EXPIRES (December 31,2010 4 Ali/ Board of Health /� /wD✓f� Page 1 h • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4n'FLOOR TEL. (978) 741-1800 KIINMERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUM(a)SALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 Annlication to Overate a Hotel / Motel �L $200.00 sr Name of Establishment: H Q W-�ht7 r n e. W n�-P_1 Address of Establishment: V; WnShln SQtian? W?S+, 1)oAe.rn MA . Mailing Address (if different): Tel#: q' s- 9qq— y09i0 1 Fax#: qq(p) - X141 Business Email Jdelr@h6W�Y���1 Website: NVV W- n%All� l?410- A rnrn Owner's Name: Dorn-4)V ull m y-)Pn Tel# Address: ' l Rnl Vie'-la) Ave- R)P_\/P_rly MA Jl City 1 1 )I State Zip Emergency Response Person(s): J u1 1 LeCI P.r YI O lA� , Tel#: q l s - r7q q -0-;y O How many rooms are reserved forSo ests? q3 Is food served in the Establishment? N(PS Are animals allowed on the premises (other than service animals)? Yes *Please make check payable to the City of Salem. (Pay by check or money order only) This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the establishment. Pursuant to MGL Chapter 62C Section 49A,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. 0y - Aa5r-16q Signature Date Social Security or Federal Identification Number -1/------ -------o------------------- ------------- I--------------------------$tea 11/30/07 hotel-motel appl.doc Check#&Date 1 00 1 l i I June 26, 2009 ~° dUI 32009 , y , * N Jennifer Keough Code Enforcement Inspector Board of Health 120 Washington Street 4`h Floor Salem, MA 01970 Dear Ms. Keough: I am writing to you to report certain issues occurring at the Hawthorne Hotel located on 18 Washington Square Salem, MA 01970. There's mice in the employee room which is located in the hotel's basement and there's also bed bugs in the rooms. Some guests at the hotel have even been intoxicated. Gold Coast Cafe in Beverly, owned by Robert Manni, does not comply with the sanitary guidelines as stipulated by the state. I hope that you take actions into your hands and have faith that these issues will be resolved. Thanks for your prompt attention to this letter. Thank you, h Anonymous Person i I I i .../" < �i i,,. ' � ti.. ! fI! Ft . 1 " . ., q, „ la ! S� ,ri"� ,. � . r.,'•i. a € i (. 'i rt, r:F3t,• '.f:il t:Iii. �"i''G '�(`.. I s -- t`�.:�'l.�d�',.1,� :���..�:z- -� ✓t . i ��.[a.t�..e�l.,.:�'' is '4. i ;�.a�.,-i. r +. -- t - j.x�`� f)?� . �� � � �Vt�:?/'+-,,2-.hit ..Ct<l ,nlv'iT'r:%j ,•;a ��,� _ i F. 93ioN �_--------- ( IrPORTANT MESSAGE ) FOR It --77 � A.M. DATE 2-�.../ 0'ITIME �P.M. M ( ./1 C OF PHONE AREA CODE NUMBER E ❑ FAX ❑ MOBII F AREA CODE NUMBER TIME TO CALL TELEPHONED y PLEASE CALL CAME-TO SEE YOU I WILL CALL AGAIN WANTS TO SEE YOU I RUSH RETURNEDYOUR US/ALL1 , } LWILL ,FAX �TO YOU ME 1.Q._ '1 I/ A i TSaLu+ gc--)rrLo. na is rl - 1 ` I . I r ci. C71sZV 1` noo— SIGNED �.,. C A FORM 400 �S . MADE IN U.SU 5 A Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,41h Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name // 1/ Date T�ye of Operation(sl Tyoe of Insoection u'T-fo1v€ STEL �� oodService f�I:Houtine Address Ris etail ❑ Re-inspection W G sl Lim Td h S /lLN2 Level ❑ Residential Kitchen Previous Inspection Telephone q -7 � 7 f{/� [�� D M ❑ Mobile Date: _L `/ HACCP Y/N El Temporary ElPre-operationOwner (1 Ef ^ �C�vtC� Cool-f I ❑ Caterer ❑ Suspect Illness Person in /Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint Inspector p no z l-0 In: 2W M Permf No OO$ ! El❑Other CP I .9 tk( out.3.3 0 ;o Each violation checked requires an explanation on the narrative pagets) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT'S 4- " „w, [112. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities "EMPLOYEE HEALTH"...-... _. - ...,. .,...: ..) PROTECTION FROM CHEMICALS ' ❑ 2. Reporting of Diseases by Food Employee and PIC - - ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals ,FOOD FROM APPROVED SOURCE'-'_-',' . .. . .....�_.. .- . =..r ; TIMEITEMPERATURE CONTROLS(Potentially Ha"Hous Foods)`""" ❑ 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 i PROTECTION FROM CONTAMINATION - " - ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing !REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY. , ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 5001nVp tFor 14 dw Inspector's Signature: Print: PIC'sSignature: �/�' �� = Print: N�®.rii✓/ l�6`�f'>7iw)Iii) Page�of ages rr . A Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT_ ( S ( Cross-contamination ( 1 596.003(A) Assignment of Responsibility* ( 3-302.11(A)(1) Raw Annual Foods Separated from 590.003(B) Demonstration of Knowledge* ( Cooked and RTE Foals* ( 2-103.11 Person in charge--duties ( Contamination from Raw Ingredients 3-30111(A)(2) Raw Animal Fouds Separated from Each EMPLOYEE HEALTH Other' 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment- -- require reporting by food employees and 3-302.11(A) Food Protection" applicants* 3302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Fvxt Employee Or An 13-304.1 1 Food Contact with Equipment and Applicant To Report To The Person to Utensils* Charge* ( Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 1 1 3-306.14(A)(B) Returned Food and Reservice of Forxl* ( 3 590.003(D) Exclusions and Restrictions* I Disposition of Adulterated or Contaminated 590.003(F.) Removal of Exclusions and Restrictions Food 3-701.1 1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Foal" 4 Food and Water From Regulated Sources ( 9 Food Contact Surfaces 590.004(.4-B) Compliance with Food law* ( 4-501.1 i 1 Manual Warewashing-HM Water ( 3-201.12 Food in a Hermeticall}Sealed Container* ( Sanitization Temperatures* ( 3301.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashinr I-lot Water ( 3-202.13 ( Shell Epps* ( Samdzation Temperatures' 3-202.14 Eggs and Milk Products.Pasteurized* 4-501,114 I Chemical Sanitim ion-temp.,pH, d d h and arness," 3-202.16 lee Made From Potable Drinking Water* i concentration -- __-) 5-101.11 Drinking Water from an Approved System' 14-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 3-502 590.006(B) Water Meets Standards m 310 CMR 220„ Contact 1 .71 Cleaned Frequency of Equipment Food- 590.006(B) Shellfish and Fish From an Approved Source ( Surfaces and Utensils' 4-702.71 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan I Food Contact Surfaces of Equipment* Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed 14-703.11 Methods of Sanitization-Hot Water and Chemical* Sources* ( to I Proper.Adequate Handwashing Game and Wild Mushrooms Approved by *d H i d C 11 Clean Condition- ans and Anns Regulatory Authority 2.301 I - - ( 3-202.18 ( Shellstock Identification Present* 2-301.12 Cleanine Procedure* ( 590.004(C) Wild Mushrooms* ( 2-301.14 When to Wash* ( 3-201.17 Game Animals* ( ( 1 t I Good Hygienic Practices ( 51 Receiving/Condition ( 2-401.11 Eating,Drinking or Using Tobacco* _ ( 3-202.11 ( PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes,Nose and 3-202.15 ( Package integrity- ( Mouth` 3-101.11 ( Food Safe and Unadaltcrated* ( 3-301.12 Preventing Contamination When Tasting* ( 6 TagstRecords:Shellstock ( ( 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification''` 590.004(E) Preventing Contamination from ( 3-203.12 Shellstock identification Maintained* Employees* TagslRecords:Fish Products ( ( 13 ( Handwash Facilities 3402.11 Parasite Destruction" ( ( Conveniently Located and Accessible 3-402.12Records.Creation and Retention"` ( 5-203.11 Numbers and Capacities* s' ( 5-204.11 location and Placement* 590.004(J) Labeling of ingredient 7 Conformance with Approved Procedures I ( 5-205.11 Accessibility,Operation and:Maintenance fHACCP Plans I Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods' Devices ( ( 6-301.11 Handwashing Cleanser,Availability 3-502.72 Reduced oxygen packaging,criteria* - - -- --_ ( 8-103.12 Conformance with Approved Procedures` ( 6-301.12 ( Hand Drying Provision *Denotes ci ideal rem in the fedend 1999 pond Code or 105 Olfk 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: (7A vt/Tl7FoYe �✓E [Ta7_6:L_ 6:L- Date: 1/ -/ SI-0R Page: Z of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY I (� C Q H a _s tie c e ssa r r'ace vara-�/a ter, 0b5,--ee,^eJ c lea, r�eKs,`/s /6 i.-I /C,i�cGta l .ti r°ylfa-, �� G, c G. . �t h_ d j I pq"/J G_�et 1��13u ��'a_ — !� o sir �� e e Y r"Li� 4-0�V`e�fal I 27,EZo215- /ve ecv�e/w�ul DrCS14- eoP&bo Se.,"L_%ce Gok , elfs a C/ ? Da-C,r ` 3 kti-0 �/- z S '' tic �_ -& 74 cgPo P _ I � Discussion With Person in Charge: Corrective Action Required: I o ' No Yes have read this report, have had the opportunity to ask questions and agree to correct all &1'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 gcDde, I understand that noncompliance may result in daily fines of tw - ive ars s sion/revocation of ❑ Embargo ❑ Emergency Closure your food permit_. ❑ Voluntary Disposal 0 Other: ! t PHF< Receiwd 'Perstix;r:iluren Violations Relayed to Foodborne lttmass Inlememians and Risk Arcrriin;t to Lai= C oolx ::d a, Factors(Itet st 1-221 (Coot.) I II'F/4Y'F W-itbin I H,ran s. * { Cooiul±lfethod for PHP, PROTECTION FROM CHEMICALS 19 f PHF Hot and Cold}folding I { 14 + Food or Color Additives ( 13 5;)1.16„(t) ('.�Id PHIs Mainlimoklat or b,elow i'2ls3.12 i Aticl(tir G>” { 540(}rt y-) 41,.144,.F- 3-102A4 -3-02A4 { Prntet:lionfro,nL'na#,p,-,,;eel ":ddiiivc•. I ( 3 50 1 INA) Ilot PHFs Rtniniaiated,=ttirah,ne 1,5 ' i Poisonous or Toxic Substari-es 1 i.10'K 4 i 101.11 ldeutitznlg tnlnnnivor. , titin ma ! {-ottt.,.Euen` ko,,815 Hold at or note 13ts T " { 1 )t} - Time as a Public Health Control ( 7-102,1€ Cot.sm„nN:mte - `4or6t+,gCtmruner,` f 1 3 +0i 19 Timm as a I'ubtic Iiealth Corral, 7-u() ,1! R-,vicn„n -Sttaaoc ' { `oU.11tAtrti} Variancekequirrnmit 7�2()».I# 1tc..i;'iG4on-Ysexnrcat:dt'.e" E --------- 7-.43.12 Condition,of U,r' 7-?43.11 Toxic ' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE '-2)1.Ei SanStICliv,Crt.,rit,—i'}emit;;W POPULATIONS(HSP) I7.2()4.1* ! C'l,cxtie,;ht:,r'Vssshu,F P1'aSurc.C'rimia' it ( 1-801111A4 l;npactem'tc:d Pre-pad,toxd kutes and {(-7-?0-#.I4 k Drz�nr At*etu..i:nt,:ria" ! { i lteketa,res with tgarning I,atsoi;i^ � I( , !_. .• u, ' : i 4-801 11(13) Pa ,.'d Eev,• ?-205.11 LxidentM F.Xxi(' ntct. 3-SOI !(f ) Ktw or ParliaEyu Fxd auf 1-206.(1 i Re„inc a t.u}e n des (:nt>E Io” 1 f f St.nt Seed Sprl,at�„Sta SerVe3. ' 1 7-:06.12 ! k(X!«,w 13,151 sl too,'" 1 ! ., t 3r 3gt i-'06 13 t lr,ickinr P•rtder<.1':,t C',jntr,:{and . :i C•! I lin„potter{ Food i'acl;age Not kr. .:rt•cr[ • E Mt ,nEtccin}' CONSUMER ADVISORY TIMEtPaMPERATURE CONTROLS22 3 r,0,.t I ( Cuncunwi .Allviwry Ptact„d for C ntsomption of i 16 Proper Cooking Tempasatures for i il,utt.tl rta J,'ilsm an kitu",!l:iYderax=ket3 0 PHFs ! Not Otimry Esc#roceased u,, iminwe I 310111 Af?;(.;t Fc,t:,.. ;53'F 155,C. Patho,tcns -_.`:` v..tts tagsInan,c•dtau 5rr.icc I Ii TI^:.ec ',302.1 i Psrcnnrod Eggs Sulh.ntuw lox kuw Sho�!! V ,401.11W(2) C•,mminwed fish, Mcws&, Gamic Ec"v ' Anunats- :5; P t SPECIAL REQUIREMENTS 1 :-t0#.i it13)t 1;531 Pitt!: ar•r, !3eet R,t:<.,t i 10'!' 121 ntin' 594(A)')(A)-(I)) Violations el Section 5?0,009iA}(D) in ) 3-4{aE.iltAli=, iFatitc:,,lnxr;^-ctLtrata- i55I' i� i j c. > catering, tnohilc tcxxi,irrnporarv' add i d i1.YtsAi:?} E'o,lltry. ChidC',:snte. SiufP i PHFs, kitchen oileradorI Ahould be i Sit-fft: :C,gou q in.' 'is11 htei:., deblled under the appropriate r:nt:tn or Etantc,-Ir:j 1' 15.wc. :tlx>ve If relal A to C-,Ehiht)rnc' ill:ir.Ss 3-41t.11(C, ;; 5?a<.te-nt r l . Intact I;,,J jolef veil tioil s and eisk fa om, (Rhes 547 4• .. 1 590,009 violations relating I(,-tn,d roai! 1 3-401.1' Raw �Utirrul F•Nxi,Cooked it It I practices should Iv debited undo #19 - I itc,,,v:ai lfa`I'° Sp•:cial Requirements. '40l.Et(A)(l ith) All fknerl'IIFc- 115`1- If.cc. ` 17 Reneatmq for Hot Holding j VIOLATIONS R?LATED TO GOOD RETAIL PRACTICES j -4f33.t1(A}R{L'} ( t'tiF: tb3`f 17 eco • j (Iten1R?3-10) 403(.X($) itCtuw at e- le"P: Nlowte SLlnding l Crid,,d avd non-,rtflcal vi,dahon,,, w•itich do no; r'ciate m the I snc' t ,)•wdhorne itiaasa imrr vertiotis and risA Jar rorr It wdahon: con br ;-103.11(C) Cominetrialip Po:w .si•d R'E'F t,t•,d - /nun<i In the'jo7lowng sn tient r7 the Bond Code and 105 CAP? 34011!(E) fte,n:unina• Ln,ltced Pert 617<Oft3c'Ll Item Good Retail Practices I FC _ Sm000,- R 23. Manatlernent and Personnel _ FC- 2 1 .(0103 18 Proper Cooling of PHFs 24 Fano and Fwd Protection FC -3 ;- On4 1 ! tat 25. Egypm,ant and Utero i FC, - 4 .005 , .,E114(A) ! C'oulina Cas$rd PHI-I' i,nnt 14WFl(, I I`:- ._,=--t- - -”' 26--- i `Tiatat,Plumt,mcl and Nate I FC-.z 04a 75'.- 4t-i!tjoI2 l„u:: t!1,1 r�mTy#' � rt_. - I ' ' nt r X27 i'hy,;ica;Fac+litV i FC-8 I 007 { 2!'F:'+#YF N'ni,in I Hotiv, j 2x _ I PoIsoncus orTo,C Matoriais FC-'7 t 003 _ 1 ; 501 14(k) C<•c,iiti PHFI,Nitidu Hold Aalbmit I 'g. 3n• ..1ai Raouirem(azts --_-- .mg Tcropc,nuteehtered,ent,=.<,4;-I;`#i'F (_: _Oittea t— .� 30_ --- _ 'ilCpolL,tri(tCOt.fC,Y:of!6d Cd.!<:rd #(rh}O.:Mj 1,x6”•,. t0:4 iti,5,)rt,jf,ti Commonwealth of!Massachusetts s City of Salem Board of Health lQmberley Driscoll 120 Washington Street,4th Floor ypr SALEM,MA 01970 FooWRetail Establishment Permit DATE PRINTED: 12118/2008 ESTABLISHMENT NAME: Hawthorne Hotel File Numba:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes FOOD SERVICE BHP-2009-0066 Dec 18,2008 Dec 31,2009 $420.00 ESTABLISHMENT Total Fees: $420.00 PERMIT EXPIRES IDecember 31,2009 Board of Health 1.. This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 I CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4""FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR IDIONNE(a SALEM.COM JANET DIONNE, I ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Haw�horrp- 1 t)+e l L TEL# 1'18 - '1414' 11®BO ADDRESS OF ESTABLISHMENT I$WaSIllnq�no 5V(K2Ilt)Q_ST FAX# qIS - -14I - 3553 MAILING ADDRESS(if different) `J EMAIL- I c�'n1�nt� 1CX f1�I l OT/L I. UM W ebsite: W IN W. 11JTfl�f fll?Ylf)Tt?\ . C Ott() OWNER'S NAME I 1 TEL ADDRESS BaLA 1e A] A\/ pse'uerly MA STREEi CITY STATE zip CERTIFIED FOOD MANAGER'S NAME(S)I S+eVe, Nelson_ CERTIFICATE#(S) 1 I L-I -1 (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON . III 1 1 olerh(au5 HOME TEL# Il lA `ILi0- 05L40 I DAYSOF-OPERATION: -1.-- Monday` ' 1 '-.'`Tuesday Wednesday-, j .:Thursday '-1 -: 'Friday.' 1 Saturday . 1 Sunday' HOURS OF OPERATION /� r c Please write in time of day. IOQITI- IQ t (For example I1am-11pm) I 1 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YESNO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 — — — -------- --------- ---------- RESTAURANT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart$2 more seats 42X.CO more than 99 seats $420 --� ------------------------------------------------------------- --- ----------------------------------------------------------------------------------......--- BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES------------ ----------------------------------------------------------------............------------...... ------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YESNO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns a paid all state xes r u under the law. oy aaa���� Signature/ Date Social Security or Federal Identification Number ----- / ---------'--------' '--------- --- ----------------- Revised 424/07 FOODAP2008.adm Check#&Date a2y'��7 $ F Commonwealth of Massachusetts s i City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Hotel - Motel Permit DATE PRINTED: 12/18/2008 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Hotel/Motel BHP-2009-0064 Dee 18,2008 Dec 31,2009 $200.00 Operations Permit Total Fees: $200.00 PERMIT EXPIRES IDecember3l, 2009 f Board of Health L Page 1 f + CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH ^, 120 WASHINGTON STREET,4O.FLOOR •/r� TEL. (978) 741-1800 Z/ A I4MBERLEY DffiSCOLL FAx(978) 745-0343 I /L MAYOR IDiONNIS([�S U.1?M1LCn I /// //�� JANET DIONNE, {� 12 ( I ACTING HEALTH AGENT U J 2009 An>plication to Qoerate a Motel / Motel; $200.00 Name of Establishment: NA.w1J )orne 1- AF1 Address of Establishment: 1$ Way 1nq}w SQilnre, �na1Pm MA Mailing Address (if different): Tel#: '17b - r14 1-I - 1-111OW Fax#: q'-I a - `l y C;5:3 I - ?> Business Email:�l dQM6IA fl)QCnl?--6WCM Website: W W W. \nnlAr}�-,or Owner's Name:—DorAV)%j �4arrl )3AT)n Tel# Address: �1.__CB v 1 e-w Avv. 6_.1)(2.f 11� MA City i State Zip Emergency Response Person(s): cke.rkn i is Tel#: q9 S -` +4 -'0,5 Ll How many rooms are reserved for guests? Q� Is food served in the Establishment? 12.5 Are animals allowed on the premises (other than service animals)? *Please make check payable to the City of Salem. (Pay by check or money order only) This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the establishment. Pursuant to MGL Chapter 62C Section 49A,I certify under the pains and penalties of pequry that 1,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law Signal Date Social Security or Federal Identification Number 11/30 hotel-motel appl.doc Check#&Date IIIIIIIIIIIIIIIIIIIIIRi 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) } 744-4080 - Equipment and Utensils FAIL Non-Critical BLUE t Owner: Comment:The door on the basement walk in freezer does not close properly. Repair door to close properly. H&C Service Corporation. A door has been ordered. See invoice in file. (PIC: Claire Kallelis Inspector: David Greenbaum Date Inspected:Correct By: $4/15/2008 IRisk Level: I Permit Number: j BHP-2008-0204 Status: SIGNED OFF (#of Critical Violations: -. 0 k i, S ;Time IN: I Time OUT: ,:Urgency Description(s): J BLUE: All other violations cited in the 4/15/08 inspection report have been corrected. Violations Related to Good Retail Practices (Critical 'violations must be corrected- immediately or within 10 days)(Non-critical violations must be corrected immediately 'or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 30,2008 ) Page 1 oft Item Status Violation Critical Urgency RED' ,Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) I Cityof Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 30,2008 ) Page 2 oft 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: 1 PROTECTION FROM CONTAMINATION 744-4080 I Separation/Segre ion/Protection FAIL Critical RED Owner: Co ant:The walk in has potentially hazardous food stored above/next to ready to eat food. Store all PHF separate and below H&C Service Corporation E food to prevent cross contamination. 'PIC: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED Ken O'KeefeC me Inspector: nta The sanitizer at the middle prep area found too weak. Provide sanitizing solution of proper concentration at all work tations at all times. David Greenbaum re was no sanitizing solution at the prep table near the walk in. Sanitizing solution of proper concentration must be readily Date Inspected:Correct By: available at all work stations at all times. 4/15/2008 Handwash Facil ' s FAIL Critical ❑Q RED Risk Level: Co ment:The middle hand wash sink found obstructed. Hand wash sinks must be kept clear an accessible at all times. Permit Number: BHP-2008-0204 Status: VIOLATION #of Critical Violations: 4 Time IN: Time OUT: � Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 17,2008 ) Page 1 of r Item Status Violation Critical Urgency RED: 4, Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food P lection FAIL Critical BLUE Foodborne Illness Interventions C ment: he drawer unit in the cook line has uncovered fish. All food in storage must be covered. and Risk Factors (Require immediate corrective action) T e are uncovered dry ingredients on the metal rack near the middle prep area. Keep all dry ingredients covered Equip nt a Utensils FAIL Non-Critical BLUE omm :The small Magic chef freezer needs a thorough cleaning and defrosting. e Tr Isen unit needs a thorough cleaning. e B dgett ovens in the cook line have an accumulation of grease. Thoroughly clean the ovens. 4Be rage air said unit needs a general cleaning. Trage air dessert unit needs a general cleaning. T foo armer has an accumulation of food spills and splatter. Thoroughly clean the wrmer. Th it cook and hold warmer has an accumulation of food spills. Thoroughly clean the warmer. e Blodgett ovens in the prep area have an accumulation of grease. Thoroughly clean the ovens. :T�16read drawers need general cleaning. T small rolling rack in the walk in has an accumulation of food debris,spills and splatter. Thoroughly clean this rack. T wa m flooring needs a thorough cleaning. T walk in freezer flooring needs a thorough cleaning. ,T The door,on the basement walk in freezer does not close properly. Repair door to close properly. T rolling rack in the break room needs thorough cleaning. Th uice machine in the break room needs thorough cleaning. e microwaves in the break room need cleaning. T enmore unit in the Tavern needs a general cleaning. T same unit needs a visible,accurate thermometer. ,Sanyo unit in the tavern needs general cleaning. Magic Chef unit in the Tavern needs general cleaning. Physical Facility FAIL Non-Critical BLUE , Cgrhment:The light fixture in the walk in freezer is missing a cover. Provide a protective cover on this light fixture. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 17,2008 ) Page 2 of • Item Status Violation Critical Urgency Reinspection in two weeks, all violations to be corrected. flVLj W Ci of Salem Board of Health 120 Washington Street 4th Floor SALEM MA 01970 978 741-1600 H e ( ) GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 17,2008 ) Page 3 of J , 18 Washington Square West Salem,MA 01970 978-744-4080 t- 1-800 SAY-STAY(729-7829) H AW THORNE HOTEL �.�,G4ES Git.LISS Cblel Gur.!Llnz 1`i'41 X'_`.-T if:i 1`f781 744-4USr)•Fax 19781 87i-0199 199•e-maJFax )amc.r,haa9homehotel cum ()II l he Cnnmmu_S.Jenf,MA 01471) — mo,,H.101h,,,HO@1 com 1 To: �+�7 \ 1 �" From: C h Fax: 6 1 ( 5%>C) �p— I q : Pages: ' Phone: Date: Re: F .Y SOY CC: ❑ Urgent V_FGIr Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: C6 I� f ��cpO,�RFWE� 1N See. Lenox-Martell, Irks 89 Reath Street, Boston,MA 02930 617-442-7777 tel. 617-522-9455 fax jj FAX TRANSMITTAL, FORM DATE. "7'" i'..a�` J J COMPANY- /-' N f PERSON TO RECEIVE: FAX NUMBER. NUMBER OF PAGES INCLUDING COVER SKEET: - SPECIAL LVSTRUCTIONS. THANK YOU, TOCf�j 1131uvw YoN31 SSF6ZZS:T9 Xt+d OC Z1 400Z, h.-fin ie in�Ta�zii SUBMITTED TO Ffv91,✓ e e STREET_ P ® , CITY,STATE � C�'y'>:� ��11�. U' 7(,7 PHONE7�� FZ�' - A{ 7 DATE a CONTACT PERSON �/$L!' rN/cAo'8R6NED %%"p6`6 SOURCE; OEXISTING CUSTOMER ❑ YELLOW PAGES 89 HEATH STREET-BOSTON,MA62190 ❑ DIRECT MARL ❑ OTHER 517.442.7771 111617-522-9455 Itis �'1Z�/'��5� �"� /.z• ;ria r ,� rlt� �;� f����?� fz TERMS: CREDIT APPROVAL: WARRANTY' CONTRACT EXCLUSIONS: ACCT. # __ LABOR The following exclusions appy EOUIPMENTIPRODUCT DROP SHIPMENT: SALE b __ EST. unless lined through end duly Lenox-Martell, Inc. assumes no responsibility for noted by an authorized damaged items. It is the RECEIVER'S :.EASE # U GP representative of Lenox-Marvell, RESPONSIBILITY TO INSPECT ITEMS FOR SYRUP # J RK Inc. DAMAGE and either refuse shipment or SALE/LEASE ACCEPTANCE C1 RK CARPENTRY(rough,finish), document all damage on the shipper's copy of UPON APPROVAL BY SALES ELECTRICAL,MASONRYthe bill of lading PRIOR TO ACCEPTING. MANAGER lJ RT PLUMBING AND RIGGING X rU GRS Any alteration or ri-ii:loin f°:r above specifications invoivinp extra costs will be executed Authorized or;y jinn written order;, lid Wli becorna nn extra rhame over End nbCve Ina esamafe.All Signature fire,to taoo and other necessary insurance riot accepted within '3 days rcr}ltrtttcr of jN-.np;lam( -The atmv6 prros,speclficaI107.a and conditions e,,Ignature ---t��f �ry are satisfactory and are��h''e�rre>loy ccep; and authorized. {{� ��++ pp� S, Date of Accopl-, _yam 70 _ Print Name cJ' Vr l 1 N S _ Zooid 1131HVK TOV37 c2l`6z LT9 %F3 OL :ZT 8t)n ifZ%60 .., w..' . ,•-hkma.. .. .. .-r5 -.:,eg w.:r,. . . . ,... N u - ¢d.-5, . .k1 ¢.ri"^„nrr:+. a. rgeM�1. f —' Commonwealth of Massachusetts City of Salem Board of Health IQ mberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Hotel - Motel Permit DATE PRINTED: 01/28/2008 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 101970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA . 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Hotel/Motel BHP-2008-0398 Jan 2,2008 Dec 31,2008 $200.00 Operations Permit Total Fees: $200.00 PERMIT EXPIRES IDecember3l,2008 i Board of Health . v Page 1 of 3 CITY OF SALEM, MASSACHUSETTS �1. BOARD OF HEALTH R 120 WASHINGTON STREET, 4TH FLOOR io SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 n KIMBERLEY DRISCOLL JSCOTT@SALEM.COM MAYOR �Ec28 ®�t® JOANNE SCOTT ZQO, HEALTH AGENT �Fky �Ty 2008 Application to Operate a Hotel / Motel Name of Establishment: 44to 0rlI0%,C �/�('o�L Address of Establishment: � WAS h +nj9 To r.) sl v4?i W , 34rr7 Mailing Address (if different): Tel#: 9-19 —[7 Lk Lf— `�I o eo o Fax#: ,/4/` /q/` SJ y Business Email: ;A e 6 W46 OKa -bsite: Owner's Name: 1-4 +C gQ_K_Q1 c-9 P0K1? - Tel# gL14bb Address: �#04v � 1iV 7A fern Mq IN R7b iTty / State Zip 2 A Emergency Response Person(s): J vL\ LCO 16 AvS Tel#: °h How many rooms are reserved for guests? Is food served in the Establishment? Ll QS' Are animals allowed on the premises (other than service animals)? Nes *Please make check payable to the City of Salem. (Pay by check or money order only) This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the establishment. Pursuant to MGL Chapter 62C Section 49A,I certify under the pains and penalties of perjury that[,to my best knowledge and belief,have filed all state cax returns and paid all state taxes required under the law. l V JA1 CV , 4-x217 DL(— Zq 757 I I Si� ----------------------------ure lite Social Security or Federal Identification Number -- ---- - -- ----L $-- ----- -- - ---------------------------- 11/30/07 hotel-motel appl.doc Check#&DateJ,L./(7t vo t Commonwealth of Massachusetts s � City of Salem Board of Health 120 Washington Street,4th Floor IGmberley DriscollMayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/07/2008 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0204 Jan 4,2008 Dec 31,2008 $420.00 ESTABLISHMENT Total Fees: $420.00 PERMIT EXPIRES December 31, 2008 Board of Health U This Permit is not transferable and must be reissued upon change of ownership-or location.The permit must be posted in a prominent location in the Establishment. - - In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. - Page 12 of 24 n�6 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"t FLOOR l � TEL(978)741-1800 IVED KIMBERLEY DRISOOLL FAX(978)745-0343 E rP MAYOR iscorrOsALFu COM MC 2$ZOOi JOANNE SCOTT, CITY OF SFai-E%14 HEALTHAGENr BOARD Or}tEALfH 2008,APPLICATION FOR PER+,MIIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ��A wA 01'Z 9D�% C {{ TEL# /1�r�y�q--7 '44}. i ~`►0VD ADDRESS OF ESTABLISHMENT t LVAS/-,i.-1 i-&' Sc\ W O'A" FAX# �I' 1 �) I"T l " 35n MAILING ADDRESS(if different) �t,,T�t m�/ �t, EMAIL-Business': Website•4" tMVXEA t ' 1.h OWNER'S NAME _ ��'� �t (_2 ._ r} ITEL#. �)YI' 7 �� ��D lJ 42o�1� r� t , ADDRESS_ _ _ . �ASR1N.J fl->o-I �q uAr26 USS:;- ., A IPr'1 ✓YI ©I R7lL STREET k CITY - - STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) J 1 4[ N e e so d CERTIFICATE#(S) l 7 S (Required in an establishment where potentially hazardous foodisp'rreepared)}} EMERGENCY RESPONSE PERSON `1 ) (I�i L{,/}22 h t1 VS HOME TEL#-92- DAYS OF OPERATION Mondav Tuesday Wednesday 4 Thursday Friday Saturday ( Sunday I HOURS OF OPERATaIyON " I 1 I { I Pleasevmtefifimeafd 1 t"3a W, I '3TuYyr+ L li b:3Dts•a - 63n (Forexamalettamttomt II AM I pr1 /1 t lip& TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES 6D less than 100osq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 _... -----...•------------------------•------------------•------....--•' RESTAURANT YE NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210 25-99 seats more than 99 seats BED/BREAKFAST/ YES NO $100 CNILD ARE SERVICE ............................. .....................................-......_..,._-............. ._... ADDITIONAL PERMITS MAKE(not just serve)ICE CREAM,YOGURTISOFT SERVE YES $25 TOBACCO VENDOR YES 0 $135 ALL NON-PROFIT(such as church kitchens) YES $25 *Please pay total with one check payable to the City of Salem. This Permit Is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of pedury that I,to my best knowledge and belief,have filed all state tax retum nd paid aA tate x required under the to/w../ ) �t Signa ! -"3 ate Social Security or Federal Identification Number Revises 4/24/07 FOODAP2008.adm Checktl&Date !°�- f"�Q� 0Z $ 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-4080 Physical Facility FAIL Non-Critical BLUE Owner: Comment:There are missing tiles on the wall just inside the kitchen doors. Replace all missing tiles. H&C Service Corporation PIC: GENERAL COMMENTS: Steven Nelson All other violations cited in the 10/3/07 inspection report have been corrected. Inspector: David Greenbaum Date Inspected:Correct By: 10/10/2007 Risk Level: Permit Number: BHP-2007- Status: SIGNED OFF #of Critical Violations: 0 Time IN: Time OUT: j Urgency Description(s): i BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 11,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) WAZ City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 11,2007 ) Page 2 of "s 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-4080 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑1 RED OWner: G6mment:The ice scoops for tyhe ice machines in the room service area and the basement found stored on top of the ice H&C Service Corporation Imachines.aclean and sanitize the ice scoops and place in the ice handle side up or in a sanitized container labeled"Ice Scoop PIC: Only" ,r c�g boards are stained and scored. Resurface or replace the cutting boards. Inspector. David Greenbaum Date Inspected:Correct By: 10/3/2007 Risk Level: Permit Number: BHP-2007-0179 Status: VIOLATION #of Critical Violations: 2 Time IN: Time OUT: i Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 03,2007 ) Page I of r Item Status Violation Critical Urgency RED: Violations Relate to Good Retail Practices (Blue Items) Violations Related to Food and F od Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comment:The Traulsen reach in has uncovered food. All food in storage must be covered. immediate corrective action) Equipment and Utensils FAIL Non-Critical BLUE C ment:The True unit in the room service area needs a thorough cleaning. Cy The Traulsen unit in the cookline has an accumulation of food debris,spills and splatter. Thoroughly clean this unit including all shelving e unit needs a visible accurate thermometer. e dra r unit in the cookline needs a thorough cleaning. �T� nit needs a new,visible,accurate thermometer. e air salad unit needs a visible,accurate thermometer. e B erage air dessert unit has an accumulation of food spills. Thoroughly clean this unit. e brea warmer needs a thorough cleaaning. T .4 True unit needs a general cleaning. tecri tt ovens have an accumulation of food spills and splatter. Thoroughly clean all ovens. he food warmer has an accumulation of food debris,spills and splatter. Thoroughly clean this unit. � e kitc n walk in freezer flooring needs a thorough cleaning. Th oor gasket on the basement walk in freezer is in disrepair. Replace the door gasket. T basement walk in freezer door has an accumulation of ice and does not close properly. Remove the ice and repair door to close or perly. T refrigerator/freezer unit in the Tavern has an accumulation of ice. Remove the ice build up. rm refrigerator/freezer unit in the Tavern has an accumulation of frost.Remove the frost build up. T �Zore Chef refrigerator/freezer reach in in the Tavern needs visible,accurate thermometers. Physical Facility FAIL Non-Critical BLUE Comment:There are missing tiles on the wall just inside the kitchen doors. Replace all missing tiles. 7 e are water stained ceiling tiles in the room service area. Investigate the source of the leak and repair. Replace all stained ening tiles. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 03,2007 ) Page 2 of Item Status Violation Critical Urgency GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. . i City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 03,2007 ) Page 3 of 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-4080 Equipment and Utensils FAIL BLUE Owner: Comment:Walk in freezer upstairs has accumulation of ice on ceiling and walls. Remove ice. H&C Service Corporation PIC: Walk in freezer downstairs has ice build up on outside of door. Repair door as needed. Steven Nelson Sanitizer log being kept at higher ppm than strips are reading. Log to be maintained at 200 ppm as mandated. Inspector: John Gehan GENERAL COMMENTS: Date Inspected:Correct By: All violations unless noted have been corrected. 211412007 Risk Level: Permit Number: BHP-2007-0179 Status: SIGNED OFF #of Critical Violations: 0 Time IN. Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 14,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) rmj City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 14,2007 ) Page 2 of IMPORTANT MESSAGE ) FOR 2 OATS E"'/•��//J� w -7 TIM �I P.M. M ( �A� c P✓ (/ OF AREA CODE NUMBER EXTENSION 0 FAX 0 MOBN F AREA COLE N BER TIME TO CALL TELEPHONED PLEASE CALL , CAME TO SEE YOU WILL CALL AGAIN , WANTS TO SEE YOU RUSH I RETURNED YOUR CALL WILL FAX TO YOU MESSAGE /)f2-�IS2 ;#I- SIGNED �la,,� MTM FORM 40 9 ��/��7 MADE IN U .A. O � � � � ', j CITY OF SALEMr MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745.0343 Kimberley Driscoll www.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT FtPtIw�TY�oQ,r�-- "S�i eA y TEL# CL}1 k� IIID 71N-' ADDRESS OF ESTABLISHMENT \Q7TVI 1 SI �tklPlar I�I(j FAX# 07k) 74/-&53 MAILING ADDRESS (if different) �J EMAIL--Business': A(�ydt1 �cMilT�laLX2f E I�CS�E1 . CJ.AA owner's: tg6_OLiJ�}J/�14Ak) }(b1ChSEl-�o1EL• GvA OWNER'S NAME t1`f C -eJiCc �Cti'o�o2DTo{tii TEL# l�`TS ��TtItJ'�I( StL3 ADDRESS OWI ktN( i�>1 QjOee, `rY/t _ I1� 01 "'ID STREET I 1' CITY STATE ZIP �l CERTIFIED FOOD MANAGER'S NAME(S) sre\le !�/�l�sr.1 CERTIFICATE#(S) 71 H DTs- (Required in an establishment where potentially hazardous food is prepared) // EMERGENCY RESPONSE PERSON J U�i LAW HOME TEL#tai''by 11.go_05,40 I DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday ROURSOEOPERATION ) )-- iPleasewrdeindmaofdaY. ( � Lir (2A, LAW-12� �p�-�a rO ( 61-(� J-. AIN ` {Foreltamptettam-1110m) �Aa1 Ate' �c qi� - AM`(a I TYPE OF ESTABLISHMENT FEE (check onlvl RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 --- ....... ...YES .... .... ..... _ _ S,10_0.. . .. ...... ...... -....- - - ----- - ....... ..... ...... ...... BEDlBREAKFAST NO --- ------ -- -- - ---- -- - _.....-_......_..._.. . --- ..._ .... .... .... .............. .. .. ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR ES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO S25 *Please pay total with one check payable to the City of Salern This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that t, to my best knowledge and belief, have ded all state tax return and pard all state taxes required under the law. Sir to 1 Date Social Security or Federal Identification Number ------------------- ----- ---------------V- ---- - --------- ---------------------- ------ ------------------ --------------------- --- Revised 11/13/06 FOODAP2007.3dm Check#&Date r�p�Z,w _, J> I1ab_ b 2 50•PO y'i'8; '� �' +M+CP"f #tiP � >+ j'+34 +C« .a?Swyytw,�'';^'d�„}`r" .eM'i��""`'a'� K °{w •_.µL: e 1r.w. �[!>•.,� ~�' 't� 'w e. 'N `- . °f M�&; r«.,C'''` ,o .n'1,S.�,4'.i„°7n,,yA�.i.no-a"�: ft7 WF.epi ���. .?�Fp,.'°.tgS..°e •«.�S,do-.'ommonw•ealth of Massachusetts1.Min r s` ” i , omt'.d a ,,, " ..1^y�% AY� .a6;i.•;.„Y•?b; F=v Boar'dofHealth^ AEIGmberleY, 120 Washmgtdn Street,Ah Floor; 1c 'ax'r Mayor` ' •'*r , ' '°"`. yf, '4•"S: s"•75h�"'\�,v a< 'T'�:` 've?'A .ah .'S; Kr*t q t .n r SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Hawthorne Hotel File Number:BHF-2004-000151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0179 Dec 20,2006 Dec 31,2007 $200.00 ESTABLISHMENT Total Fees: $200.00 PERMIT EXPIRES 'December 31, 2007 Board of Health v This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 5 of 8 Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 DATE PRINTED: 02/10/2006 WHO'S PLACE OF BUSINESS IS: Hawthorne Hotel File Number BHF-2004-0151 18 Washington Square West Salem MA 01970 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes TEMPORARY FOOD BHP-2006-0410 Feb 10,2006 Feb 11,2006 $0.00 /TO BE SERVED: White choc. & macadamia nut bread pudding Total Fees: $0.00 PERMIT EXPIRES (February 11, 2006 Board of Health Page 6 of 9 « A 4 Sep 19 OS 12:40p J-!%anne Samet Salem BOH 97H 745 0343 p.2 T:>TY OF SALEM. MAISSAcwusETTB $OARD OF NZALTH 120 WASHINGTON 5TRIIET,GTN FLOOR 5A1.CM. MAC 1070 Teu. 878.741-1600 ,a FAX 076-745-0343 SIANLFY U$OYiOY.JR. JOANNI, SCOTT. MPH RS. CMD MAYa0 Hf.AI,TH ACENt APPLICATION FOR A TEMPORARY FOOD SERVICE PERMIT FEE: 1-3 DAYS= $200 4,7 DAYs= $300 MORE THAN 7 nAYR a 5400 T �f(JJ V4tCKf TYA%i TDTHfiaTYOF SALEM.NOCASM NAME OF EVENT J LOCATION DATE(S)OF EVENT -Ito In NAME OF APPUCANT �<(' 1 CIiFP N' TELEPHONE# I t� Z}GS -[ -(Ca ADDRESS NAME O<BUSINESS fvG,- � i TELEPHONE#178 �$25-'q3 VO AimREssDA4 , C0un+L jyl `244~ MA .,P��/1 `/y M GERflFIED F000 MANAGERS NAMt:--fD►F6­ i3�K�pk —.- CERTIFICATtONl1 71�Y1 ?�� O 71IL A PLAN OF THE ESTABLISHMENT IS' _! ENCLOSED ­DRAWNON THE BACK TYPE OF REFRIGERATION. ,",GAS ICE DRY ICE _DTNea '11�A- n i METHOD FOR COOKINGIHOT HOIXIING. :_GAS .�OTHER,C�]�YJCj Lld� 0164edNO METHOD FOR SANITIZING, �(;lCHEMICAL OTHER 7 SOURCE OF FOOD' NAMEADORESS FOODS TO 01;SERVED INCLUDING iNGREDIMNU ASND METHLO,,D OF PREPARATION' �t)Inlnt W� 11 l��l�P,lr `�LtVh tn�I` &IJT* 1 pwj b1 CUi,& , 13A)( to UE— {�`��SLng fJ oItj!. tUSL,iA,4��c�', f'Civ✓r�lra f r1/p�'1r N rCk 1 HAVE READ THE 80ARD OF HEN.ni. "MOUIREMENTSFOR TEMPORARY FOOD ESTABLISHMENTS,"I HAVE I"THE OPPORTUNITY TO ASK QUESTIONS REGARONG 1'110$15 REQUIREMENTS. 1 UNUERSTANO THEM.AGREE I V AIJ OE BY TH1:'M AMC UNDERGYANU THAT FAILURE 1 O 00 50 Will RESULT fiv REVOCATION OF MY TEMPORARY FOOD ESTABLISHMENT PERMIT. PERSUAN'I To MGL C62c,5491'•,1 CERTIFY UNDER TRCPENAINICS OF PERJURY I IIA1 I, IU MY 59SY KNOWLCOGC AND IiLLILF. HAVE TILED All E TAX RTU�'Y A76 ATLL`�S'T!ATE TAXES Rn[O/UtREO UNDER LAW. � _ 1.4. . I�I/ 1!7 IGNATUHE w BATE SOCIAL SECURITY OR FEDERAL 10# T8 39Ud 1310Fi 3N2i0Hlh7tlti 9Z9ZSPL8L6 SD:EZ 900Z/6T/T0 0038 WASHTNGTDN SQUARE WE Hawthorne Hoyle/ City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Item Status Violation Type Urgency Violations Related to Good Retail Practices Address: 0018 WASHINGTON SQUAFE WE (Blue Items) Equipment and Utensils FAIL Non-Critical BLUE Telephone: 744-4080 COMMENTS: The Wittlo warming unit needs a thorough cleaning. Owner: H&C Service Corporation PIC: James Kluge There is soap and paper towels at the utility sink. Remove the soap and paper towel Inspector: David Greenbaum dispensers. Date: 9/22/06 Risk Level: HACCP: No Correct By. Physical Facility FAIL Non-Critical BLUE COMMENTS: The ceiling in the wait station is near the balirrom damaged. Repair the Permit Number: BHP-2006-0101 ceiling. Status: SIGNEDOFF #� of Critical Violations: 0 There are unfinished wood shelves in the basement. Finish shelves in the basement to be impervious and easily cleanable. This violation to be corrected by the next routine inspection. Time IN: OUT: Urgency Description(s): GENERAL COMMENTS: All other violations cited in the 9/14/06 inspection report have been corrected BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be My or Salem Board of Health 120 Washington Street,4th floor SALEM MA 01970 (979)741-1800 G"TMS®2005 Des Laurlets Municipal Soudfons,Inc. COMMONWEALTH OF MASSACHUSETTS Page 1 0018 WASHrNGMN SQUARE WE Hawthorne Hotel City Of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Item Status Violation Type Urgency corrected immediately or within 90 days) RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Inspectornature 5N na m City of Salem Board of Health 120 Washington Street,Ota Floor SALEM MA 01970 (976)741-IWW ceoTMs®2005 Hes Landers Municipal solutions,Inc. COMMONWEALTH OF MASSACHUSErrs Page 2 0018 WASHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency .Telephone: PROTECTION FROM CONTAMINATION 744-4080 .. Food Contact Surfaces Cleaning and Sanitizing FAIL Critical S6 RED Owneromment:The cutting boards are stained and scored. Resurface or replace all cutting boards. H&C Service Corporation PIC: _ The t slicer has an accumulation of food debris. Thoroughly clean and sanitize the meat slicer after each use. Hand Facilities FAIL Critical EVI RED Inspector: La om t:The hand wash sink near the pole in the kitchen found obstructed and not working. Keep hand wash sink clear and David Greenbaum ssib all times and repair to good working order. Date Inspected: Correct By: T s e hand wash sink is missing a soap dispenser. Provide a wall hung soap dispenser at this hand wash sink. 9/14/2006 Risk LBVEI: a hand wash sink at the Tavern wait station has no hot water. Restore hot water at a minimum temperature of 710°F immediately. TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) . Permit Number: Hot and Cold Holding FAIL Critical 0 RED BHP-2006-0101Co eot:The small drawer cooling unit across from the cookline had a temperature of 50°F.Repair unit to maintain a temperature Status: 47°F or below. VIOLATION #of Critical Violations: 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 15,2006 ) Page ! of Item Status Violation Critical Urgency RED: Violations Related to Gqp"etail Practices (Blue Items) Violations Related to Equipment and nsils FAIL Non-Critical BLUE Foodborne Illness Interventions and Risk Factors (Require mm :The Magic Chef freezer has an accumulation of food spills and splatter. Thoroughly clean this unit. immediate Corrective action) a Tr sen reach in has an accumulation of food debris. Thoroughly clean this unit. e same u It ne s a visible,accurate thermometer. arge ewer unit in the cookline needs a thorough cleaning. All od vens need to be thoroughly cleaned. B rage air salad unit needs a thorough cleaning. e same it needs a visible,accurate thermometer. eve air reach in with the microwave needs a thorough cleaning. T mi ave has an accumulation of food spills and splatter. Thoroughly clean the microwave. T shelves when:the cereal is stored need a thorough cleaning. The Wi warming unit needs a thorough cleaning. T canopener has an accumulation of grime. Thoroughly clean the canopener. There is soap and paper towels at the produce sink. Remove the soap and paper towel dispensers. Label the sink"Produce Only" and use for ft�UUUfU�hat only. The reach in needs a thorough cleaning. Salk in fr er floor needs a thorough cleaning. he es in the walk in have an accumulation of grime. Thoroughly clean all shelves in the walk in. icrowave in the employee lounge needs a thorough cleaning. T� hgWhits Kenmore refrigerator at the Tavern bar needs a thorough cleaning. The S o refrigerator at the Tavern bar needs a thorough cleaning. Physical Facility FAIL Non-Critical BLUE C.ComZm"nt:There is areas of damage on the kitchen ceiling near the dishwasher. Repair the ceiling. eng in the wait station is damaged. Repair the ceiling. I There are unfinished wood shelves in the basement. Finish shelves in the basement to be impervious and easily cleanable. All s and floors have an accumulation of food spills and splatter. Thoroughly clean all floors and walls,including under and Ci Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 15,2006 ) Page 2 of 1 Item Status Violation Critical Urgency around all equipment. GENERAL COMMENTS: 826:Reinspection will be in one week. All violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 15,2006 ) Page 3 of IMPMTARIT MESSAGE ) FOP G, �AM/ DATF �7�_a�a`� TIME O '56O PrIVI. M KJ (_a�ILP� �ZoX d D t� OF -e- / PHONE AREA COOE NUMBER EXTENSION D FAX D MOBII F AREA COOE NUMBER TIME TO CALL TELEPHONED ') PLEASE CALL CAME TO SEE YOU I� WILL CALL AGAIN j WANTS TO SEE YOU 'I RUSH RETURNED YOUR CALL //1�� WILL FAX TO YOU MESSAGE I ( d Zl"Wl4 Ad-(P T SI>GTO FORM 4009 MARE IN U SA ,.--- � Z � a / � �. �. \,\ � `� � ��, , � � �, �` � , �, �� �, !, i � \ � � i \ i_. _,-- �./ oro . 'G�Zfc 17-- �/ /Lj • �Y' z 0018 t4*SHINGTON SQUARE WE Hawthorne Hotel City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-4080 Food Contact Surfaces Cleaning and Sanitizing FAIL ./❑ RED Owner: Comments: some cutting boards throughout stained and scored. resurface or replace.contact office when new board comes in. H&C Service Corporation Prevention of Contamination from Hands PASS Q RED PIC: Steven Nelson Handwash Facilities PASS 0 RED Inspector. Violations Related to Good Retail Practices (Blue Items) Janet Dionne Food and Food Protection PASS BLUE Date Inspected. Correct By: 3/7/2006 Equipment and Utensils FAIL BLUE Risk Level. Comments:walkin freezer holding at 4°f.freezers to be maintained at 0°f or below as mandated. Permit Number: Tavern-warewash machine not reaching proper temp for final rinse.service machine check thermostat gauge to ensure proper BHP-2006-0101 temp is reached.notify Board of Health once serviced. Status: Open #of Critical Violations: Physical Facility PASS BLUE 1 Other-See Notes PASS BLUE Time IN. Time OUT. GENERAL COMMENTS: Urgency Description(s)' BLUE 526:AII other violations cited in the 3/7/2006 have been corrected.Thank You. Violations Related to Good Retail Practices (Critical, violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 24,2006 ) Page I oft 41 A{A Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 24,2006 ) Page 2 of 0018 WASHINGTON SQUARE WE Hawthorne Hotel l City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 744-4080 PIC Assigned/Knowledgeable/Duties PASS ❑d RED Owner: Non-compliance with: H&C Service Corporation Anti-Choking PASS PIC: Steven Nelson . . Tobacco PASS Inspector: t Dionne EMPLOYEE HEALTH Jane Date t Dionne Correct By. Reporting of Diseases by Food Employee and PIC PASS ❑J RED $/7/2006 Personnel with Infections Restricted/Excluded PASS RED Risk Level: - FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2006-0101 Receiving/Condition PASS ❑d RED Status: Open Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS ❑ RED 6 Time IN. Time OUT Urgency Description(s): BLUE' Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 14,2006 ) Page 1 of Item ' Status Violation Critical Urgency VItavern-small fridge behind bar missing thermometer. provide visible accurate thermometer maintained at 41°f of below as mandated. Tavern-warewash machine not reaching proper temp for final rinse.service machine check thermostat gauge to ensure proper temp is reached. ,,�Nathaniels-ice scoop stored incorrectly.clean and sanitize ice scoop and store handle side up in ice or in a cleaned and sanitized container labeled ICE SCOOP ONLY. vKnife stored in container with corks.knife to be cleaned and sanitized and stored in proper manner. "sanitizer at both restaurants reading below proper parts per million.provide sanitizing solution at ppm. Water, Plumbing and Waste PASS BLUE Physical Facility FAIL Critical BLUE +Comments:there were spaces above prep line that where open possible vents? provide proper cover to make intact. yenfs from ceiling duct need general cleaning of dust accumulation. ,,poor throughout kitchen and under units general cleaning. oom service station back splash needs general cleaning. area outlet missing face plate. ,.�ame area hole in wall beneath circuit breaker box.seal hole. V�ff a area wiring exposed in eletrical casing to left of door. right of elevator. fling above room service area has what appeared to be tracks for drop ceiling.ceiling in food prep,food storage areas to be intact,and easily cleanable. provide proper ceiling. xterior door upstairs off of storage area had many gaps around door and frame.all gaps to be sealed to prevent entrance of rodents and insects. Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes FAIL BLUE omments: Mops stored upstairs and down stairs stored incorrectly.mops to be stored mop head up not touching any surface to air dry. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 14,2006 ) Page 5 of Item Status Violation Critical Urgency GENERAL COMMENTS: 512: v/ City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 14,2006 ) Page 6 of r Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS Q RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED immediate corrective action) Comments: some cutting boards throughout stained and scored. resurface or replace. Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS ❑d RED Prevention of Contamination from Hands FAIL Critical ❑d RED Comments:at time of inspection employee not wearing gloves when handling ready to eat foods. Handwash Facilities FAIL Critical ❑d RED - moments: hand sink across from salad prep area missing sign. provide hand wash sink only sign. l—there was accumulation of food debris at bottom of handsink at end of prepline.All hand sinks to be used for handwashing only. L-1 randsink near wittco refrig unit missing sign. provide hand washing only sign. in employees cafeteria area had temp of 137'f. burn hazard.water should be maintain between 110°f and 1301. olaflianiels-three bay sink one bay to be labeled for handwashing only. PROTECTION FROM CHEMICALS Approved Food or Color Additives PASSd❑ RED Toxic Chemicals PASS ❑Q RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑J RED Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS ❑Q RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 14,2006 ) Page 2 of s Item Status Violation Critical Urgency CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 14,2006 ) Page 3 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE VC10mments: ice machine downstairs had what appeared to be used soiled towel.Head chef was present. ice to be dicarded. ice - machine to be cleaned and sanitized before ice is used from this machine. fern-personal food item stored stored in franklin chef fridge. no personal items to be stored in same area with food for customer consumption.relocate to employee area. aver,-snacks being offered at bar.single serve portions to be offered to prevent bare hand contact. Equipment and Utensils FAIL Critical BLUE I-Iffo-mments:warewashing machine was only reaching temp of 176°f upon final rinse. Machine must reach minimum temp of 180°f for proper sanitizing.Service warewashing machine. ,' / umulation of dust on bakery shelves where tongs are stored;thoroughly clean shelves. i beverage air unit underneath microwave needs general cleaning. ,, a arage air salad prep area,had uncovered food.all food in storage must be covered. ,, e unit had temp of 48°f. unit to be maintained at 41°f or below as mandated. containers holding utensils and knives below prep line had accumulation of crumbs and food debris.thoroughly clean and sanitize container. --there were many units on prep line that were missing fan covers or shields on front of equipment.provide covers to prevent entrance of insects. otline all units need general cleaning of food debris accumulation. alkin freezer had accumulation of ice and frost. remove all buildup. same unit holding at 10°f.freezers to be maintained at 0°f or below as mandated. ,,used ladel`with food debris hanging in from shelves in walkin. untensils to be cleaned and sanitized between uses. True fridge/coke cola unit needs general cleaning. ,Vdan opener had accumulation of dried food debris.Thoroughly clean and sanitize. tjce-scoop container need to be cleaned and sanitized. ownstair walkin refrig. had accumulation of dust on fans.clean fans. mploe rea refrigerator needs general cleaning. aver,-ice scoop stored incorrectly in ice. ice to be cleaned and sanitized and placed handleside up in ice or in a cleaned and sanitized container labeled ICE SCOOP ONLY City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 14,2006 ) Page 4 of 4 City of Salem, Massachusetts -ire Department 48 Lafayette Street David'W. Cody Salem, Massachusetts 01970-3695 Fire Prevention Chief Tel. 978-744-1235 Bureau 978-744-6990 FaX 978-745-4646 978-745-7777 dcody@safem.com Order#2005-2 Ms. Juli Lederhaus H&C Service Corp. DBA The Hawthorne Hotel 18 Washington Square West Salem,MA 01970 January 17,2006 Dear Ms.Lederhaus: As a result of the tragic nightclub fire in Warwick,Rhode Island,the Commonwealth of Massachusetts enacted Chapter 304 of the Acts of 2004,An Act Relative to Fire Safety in the Commonwealth. Section 5 of this new law added Massachusetts General Law chapter 148,section 26G1/2 which requires every building or portion thereof,of public assembly,with a capacity of 100 persons or more that is designed or used for occupancy as a nightclub,dancehatt,discotheque,bar or for similar entertainment purposes to be equipped with an adequate system of automatic sprinklers. Upon review it has been determined that the above referenced establishment falls under this new law. You are hereby ORDERED to comply with the provisions of the statute in accordance with the following schedule: 1. Plans and specifications for an adequate sprinkler system as required by statute shall be submitted to this office with a copy to the building inspector no later than May 15, 2006. 2. The sprinkler system must be completed no later than November 15,2007. You are strongly urged to take appropriate action at this time in order to meet the compliance deadlines of the new law. Under provisions of M.G.L.c. 148, s. 26GI/2,you have the right to appeal this order to the Commonwealth's Automatic Sprinkler Appeals Board,P.O. Box 1025, State Road, Stow,MA 01775, within 45 days after service of this letter. If you have any questions please contact Salem Fire Prevention at(978)745-7777. So O dered Chief Cc: File Bin ding Licensing Health . �.«...=� _ " „�. � 'v- �� i �.r'�, 'fin . . ,, , -� . y,. e.�:r�,rer '/Ks` " � �1" - • �Ht�, ar.<r'wrrw �vn�+-. 'i ror Fsr: � `' 's. .w-r, -.._ ,.,.,--,. yJ• '-e ''�p�'t y ;tr�" 'I1.,+aY+... -••^ M1i I P � 4rvy-Yt '4w2. - A, X-'1 .'�i to i�4."r x{.v..vt3 �i� Wit+.-1: T 'Coinmonwealth of Massachusetts "' � '' z a'�;��K�;`:" yin; "� 'moi" .a. '.irv.>F�... paha !. . `_ , •'i' R+ M' ....'1 .'�i.. .�$...iR•- Ci 1-3 Board of Health ' - ` 120 Washington Street,4th Floor s « SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Hawthorne Hotel File Number BHF-2004-0151 18 Washington Square West Salem MA 01,070 LOCATED AT: 0018 WASHINGTON SQUARE WE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0101 Jan 3,2006 Dec 31,2006 $200.00 ESTABLISHMENT TOBACCO VENDOR BHP-2006-0102 Jan 3,2006 Dec 31,2006 $50.00 Total Fees: $250.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,heofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 3 of 9 CITY OF SALEM, MASSACHUSETTS , BOARD OF HEALTH f 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 /f TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAx 978-745-0343 y W W W.SALEM.COM MAYOR JOANNE SCOTT, MPH, RS, CHO ''�'� 0FL,Ac�'LM HEALTH AGENT HEq�TH 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Hawthorne Hotel TEL# (978) 744-4080 ADDRESS OF ESTABLISHMENT 18 Washington Square West , Salem, MA 01970, MAILING ADDRESS (if different) OWNER'S NAME H&C Service Corporation TEL# (978) 744-4080 ADDRESS 18 Washington Square West CITY 3aleu` STATE rlik ZIP U1y/U CERTIFIED FOOD MANAGER'S NAME(S)S ev N 1 Gnn CERTIFICATE#(s) 714175 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Juli Lederhaus HOMETEL# (978) 740-0540 HOURS OF OPERATION: Mon. Tue. Wed. Thu. Fri. Sat. Sun. 7_days 6—am - 12 midnight---------------------- TYPE OF ESTABLISHMENT FEE (check only). RETAIL STORE YES NO less than 1000sq.ft. -$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YE NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 - -----------------------------------------------------------------------------------$.. ----------------- BEDIBREAKFAST YES NO $100 ADDITIONAL PERMITS ---------------------------------------------.---------------------------------------------------------------------------- tviAKE(not-just_Ser Serve) ICE CREAM, YOGURT, S FTSE `1E 1'ES NO $5 CTOBACCO VENDOJR -0 YES NO $50 ALL NON-PROFIT(such as church kitchensJJJJ"'' YES NO 25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. 12/02/05 04-2925769 Signatur Date Social Security or Federal Identification Number ---------- ------------------------------------------------------------------------------------------------------------------------ Revised 11/03/05 FOODAP2.adm Check#&Date 11'x/X �,�, -'01 a-6