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HESS EXPRESS - ESTABLISHMENTS ulversai one, www.myuniversalop.com phone: 1-800-756-4676 UNV16162 MADE w Asa l i . X Commonwealth of Massachusetts ` City of Salem Board of Health Kimberley Driscoll 1 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Hess Express 21519 File Number:BHF-2004-000059 I Hess Plaza/J. Flaherty Woodbridge NJ 07095 LOCATED AT: 0086 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0021 Jan 1,2011 Dec 31,2011 $280.00 TOBACCO VENDOR 13HP-2011-0022 Jan 1,2011 Dec 31,2011 $135.00 Total Fees: $415.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health 7 This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4r"FLOOR TEL. (978) 741-1800 KINMERLEY DRISCOLL' FAx(978) 745-0343 MAYOR DG11LENaauM(t",ALSM.COM DAVID GREENBAUM,RS ACTING HE EM AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT V)l y 4se PteSS TEL# ADDRESS OF ESTABLISHMENTRe DQe FAX MAILING ADDRESS(if different) t� i ATON 1 i lepails J rs Pia:a l Flahergr EMAIL- Business': 19 Q NeSS. COrhWOO e' 070�/eb96 732- 50-Sassite: OWNER'S NAME TEL# ADDRESS WOe 'NJ 07W STREET "2 750 6359 CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardousfoodis prepared)J EMERGENCY RESPONSE PERSON : la�G' l.,) 0)(Cl HOME TEL# 78f-0©,'7-a�� rD'AYS"OF.,>OFERgTIQN ' ,; - ",Monda ", x , Tuesday; 'Wednesday � _ Thursda � "f t Fddayj HOURS OF OPERATION y i Please write in time of da . l i For exam etiam•tt I y71� - TYPE OF ESTABLISHMENT � FEE (check only) RETAIL STORE NO less than 1000sq.ft. =$ 70 1000-10,00Nq.f l =$280 more than 10,000sq.ft. 20 - -.._........... •---....-----••---- ------------- -•-----------••------•------------------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 -•......... .... ... ... . ...........-------------.....----------•------.--------------•----------------$---10-------- BEDlBREAKFAST! YES .. 0 CHILDCARE SERVICESfNURSING HOME-... - ... ADDITIONAL Y&WITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE NO *25 TOBACCO VENDOR YEi ALL NON-PROFIT(such as church kitchens) YES "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem.Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax returns and paid all state t xes required under the law. r � ////S//o l3- y9alao-� Signature Date Social Security or Federal Identification Number q W--1- - ---- --- Revised 10/7/11 FOODAP241 t.adm CheckN&Date ---------------------- j ;?j,1 Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 03/29/2010 ESTABLISHMENT NAME: Hess Express 21519 File Number: BHF-2004-000059 1 Hess Plaza/J.Flaherty Woodbridge NJ 07095 LOCATED AT: 0086 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0191 Jan 4,2010 Dec 31,2010 $280.00 TOBACCO VENDOR BHP-2010-0192 Jan 4,2010 Dec 31,2010 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31, 2010 Board of Health This Permit is not transferable and must,be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 *(w M CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4T"FLOOR TEL, (978)741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUM @ SALEM.COM DA,,ID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT �} NAME OF ESTABLISHMENT l `N YE'PSS 0? 15] � TEL# ADDRESS OF ESTABLISHMENT FAX# MAILING ADDRESS(if different) HESS CORPO ! EMAIL-Business': 111099 OWNER'S NAME Woodbridge, NJ 07095 TEL# ADDRESS SIRE CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATE#(S) (Required in an establishment where potentially h rdou food is pr marred)ry1 EMERGENCY RESPONSE PERSON - a71Irr? q`� HOME TEL# A 70PERATIOP HOURS OF Please write I0dayPorezam le -11pm E TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft.'&V =$280 v' more than 1 0,000sq.ft. =$420 ^- ... ... •................ .... .......------- -----... ...---- RESTAURANT YE5 NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 8€6i6REAKFASTt YES NO $100 CHILDCARE SERVICES/NURSING HOME... - ............................ .............. ... ........ ., ...................... ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YE NO $25 TOBACCO VENDOR Y NO $135✓ ALL NON-PROFIT(such as church kitchens) $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax returns and paid all state es required under the law. Z �z136F I3-y�/00g Signature �� Date Social Security or Federal Identification Number Revised 424X07 FOODAP2008.adm Check#&Date ""�y�n�__� J Y/ S (I I I II OPOSTAGE NECESSARY IF MAILED IN THE UNITED STATES BUSINESS REPLY MAIL FIRST CLASS MAIL PERMIT NO.142 WOODBRIDGE NJ POSTAGE WILL BE PAID BY ADDRESSEE AMERADA HESS CORPORATION Janice Flaherty ATTN: WB-11 1 HESS PLAZA WOODBRIDGE NJ 07095-0961 * — Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 03/29/2010 ESTABLISHMENT NAME: Hess Express #21334 File Number:BHF-2004-000154 1 Hess Plazad.Flaherty Woodbridge NI 07095 LOCATED AT: 0295 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0190 Jan 4,2010 Dec 31,2010 $70.00 TOBACCO VENDOR BHP-2010-0189 Jan 4,2010 Dec 31,2010 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31,2010 Board of Health --- — This Permit is not transferable and must be reissued upon change of ownership or location.The permit musk 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 t CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,47 FLOOR m TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR, -: _ - DGREF:NBAUMQSALEM.COM DAVID GREENBAum, .. ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT i-i�SS Z�KfS'S G? 133 TEL# tI-�y 13 ADDRESS OF ESTABLISHMENT FAX#— MAILING ADDRESS(if different) H CORDO 1 EMAIL-Business': OWNER'S NAM r> Woodbridge, NJ 07095 TEL## ADDRESS STRE CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) - +- . . I Q ' / // EMERGENCY RESPONSE PERSON � nY \YY-, y �rr) HOMETEL# / 7�3'7.6 1O DAYS'-O PERAIIO% 2MondMWTuesd'aysCuWed_n@sdN ' ±Thursday' Fitla �Saturdaya ±"t a and � s HOURS OF OPERATION I Please write in time of day. i For example 11 am-11 pm 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 RESTAURANT YES 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 SERVICESINURSING HOME- -------------------------------------------------------------- ------------------------ ----------------- --------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YE `fdQ $25 TOBACCO VENDOR Y Sit `IdtT $135✓ ALL NON-PROFIT(such as church kitchens) S ©O $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C.Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state tAxes required under the law. ;L 19 bb? /3-4N2100a Signature ---"-Date Social Security or Federal Identification Number, Revised 424/07 FOODAP2008.adm Check#.&Date - 'Wsg;516 /iT9��f $�.7 0086 NORTH STREET Hess Express 21519 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: - PROTECTION FROM CONTAMINATION 744-1696 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED `Owner: Comment:Sanitizer slightly weak at time of re-inspection at approx.150ppm.Provide sanitizer of proper concentration(200ppm)at Amerada Hess Corp. all times.PIC states sanitizer company has been called to adjust automatic feed. PIC: Daily log of sanitizer concentration must be kept.Log sheets given to PIC at time of re-inspection. Chuck Braman Violations Related to Good Retail Practices (Blue Items) Inspector: Equipment and Utensils FAIL Non-Critical BLUE Elizabeth Salandrea Comment:Sanitize bay of the 3bay sink must be re-labelled. Date Inspected:Correct By: 3/17/2009 Risk Level: Permit Number: ' BHP-2009-0132 Status: . SIGNED OFF 4 of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: All other violations noted in the 3/9/09 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 GeoTMSO 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 17,2009 ) Page 1 oft 'r Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventionsi and Risk Factors (Require I immediate corrective action) 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. Mar 17,2009 ) Page 2 oft `f Express 21519 Hess Ex 0086 NORTH STREET P City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-1696 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED -Owner: - /Iomment:Sanitizer was available at hot dog counter,but was under the sink and PIC was not sure which bottle it was.Sanitizer Amerada Hess Corp. �must be available at all times and labelled appropriately for use. PIC: t/Sanitizer weak at time of inspection. Provide sanitizer of proper concentration(200ppm)at all times. Chuck Braman Inspector: - —Daily log of Sanitizer concentration must be kept.5t`� G? "hkK _C rr-,&3n Elizabeth Salandrea — ✓ bay sink completely obstructed at time of inspection.3bay sink must be accessible&free from obstructions at all times to Date Inspected:Correct By: properly wash,rinse andsanitize all utensils. ,� cst.n 0� redb- Iin 'vaSki bap i cwt+ � 5te"Cu mis-I- to is bce/ $/9/2669 G ongs for hot dogs were being stored on equipment; PIC stated a hook had been used but had broken.Tongs must be stored Risk Level: either hanging or in a separate clean,sanitized container and may not be stored laying on equipment. Handwash Facilities FAIL Critical RED `Permit Number: vteomment: Handwash sink at counter is used to fill cleaning buckets.Hand wash sink must be used only for handwashing;fill BHP-2009-01$2 buckets for cleaning in mop sink.Label this sink'handwashing only'. Status: yeack handwash sink obstructed by a ladder.Handwash sinks must be accessible and free from obstructions at all times. VIOLATION TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) #of Critical Violations: Hot and Col/old Holding FAIL Critical ❑�/ RED 4 ieomment: Hot dogs measured at a temperature of 124°F at time of inspection. PIC did not know how long they had been out; hot Time IN: Time OUT: dogs were discarded. Hot dogs must be held at a temperature of 140°F or higher at all times. 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®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 11,2009 ) Page 1 of I! 1 Item Status Violation .. Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related t0 Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions Veornment:Condiments did not all have their own utensils. Provide separate utensils for all condiments to prevent cross and Risk Factors (Require contamination. immediate corrective action) /he following outdated items were removed: 2 starbucks vanilla frappucinos 2 minute maid of 4 tropicana twister juice 17 nestle pure life iced tea 18 nestea decal iced tea 1 dasani raspberry 13 dasani plus orange tangerine 6 dasani plus kiwi strawberry 51q.gatorade lemon lime 9 1q.gatorade orange 10 red gatorade tiger Approx.24 G2 fruit punch 5 G2 orange 8 powerade zero strawberry 2 soba life water 4 aquafina alive orange/lime 11 lemon propel 7 sugar free red bull 5 mug root beer 10 sierra mist 6 schweppes ginger ale 1 mountain dew 5 grape tropicana twister 10 grape fanta 12 coke zero 2 slim jim beef&cheese 2 old wisconsin beef/cheese sticks 1 bag wise chips Owner to closely monitor all expiration dates. Equipment and Utensils FAIL Non-Critical BLUE Comment:Sanitize bay of the 3bay sink must be re-labelled. &.04`ket on cooler door in back room is broken. Repair or replace gasket to ensure door closes and seals properly. iii,�4offee counter needs general cleaning. VBottom milk racks in the cooler need general cleaning. Both drink coolers at front counter need visible,accurate internal thermometers in them. 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. Mar 11,2009 ) Page 2 of �y 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. Mar 11,2009 ) Page 3 of Commonwealth of Massachusetts i City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo"etail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: Hess Express 21519 File Number:BHF-2004-000059 1 Hess Plaza/J.Flaherty Woodbridge NJ 07095 LOCATED AT: 0086 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0132 Dec 23,2008 Dec 31,2009 $280.00 TOBACCO VENDOR BHP-2009-0133 Dec 23,2008 Dec 31,2009 $135.00 Total Fees: $415.00 PERMIT EXPIRES IDecember 31, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any 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 * 1 QTY OF SALEM, MASSACE IUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4'H FLOOR `ISL.(978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR LCOTr(a?SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1 eS5 EIKPse5�5 a\5101 TEL# -1 Ll q-I R�1 ADDRESS OF ESTABLISHMENT �(� Ne r`W QJI FAX# MAILING ADDRESS(if different) EMAIL-Business': $ Hess Plawlflaherty Woodbirldge, J OWNER'S NAME 733.780p88b0 TEL# ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) fired in an establishment where potentiallyhazardousfood is prepared) EMERGENCY RESPONSE PERSON ('�1VCW V\C I AHOME TEL# ��5`�3 0 C�'�`✓ �� DAYS OF OPERATION i Monday Tuesday i Wednesday 1 Thursday I Friday i Saturday` Sunda HOURS OF OPERATION Please write in timeof day. s(\� (For example I lamtamd1pm) "'1111 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE Y NO less than I00osq.ft. 1000-10,000sq.ft.11%W = 28 more than 10,000sq.ft. =$420 - - ------••------ - - - ------ -----less-- .than..---255 seat e.as _------ RESTAURANT YEES O t $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 - --------------- -------YES ... ............................_...-_..... -........ .... - ..... --$100-...------ BED/BREAKFAST/ YES N ADDITIONAL PERMITS------------------- - - _ CHILDCARE SERVICES --------------- ------------------_----------- ---_-- ---------•••---- - - -----------------.. --- . MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y NO TOBACCO VENDOR ES 135 ALL NON-PROFIT(such as church kitchens) 6 *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 as must be submitted to and approved by the Salem Board of Health. uant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that t,to my best knowledge and belief,have filed all state tax s and paid all state taxes rec uired under the law. — G _ tl/e,/asr 13-y9dra Signature Date Social Security or Federal Identification Number -------------------------------------------------------------------------------------'-`------ ---"--- ---'------.....___....---'--- {.- Revised4124107FOODAP2008.adm Check#&Date II I I II NECESSARY EESSA Y IF MAILED IN THE UNITED STATES BUSINESS REPLY MAIL FIRST CLASS MAIL PERMIT NO.142 WOODBRIDGE NJ POSTAGE WILL BE PAID BY ADDRESSEE AMERADA HESS CORPORATION gTTN; JANICE FLAFIERTY 1 HESS PLAZA WB-1I WOODBRIDGE NJ 07095-0961 III,��L�JIL„IJ��JJ�II��IJ��IL�„�IL�ILI Page 1 of 2 Joanne Scott From: NNW Sent: Thursday, July 31, 2008 10:39 AM To: Joanne Scott Subject: RE: Health hazard /complaint Hi Joanne, I just wanted to make sure you were the right person. This is something I am surprised you havent heard about yet. First off, I please ask you to keep my complaint anonymous. The HESS Gas Station on North st, across from HMA Car Wash has a payphone next to the air pump. I was making a call on this phone about a month ago and didnt notice until I was almost done that there were a couple bees flying around me. Now I am a big guy, tattooed, can take pain, etc. but I am really afraid of bees, so I freaked out but I was done with the phone so I hung up. As I hung up and started to back away swiftly from the payphone, I saw a bunch of bees flying around inside the payphone area, like in the little compartment where the phone is mounted. Then I noticed where they were all heading....there is a bee hive inside the payphone compartment, in the upper right hand corner!! It is about the size of a golfball, but flatter on top where it is attached. I saw atleast 10 bees just ON the hive alone, and a few flying around it. So god knows how many are inside. So I had to go in the store anyways after I made my phone call to buy something. When I went in, I asked for the manager to let him know about this. A white male came out of the back room, about 40, going bald a little bit, kinda short...just so you know who the manager is. I told him and the clerk, who was a short, female of probably hispanic descent about the nest, and that they should get rid of it asap! I said what if someone who is allergic to beestings is on the phone and gets stung?? They are gonna have a nice lawsuit on their hands I would imagine. So I got in my truck and was getting ready to leave, started backing out of the parking spot which was near the phone, and the clerk and another customer that was in the store at the time came out to look at the hive to see if I was telling the truth. At first I heard the man say he didnt see anything, but then they saw it. So I did my part and let the manager know about it. I mean this could be a potential life threatening issue. What if a child walks by the phone or something and gets stung and is allergic?? Ive heard of people dying if they dont get medical help in time. So this was about a month ago, and everytime I have gone there to get gas, I have checked to see if they got rid of it and they have not. I went yesterday to check specifically before I looked into making my complaint, and it was still there!!! So unless they got rid of it between 830am yesterday the 30th of July, and right now at 10:30 am the 31st, I am sure it is still there, and I am sure it has probably gotten a little bigger. And these werent the little bees, these were the ones that look like they have legs coming down. So If you could look into this asap I, and probably everyone else in the area that goes to that gas station will thank you. Again, it is the HESS on NORTH ST, across from HMA car wash, not the one on what I think is New Derby st. I am surprised nobody has seen this and complained already. But I guess it fits in this day and age where everybody has a cell phone. 7/31/2008 Page 2 of 2 I do too, but my battery died, so I needed to use the payphone. If you could update me on what you plan to do about this, Id appreciate it, and I dont know how stuff like this works, but I think they deserve to be fined for this especially since they have known about it for a month now! Again, I ask that you please keep this anonymous, though they will probably know it was me who complained, because I doubt anyone else has brought this to their attention. Even though they dont know my name or anything, I go there a lot. So I guess III just go somewhere else. Sorry for such a lengthy email, but I felt like I had to tell the story in detail, so you knew exactly what you were dealing with. Thank you Joanne, and please keep me posted. Sincerely, Subject: RE: Health hazard / complaint Date: Wed, 30 Jul 2008 10:28:50 -0400 From: ]Scott@Salem.com To. Dear4PFAIVENW. If the complaint relates to a public health issue, then I would be the person to contact. It is difficult for me to answer your question with certainty since I do not know the exact nature of the complaint. Sincerely, Joanne From: Sent: Wednesday, July 30, 2008 9:09 AM To: Joanne Scott Subject: Health hazard / complaint Hi Joanne, My name is Peter Butcher. I have a complaint which could be a potential life threatening situation for someone. Im not sure if you are the person to talk to about it or not, so if you could email me back and let me know, I would appreciate it. Thanks, Keep your kids safer online with Windows Live Family Safety. Help protect your kids. Stay in touch when you're away with Windows Live Messenger. IM anytime you're online. 7/31/2008 10 � 1 1 ��/ s►.a . . ■ . - . , .. . . . .. ■_ . a � - � ■ o � e � ... n.,� � P �.• s '. � • "l. 1_ — .� .- ,i . ' � 1�I�.� � .- ...- CoyvA00cnV uy5n,3 JOT � . ),A HP Fax Series 900 Plain Paper Fax/Copier Last Fax Date Time T_)= Identification Jul 24 6:15pm Sent 919785311012 Result: OK - black and white fax r 0086 NORTH STREET Hess Express 21519 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-1696 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:Small soda reach-in missing thermometer.Provide visible,accurate internal thermometer for this unit. Amerada Hess Corp. PIC: Delia Garcia Inspector: Elizabeth Salandrea Date Inspected:Correct By: 3/46/•/2966 4/;)/0Z ES- Risk Level: Permit Number: BHP-2008-0001 Status: SIGNED OFF #of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: All other violations noted in the 3/26/08 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 18,2008 ) Page 1 oft (iQ Item Status Violation Critical Urgency RED: _ a 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®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 18,2008 ) Page 2 oft } E' 0086 NORTH STREET Hess Express 29519 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: D Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-1696 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: tow,ment:3 bay sink obstructed with boxes and product at time of inspection.3 bay sink to be kept clear and accessible at all Amerada Hess Corp. tim and used correctly in a 3-part system to wash,rinse and sanitize all utensils and dishes. PIC' anitizin solution found weak at approximately 100 ppm.pp y ppm.Provide sanitizing solution of proper concentration(200ppm)at all times. Chuck Braman - - -- -- - - Handwash acilittes FAIL Critical E/j RED Inspector: Elizabeth Salandrea omment: Back handwash sink obstructed and missing paper towels.Handwash sinks must be clear and accessible at all times, Date Inspected: and 'Correct By: ust have paper towels available at all times. 3/2612006 a faucet on the front handwash sink is loose and in disrepair. Repair or replace the faucet. Risk Level: Permit Number: BHP-2008-0001 Status: VIOLATION #of Critical Violations: 3 Time IN: I 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 02,2008 ) Page / of Z', 14 hem Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Management and Personnel FAIL BLUE Foodborne Illness Interventions and Risk Factors (Require Food Food Protection FAIL critical BLUE immediate corrective action) Comment:The following items were removed,outdated: 24 cans redbull 16 1L sprite 161L Pepsi 14 1 L coke 9 vault soda 7 1L canada dry ginger ale 7 gatorade 5 cans sobe adrenaline rush 4 diet Pepsi 3 ache essential energy 2 bags ritz bitz 1 mug root beer - 1 mountain dew 1 starbucks frappucino Owner to closely monitor all expiration dates. Equipment a Utensils FAIL Non-Critical BLUE mment:Walk-in cooler missing thermometer.Provide visible,accurate internal thermometer for this cooler. Small soda reach-in missing thermometer.Provide visible,accurate internal thermometer for this unit. GENERAL COMMENTS: 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®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 02,2008 ) Page 2 oft wl.m66"� � _ _ - .- _ _ -- �__ r - _- , ', JMPORTAP1T MESSAGE FOR DATE 7 'e2 Q 7 TIME % OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE UMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU n WILL CALL AGAIN WANTS TD SEE, 'RUSH 'IRUSH:. RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED ;WonFORM 4009 MARE IN U.S.A. d NOTES ._ s .,1 + - _ ;, ,'� as .�: "�•,�:Gr,,®•d'�F"m.w r,`u.t ...�'T. -' � »«..:I"x s �:'� u.. - `a Commonwealth of Massachusetts City of Salem r r Board of Health I('jfprleY OfISC011 126 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo&Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Hess Express 21519 File Number.BHF-2004-000059 - 1 Hess Plaza/J.Flaherty Woodbridge NJ 07095 LOCATED AT: 0086 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions!Notes RETAIL FOOD BHP-2008-0001 Jan 3,2008 Dec 31,2008 $280.00 TOBACCO VENDOR BHP-2008-0030 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31,2008 Board of Health . d This Permit is not transferable and must be reissued upon change of ownership or location.The permit must bepostedin a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,an plans for such must be submitted to and approved by the Salem Board of Health. Page 23 of 28 QTY OF SALEM, MASSACHUSETTS Q/(/ BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL pFAX(978)745-0343 MAYOR �t E , � `E D iscoma)SALEM.COM JOANNE SCOTT, , ` DEC 3- 2007 HEALTH AGENT y OF SALE.M BOARD OF HEALTH 2008 APPLICATION X FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT t >eSS CAP'fIESS �kN5I9 TEL# ADDRESS OF ESTABLISHMENT qD NO r�N'1 ?JI FAX# MAILING ADDRESS(if different) HESS CORPORATION EMAIL-Business': 1 Hess t Plaw4laherty ger ��jj OWNER'S NAME 732.71110-c350 TEL# ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) G EMERGENCY RESPONSE PERSON C_�\UcK 1rn e C Ar"Yny ({1G2- HOME TEL# DAYS OF OPERATION 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION Please write in time of day. For example Ilam-11pm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE Y NO less than 1000sq.ft. 1000-10,000sq.ft.iWO = 280 more than 10,000sq.ft. =$420 --------------------------- ----------------------------- RESTAURANT YES O less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ------------------------------- BED/BREAKFAST/ YES ----N- -------------------------------------------------------------- - ------------ .$100----- CHILDCARE SERVICES---------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y NO TOBACCO VENDORES N 135 ALL NON-PROFIT(such as church kitchens) *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. pP:-� i//a&/a-i 13-y9al Signature Date Social Security or Federal Identification Number ------------------------------------------------------------p----—-----------------j" --- -- – – ------------------- Revised 4/24/07 FOODAP2008.adm Check#&Date y�/S (, / � $ b go 0086 NORTH STREET Hess Express 21519 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-1696Food Contact Surfaces Cleaning and Sanitizing PASS Critical RED I -caner: Comments:The 3 bay sink is completely cluttered with boxes. The 3 bay sink must be kept clear and accessible and used in a Amerada Hess Corp. three part system to wash,rinse and sanitize all dishes and utensils. PIC: There is no sanitizing solution available in this establishment. Sanitizing solution of proper concentration must be readily available at all times. Inspector: � There are items stored in the ice scoop container. Properly clean and sanitizer the container and ice scoop and store ONLY the ice David Greenbaum scoop in this container. Date Inspected:Correct By: Handwash Facilities PASS Critical ❑J RED 2/5/2007 Risk Level: Comments:The faucet at the counter hand wash sink is loose and in disrepair. Repair or replace the faucet. TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Permit Number: ; Hot and Cold Holding PASS Critical ❑d RED BHP-2007-0001 Comments: The hot dogs had a temperature of 130°F. All hot potentially hazardous foods must be held at a temperature of 140°F Status: or higher. 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 05,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection PASS Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comments:The follwing items found outdated at the time of inspection: corrective action 11 -Beef jerky immediate _ ) 11 -Starburst fruit&cream smoothie 4-Tostitos salsa 11 -Tostitos Queso dip 3-BBQ Sauce 11 -Campbell's soup at hand 4-Pancake mix 20-Jack links Owner must closely monitor all expiration dates. Physical Facility PASS Non-Critical BLUE Comments:There are hoses hanging in the mop sink. Provide back flow prevention devices on these hoses or remove. The mop stored in the mop bucket. Clean mop and store upside down not touching any surface to air dry. GENERAL COMMENTS: All violations cited in the 1/29/07 inspection report have been corrected. 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 05,2007 ) Page 2 oft 0086 NORTH STREET Hess Express 21519 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-1696 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical S6 RED Owner: Co ment: The 3 bay sink is completely cluttered with boxes. The 3 bay sink must be kept clear and accessible and used in a three Amerada Hess Corp. j rt system to wash,rinse and sanitize all dishes and utensils. PIC: Th a is no sanitizing solution available in this establishment. Sanitizing solution of proper concentration must be readily Reyna Morales a,lable at all times. Inspector: Ty e�are�dems stored in the ice scoop container. Properly clean and sanitizer the container and ice scoop and store ONLY the ice David Greenbaum scl/ oop in this container. Date Inspected:Correct By: Handwash Fac,'4s FAIL Critical d❑ RED 1/29/2007 Risk Level: omment:The faucet at the counter hand wash sink is loose and in disrepair. Repair or replace the faucet. TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Permit Number: Hot and Col olding FAIL Critical ❑� RED BHP-2007-_0001 omment:The hot dogs had a temperature of 130°F. All hot potentially hazardous foods must be held at a temperature of 140°F or Status: igher. 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®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 29,2007 ) Page I oft M Item - Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comment The follwing items found outdated at the time of inspection: immediate corrective action)_ 11 -Bo ef jerky -- 11 yStarburst fruit&cream smoothie 4 yTostitos salsa 1/1 -Tostitos Queso dip /3-BBQ Sauce /11 -Campbell's soup at hand / 4-Pancake mix 1VI 20-Jack links Owner must closely monitor all expiration dates. Physical Facili ,' FAIL Non-Critical BLUE Ctmment:There are hoses hanging in the mop sink. Provide back flow prevention devices on these hoses or remove. mop stored in the mop bucket. Clean mop and store upside down not touching any surface to air dry. GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. ( J City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMSQ 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 29,2007 ) Page 2 oft a1549 10 pre CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH � �� 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 w TEL. 978-741-1800 DEC 152006 FAX 978-745.0343 CITY OF SALEM Kimberley Driscoll WWW.SALEM.COM BOJii-'IO OF HEALTH Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR GPERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT \AeS-S _ nPCeSS :Rk619 TEL# I.Elq-19`11 ADDRESS OF ESTABLISHMENT Ro NQi�t,r 1G4_ FAX# MAILING ADDRESS(if different) NESS CORPORATION EMAIL-- Business': Ness PIt a Ptnp1Aelty OWNER'S NAME Woodbridge, NJ 07095 TEL# ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL At DAYSOFOPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION f�y Please write in time of day, (for examole Ilam-llom) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 50 1000-10,000sq,ft. =$100 two more than 10,000sq.ft. --- ------- - - ..._---------- ---- - -- - -- - --- - ---- --- ---.........--- ......------ -..._.....--- RESTAURANT YE5 NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 ST Y--- _ --- ----. O N-- "._ - ....._...... .... ..._-.... ... - - - - ------------------------ ------------- - ---- ._....----- ---- BEDIBREAKFAYES NO $100 ---- ------------ ----- ----- --- ...--....-.... . ..._._._-...-- - ---- ---------------............._... .....-..... -- --- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE DYESNO $25?D TOBACCO VENDOR ALL NON-PROFIT(such as church kitchens) YES NO '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 lax returns and paid all state taxes required under the law. Signature Date Seel Seetrr+t+reFFederal Identification Number ---------------------- ------ ----------- ---- -- -- --------- - ------------- ------- ------------ -------------------------------- ----------------- Revised 11/13/06 FOODAP2007..adm '�Check#8 Date OaWA-.,z�(,�'l� $ —16-57, oO 000002]5 400390 A 10050 01 0OW15.0003 00003 A 732)750-6803 Hess Companies Attn: Accounts Payable Dept One Hess Plaza Woodbridge NJ 07095 RECEIVE® DEC 15 2006 CIT --0F SALEM BOAF.j OF HEALTH CITY OF SALEM BOARD OF HEALTH 120 WASHINGTON ST., 4TH FLOOR SALEM MA 01970 y£WQQR AA7F GiECK NQ. 0000540402 12/08/2006 0201022484 ATV/LQC itQJQIG£ KA. QATE 1 A AA. MOSS,gMQUN] ATSGAQNr AMQUNT MEr AMOT 0590 12/6/06-21519 12/06/2006 $155.00 $0.00 $155.00 FOOD/-,IG/FROZEN PERMIT RENEWAL HESS 821519 $155.00 $0.00 $155.00 -5 ,...gy ..r t y4h. b»a v1 g,+rn T r a4 •e t tr a yre. n t r ° l Y OFI SALEM MAS AS CHUS TS 14 � -�� ,ica�w....�` fR {fi^��• '° Mg 1 /, �Y.A1. T" ` i F' d�as°`.-.5.� T.t Y� fi _T l4 4W'e*.'�tYl 5 g f 4 �r�. •� •7 � • w �,yMaa � > '1�3 BOAflDxOF HEAL7HTZ^:a , st"' a � �,�� x � ^. 'r.`. a<' M;x`` ?12.OSWASHIN�TONSTAEET,`4TH;FLOORtt'.-� ,.. i." »�.4. am, �.. ' Vit•' r°�h? a aSnLErui;MA'U1970 �," w n v ..� }tttfi ..,a TEL 978-741-1800 FAx 978-745-0343 WWWSALEM.COM Kimberley Driscoll Mayor JOANNE SCOTT, MPH, AS, CHO y HEALTH AGENT April 24,2006 1 Hess Oil 90 North Street Salem, MA 01970 Dear Owner: On Wednesday April 12,2006 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old male purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Hess Oil is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of(Two Hundred Dollar fine)for the Second offense. FOLLOWING THE THIRD (3RD) OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control 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$200.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th floor, within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sjr1cerely yours, f Joanne Scott Health Agent JS/mfp CERTIFIED MAIL: 7003 3110 0005 1992 2292 cc: North Shore Tobacco Control Program Christina Harrington, Board of Health Chairman and Members `k G ✓ , �'!< rs• � "Cat,+, yid R �. '�' j1�`�$�Y,a s. � 6 v> > ✓� Y � ti � Xiy^{/„'F. ?� t r J ..n ] X i tb aa. •� 7� ..F i t t t <'' t� r 'T r ,�' �F c • �1 y !'(732)750-6803 JPMorgan chase'Bank,N.A. so 3r ;'AmeraEa Hess Companies syracuse,Newvok 213 iAttn: Accounts Payable Dept iOne Hess Plaza j Woodbridge ,.NJ: 07095 CHECK DATE CHECK NUMBER PAy IN U.S.DOLLARS 05/03/20061 0200962080 ssssxss*sss*ssssasssss(I� ftAVREn'AND 00/100 DOLLARS**s******ssss********* - 104g4KAMDUN7 TO THE ORDER OF CITY OF SALEM s200.00 ORDER BOARD OF HEALTH - - 120 WASHINGTON ST., 4TH FLOOR / SALEM MA 01970 219 Aulhonzed Signalure - VOID AFTER 60 DAYS Ila❑ 2009P. 2080n• 1:0 2 1309 379 : 60 Lee-8eel i 34 5411■ 0086 NORTH STREET Hess Express 21519 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-1696 Handwash Facilities FAIL Critical ❑Q RED Owner: Comment:The back handwash sink found obstructed. Keep handwash sinks clear and accessible at all times. :Amerada Hess Corp. PIC: ' Violations Related to Good Retail Practices (Blue Items) Inspector: Water, Plumbing and Waste FAIL Non-Critical BLUE David Greenbaum Date Inspected: Correct By: Comment:The top of the toilet tank in the men's room is missing. Replace the tank cover. 3/9/2006 A new cover has been ordered for this toilet. Risk Level: GENERAL COMMENTS: Permit Number. 524:AII other violations cited in the 3/2/06 inspection report have been corrected. BHP-2006-0310 Status SIGNED OFF #of Critical Violations: ' 1 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. Mar 13,2006 ) Page 1 oft Item Status Violation Critical Urgency RED' Violations Related to Foodborne Illness Interventions` and Risk Factors (Require immediate corrective action) �oc � ut'�� 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 13,2006 ) Page 2 oft r� 0086 NORTH STREET Hess Express 21519 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-1696 Food Xau Cleaning and Sanitizing FAIL Critical ❑� RED Owner: ere is no sanitizing solution available. Sanitizing solution of proper concentration must be readily available at all food Amerada Hess Corp. es. y PIC: The ice scoop storre on top of equipment. Clean and sanitize the ice scoop and store in sanitized container labeled"Ice Scoop Reyna MoralesOnly Inspector: ,: Handwash Facilities FAIL Critical ❑d RED David Greenbaum Comment:The back handwash sink found obstructed. Keep handwas sinks clear and accessible at all times. Date Inspected: Correct By: '.3/2/2006` Tack handwash sink missing paper towels. Provide disposable paper toewls at this handwash sink at all times. Risk Level: " TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Permlt Number '- Hot and Cold Hol g FAIL Critical RED BHP-2006-0310 Co ent: Hotdogs had a temperature of 126"F. Hot potentially hazardous foods must be held a temperature of 140`F or higher. Status: VIOLATION sf #of Critical Violations: 4 4 Time IN: Time OUT: ;a 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. Mar 02,2006 ) Page 1 of Mfr ---- Item Status Violation Critical Urgency RED. Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comment: Th` following items were found outdated at the time of inspection: immediate corrective action 4-Pint fTnilk 4 -g Vlons of OJ 2--apple juice ( -32oz OJ 1 l/ 1 -1l2 gallon OJ 2-powerbar harvest Closely monitor all expiration dates. _ duct stored in the ladies room. Food products must be stored in an appropriate food storage area. NOT in the ladies room. Equipment and Utensils FAIL Non-Critical BLUE Co rent: Defrost the ice cream freezer so the thermometer is visible. Wate tubing and Waste FAIL Non-Critical BLUE C.— Comment:The top of the toilet tank in the men's room is missing. Replace the tank cover. GENERAL COMMENTS: 507:Reinspection in one week. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Launers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 02,2006 ) Page 2 oft n E Commonwealth of Massachusetts City of Salem ` Board of Health 120 Washington Street,4th Floor '�rrrtr� SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2006 WHO'S PLACE OF BUSINESS IS: Mess Express 21519 Fife Number:BHF-2004-0059 I Hess Plaza/J.Flaherty Woodbridge NJ 07095 LOCATED AT: 0086 NORTH STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FROZEN DESSERTS BHP-2006-0308 Jan 4,2006 Dee 31,2006 $5.00 RETAIL FOOD BHP-2006-0310 Jan 4,2006 Dec 31,2006 $100.00 TOBACCO VENDOR BHP-2006-0309 Jan 4,2006 Dec 31,2006 $50.00 Total Fees: $155.00 PERMIT EXPIRES jDecernber31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 5 of 20 3 ALE', MASSACHUSETTS .; Noy 14 2000 BOARD OF HEALTH y, Y 9 20 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 - CITY OF SALEM TEL. 978-741-1800 71,fOOyl �Sj90 if BOARD OF HEALTH FAX 978-745-0343 STANLEY J. USOVICZ, JR. - JOANNE SCOTT, MPH, RS, CHO MAYOR I HEALTH AGENT 204APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT T� NAME OF ESTABLISHMENS G.x{ ff4 S�U(�(S 1 q TEL#__ 14q— 9 _ ADDRESS OF ESTABLISHMENT_ MAILING ADDRESS (if different) AMEKAUA 1, 1 HESS FI r e V i OWNERS NAME N ADDRESS---- 732-NO-52550 CITY_ STATE -.i_ ZIP CERTIFIED FOOD MANAGER'S NAME(S)� CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) i R EMERGENCY RESPONSE PERSON GI2ANirti L)ti(Y1feV1C HOME TEL# �41�—g�S�" IC73O HOURS OF OPERATION: Mon. ue`[_Wed. Thu. Fri, Sat. Sun. _TYPE OF ESTABLISHM ( n FEE check only RETAIL STORE YE NO `,O .�W less than 1000sq.ft. =$ 50 J1 , 1000-1,0,000sq.ft. � more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BEDIBREAKFAST YES NO $100 ADDITIONAL PERMITS —C{4 MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE Y S NO QW TOBACCO VENDOR S -(�(p YES NO $50 ALL NON-PROFIT(such as church kitchens) YES $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment: In accordance with the State Sanitary Code; before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledp�� belief, have filed all state tax returns and paid all state taxes required under the law. 1 /047/03 13"I! 1@100a —, Signature Date Social Security or Federal Identification Number ------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Cherk#&t7ate iL�Lf Q01 �/Q� CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA O 1970 Sb Massachusetts Department of Public Health Salem Board of Health 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 NameDet �� Tvoe of Ooeration(s) Type of Inspection ;f / ❑food Service ig-Routine Address e �s Risk (!!I Retail ❑ Re-inspection Telephone Level El Residential Kitchen Previous Inspection 7YY, i k ❑ Mobile Date: Owner HACCP Y/N [-ITemporary E] Pre-operation '4WA A Afu ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time E-1Bed&Breakfast [I General Complaint SdtJ4t Lefd(AA-e3vlc.- In: ❑ HACCP Inspector 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 P-163. Handwash Facilities EMPLOYEE HEALTH .. " ` El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMErrEMPERATURE 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 ❑ 1 : Cooling PROTECTION FROM CONTAMINATION V. 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 Handwashing [121. Food and Food Preparation for HSP ❑ 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 ofd,Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address FTI29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:50WOForm 14.do Inspector's Signature- Print: PIC's Signature: ��jv/� Print: Sys,/ A, �o.� Page oC? Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Dies s-contamina fon 1 590.003(A) A."ignment of Responsibility" 3-302.11(A)(1) Raw Animal Peds Separated fiom 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods" 2--103.1 1 Person in charge--duties Contamination from Raw Ingredients 3-302,11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other" 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Pt otection" _ applicants,* 3-302.15 Washine-Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee.Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person It Utensils* Chane* Contamination from the Consumer 590.003((3) Reporting by Person in Charge* 3-400 14(A)(B) Retuned Food and Reservice of Food" 3 590.003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590903(E) Removal of Exclusions and Restrictions Food 3-701A I Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Foal* q 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law" 4-501.111. Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products' 4-501.112 Mechanical Warewashing-Hot\Vater 3-202.13 Shell Eggs* Sanitisation Temperatures" 3-202.14 Ee*s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,PH, . 3-202.16 Ice Made From Potable DrinkinG Water" concentration and hudttess " 5-101 A I Drinking Water from an Approved System" 4-601.1 I(A) Equipment Food Contact Surfaces and 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 Pregnancy of Sanitizxrtion of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of P q ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chetmcal* Sources" 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2 Regulatory Authority .301.11 Clean Condition-Hands and Arms* 3-202.19 Shellstock Identification Present* 2-301-,12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 )Mien to Wash" 3-201.17 (lame Animals" 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking wUsing Tobacco* 3-202,11 PHFs Received at Proper Tem erattues* 2-101.12 Discharges From the Eyes.Nose and 3-202-15 Package'Inte¢rit " Month* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventl.ne Contamination When Tasting* fi TagslRecords:Shellstock 12 Prevention of Contamination from Hands 3-202.15 Shellmock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* TagsfRecords: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conversantly Located and Accessible 3-402.12 Records.Creation and Retention* 5-20111 Numbers and Ca acifies* 590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.1I Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processin�Methods* Devices 3-502.12 Reduced oxygen packagine,criteria* 6-301.11 Hand washing Cleanses Availability 5-103.12 Conformance with Approved Procedures" 6-301,12 Hand Drvir,Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.(1(10. CITY OF SALEM i BOARD OF HEALTH Establishment Name: Va rr §Pe"S S 2/;-/? Date: _7A�i df Page: 2 of 2- Item Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference - R-Red Item Verified PLEASE PRINT CLEARLY.. 2 rAwa r✓r N r r�.yr /Gd,W drn _ ►+6- i Kir s r MN 1 g,, . / 2 rf(L /Nfl 0� !'4r"aSC, age- ME&431 A pi/•e!"0 .�!'_ vt L$1 nfA, N IITiI e�S' rk df I'M'r` *Ca - P'7 N 0"'7& A er lsMY LA ff"V /Al*rrf /*w r S 14, 4" /CV 6M .IdA 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/ p PP Y 4 9 Exclusion violations before the next inspection, to observe all conditions as described, andto E3 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 ollars or s gpension/revocation of ❑ Embargo ❑ Emergency Closure Q your food permit. ❑ Voluntary Disposal ❑ Other: i r 3-501..14(0) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to I.aw Cooled to Factors(Items 1.22) (Cont) 41'F/45'F Within 4 Hours.' PROTECTION FROM CHEMICALS 3-501.'15 Conlin«Methods fur PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives' 7501 16(B) Cold PIIFs Maintained at or below 3-302.14 Prosection hour'Unai roved Additives* 590.004(F) 41"145°F` 3-501.16(A) ]-tot PHFs Maintained at or above 15 � Poisonous or Toxic Substances 14WR * Co 7-101.I1 Identifying Containers'ers'Information-Original 3-501.7.6(A) Roasts Held at or above 130°F.`K 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storages` 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Re augment 7-202.12 Conditions of Use' 7-20311 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizets,Criteria-Chemicals* . POPULATIONS(HSP) 7-204.1.2 Chemicals foi-Washirw Produce,Criter6ia4 21 3-801.11(A) Lnp isteutwed Pre-packaged Juices and 7-204.74 Drying Agents,Crlleria'" ----�- _ Beverage,,with Warning I abets* 7-205.11 Incidental Food Contact,Lubricants* 3-801.1](8) Use of Pasteurized'Lu,,UsM 7-206.1 I Restricted Use Pesticides.Criteria`" 3-801.11(D) Raw or Pmtially Cooked Animal Food and Raw Seed Sprouts Not Served.,t 7-206.12 Rodent Bait Stations` 3-8(I1.17(C) Uno cued FoodPackaaeNoURo-served. 7-206.'13 Tracking Powders,Pest Control and Monitorinn* CONSUMER ADVISORY TIMET TEMPERATURE CONTROLS 22 3 f 03.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods'that are Raw.1(ndercooked or PHFs Not Otherwise Processed to Eliminate 3-401.1IA(1)(2) Fggs- 1.55`F 1. 5 Sec. Patho<lens.* er nn�e rnizoa i E sirs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11.(A)(2) Comminuted Fish, Meats&Game Eris* Animals- 155'F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast- 130 F 121 nun" SPECIAL REQUIREMENTS _ 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering.mobile food, temporary and 3-401.1.1(A)(3) Poultry,Wild Game, Smfted Plip" residential kitchen operations should be Staffing Containing Fish, Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Conked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F '15see. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-103.11(3)&(D) PHFs 1650F 15 sec. " (Items 23-30) 3-40111(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness intervenlions and riskf actors listed above, can be 3-40111(C) Commercially Processed RTE.Foal- found is the following sections of the Food Code and 105 CMR 140'F* 590.0_0_0. 3-403.1 m .1(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts* 23. Mana eq mart and PersonnelFC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC-3 004 25 __ Etc uipment and Utensils FC 4 _005 3-501.14(0) Cooling Conked PHFs from 140°F to 26 Water,Plumbin and W asie FC-5 .006 -- 70'F Within 2 Hours and From 70"F 2/ Ph sical Facility _ FC 6 .D0707 to 41'F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14($) Cooling P1-IFs Made From Ambient 29. Special Requirements - - - .009 Temperature Ingredients to 41cF/45°F 30, Other Within 4 Hours* ssvo�.nm,Kr6¢m� Denotes eraicA item in the Weral 1999 Food C'udr or 105 CMR 590000. ` ..'•.o- 1 CITY,OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR - a 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: RETAIL FOOD Name of Establishment: Hess Express 21519 Address of Establishment: 90 North Street Owner's Name: Amerada Hess Corp. Restrictions: Application Date: 12/8/2004 Permit for Food Establishment 168-05 Frozen Desserts/Ice Cream 010-05 Permit for the Sale of Tobacco Products 41-05 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. �H AGENT f CITY OF SALEM, MASSACHUS BOARD OF HEALTH C 9, 120 WASHINGTON STREET, 4TH FLOO F ,1I q I SALEM, MA 01970 DEC - 2004 TEL. 978-741-1800 FAX 978-745-0343 CIN OF SALEM STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2005 APPLICATION FOR ,PERMIT STO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT i'CS$ EXPCeSS�AO91:51 q TEL# _I '{LI-1(0_l ADDRESS OF ESTABLISHMENT ct© No'%A " 1. MAILING ADDRESS (if different) AMEERAUA _ SS GORPORAT!011�- OWNER'S NAME 1 HESS PLAZA/J1 FVVUUUbmulorLA4 ADDRESS 732-750-6350 CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) N\ N EMERGENCY RESPONSE PERSON N\n �CJn(PfeV\C HOME TEL# X011 -$FS I" IO3O HOURS OF OPERATION: Mon.A�J�ue7 _Wed. Thu. Fri. Sat. Sun. TYPE OF ESTABLISHMELIZ FEE check only RETAIL STORE (LEV NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. � 1 more than 10,000sq.ft. =$250 RESTAURANT YES NO QioS less than 25 seats =$100 f �,U 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE Y S NOUV TOBACCO VENDOR �1-Y YES NO $50 ALL NON-PROFIT(such as church kitchens,10127-'0 YES ® $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledgq an elief, have filed all state tax returns and paid all state taxes required under the law. 5 /i//0'/05/ I3-`/98100;L Signature Date Social Security or Federal Identification Number ----------- ---------------------------- -/3------------ aorSu/3 /l - ------------------------------------ Revised 11/03/03 FOODAP2.adm Check#&Date 1 "r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR c 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: RETAIL FOOD Name of Establishment: Hess Express 21519 Address of Establishment: 90 North Street Owner's Name: Amerada Hess Corp. Restrictions: Application Date: 11/26/2003 Permit for Food Establishment 43-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 010-04 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 a • u CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 NOV 2009 `i 2 A TEL. 978-741-1800 U J FAX 978-745-0343 RCITY OF SALEM STANLEY (J tJOVIGZ, JR. JOANNE SCOTT, MPH, S, OHO BOARD �J OF HEALTH H MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ks'� Exprem TEL# �'Vy-1(09%0 ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) AMERADA HESS CORPORATION OWNER'S NAME WOODBRIDGE, N L0 ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) at l n r 4 CERTIFICATE#(s) rc� -- (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON 7Atr1 ,,64 HOME TEL# 91 -5� (3ia HOURS OF OPERATION: Mon. OO�� e. e Thu. TFri. TYPE OF ESTABLISHM T FEE check only RETAIL STORE YES NO less than 1000sq.ft. $50 1000-10,000sq.ft. 0 more than 10,000sq.ft. =$250 RESTAURANT YES NO �p less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT, SOFT SERV �Y , N *21 TOBACCO VENDOR 0!0 -i9� Sri ALL NON-PROFIT(such as church kitchens) YES NO Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge nd b liep,, have filed all sta e tax returns and paid all state taxes required under the law. t,/i1/D3 13-klgtaOoo-� Signature Date Social Security or Federal Identification Number ---------------------------------------------------------------------------------------------4--- Revised 11/03/03 FOODAP2.adm Check#&Dated �_ s..3 �C OZ '— 1 TA Massachusetts Department of Public Health Salem Board 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 Date / Tvoe of 0 eration(s) T a of Inspection l LFS S 12� j 1 f� n ❑ Food Service 0 Routine Address Risketail ,(�-Rti-inspection 9b S Level ❑ Residential Kitchen Previous In/spec/tion Telephone p 6 ❑ Mobile Date: _ /1 3/U`f HACCP YIN ❑ Temporary [__1Pre-operation Owner f t $ [3Caterer [ISuspect Illness Parson in Charge(PIC) Time 171Bed&Breakfast ElGeneral Complaint F n/4 oleaL2s In: [IHACCP Inspector � u uS(,7tx 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 .. r 1 ' 1 : I: ' ' P 3 �'s 7 PROTECTION FROM CHEMIOAL9 ; 3 ❑ 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` , a ! . , _ , ' El 4. Food and Water from Approved Source `TIMEITEMPERATURE CONTROLS(Potentially Hazardous Faods) ' ❑ 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 HIGH"SUSCEPTIBLE POPULATIONS(HSP) -' ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ` ❑ CONSUMER ADVISORI 11. Good Hygienic Practices Y ' „ ' . . ❑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 Heafth. 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 Beard of Health. Failure to correct violations 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)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:5901nspeciform6d4.d. Q '+s ignatur ..� Print: r PIC's Signature: 10 17 Print: Pagel of images yrt � . , I PY 'I Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 590003(4) I Asi-nment of Re 3-302.17(A)(1) Raw Animal Foods Separated from S90.003(B) Demonstration of yrarrx ledges` Cooked and RTE Foods* --I'll. .. .... Pcr�on in charge. - dutiel, Comaim0ation froni Raw ingradients - 2703.11-'' '( TP,1:1 3-302.1 I(A)(2) Raw,Animal Foods Separated from Each EMPLOYEE HEALTH Other, 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require jeplating by Inod employees and 3-302A I(A) Ford Pfraection- 3-30215) Washing Fruits and Veeetables 590.601(F) Responsibility Of A Food Employee Or An 1 1 Food Contact with Equipment and Applicant,To Report To The Person in Thcrlslls* -Lila,�ge' Contamination from,the G�01-'Slnrer :Eo()�661(c') % )(T�" Rctvi Returned�Food ond�Rc�ej�ice of�FoW' 3 590.003(D) Exclusions and Restrictions" Dispossen of Aduiterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions i Food 3-707.11 Discarding or Reconditiornuo Unsafe FOOD FROM APPROVED SOURCE - Foul"4 Food and Water From Regulated Sources -9 Food Contact Surfaces L---- Manual 590.004(4-6} 4-�50 1.111 Warewashing-hot Water 3-201.12 Final in a Hermetically Scaled Container* saniti7ation lmleratures* 3-201A3 --Filmr.-Milk and Milk Productr* 4-501A Q Mechanical Warewashili.-Hirt Water 3-202.13Slautization Ttooperatureii* Limit Eggs* Sanitization-Z501-114 6h�mcal Saniti7ntioll-temp.,PH, 3-202.14 Falls and Milk Products,Pasteurized" 3-202.16 Ice Made prom Potable Drinking Water concentration and hardness. 5-101.1.1 Drinkin r Water from 4-601.11(A) Equipment Food Contact Surfaces and - 590.006(4) Bottled Drink incWater' -4-60,3.,11-0 ,a ..Utensils Clean g Fmquricy of Equipment Food- 590.0068) Water Meets Standards in 3 10 CMR 220cContact Surfaces and Utensils* -8Ihelfflsh arFish From,an Approved Source 4-702.11 Frequency of Sanitization of Utcroils and 3-201.1.1 Hsh and Recreationally Caught Molluscan Food Contact Surfaces of Kqujuncut* � - Shellfish'" 4-7p;,11 Methods of Sluatization-Hot Water and 73-201.15 Molluscan Shellfish from NSSP ListedCheonoaP Sources* - � Game and Wild Mushrooms A =10 --Proper-Adequate Handwashing P-rwvod-by 2 30111 Condition- an FClean CditiHands and Anna* 3-202,18 shellstock Identification presellO 2-301.12 Cleallm Procedure*-- When to Wash, 590.004((2) Wild Mushrooms* 2-301.14 r 3-201,17 Gamc,Animals* 11 Good Hygienic Practices Receiving/Condition 2401,11 EatiTL,Drinking or Usin 'Tobacco_* 3-202.11- Received at to at cril craturcq� 2-401.12 Discharges From the Eyes, Now and 3-202.t5 Mouth* 3-101.11 Food Safe and Unadulterated 3-301..1.2 pre!2�� Tags/Records:Shellstock L12 Prevention of Contamination from Hands 590,004(E) Preventing Contamination from T202.18 Shellstock Identification * 3-203.11 stock Identification MammincP A� Haridwash Facilities III s K 'a at 'a"' .......e" 'N sit a P T Unadulterated Tags/Records: �Salo and Uad, r�ell ... agsliReoords Shellstoc Em to gees* Tags/Records:Fish Products 5-203.11 Numbers and 3-402.1) Parasite Destruction* C. )act Conveer,by Locatod and Accessible --- ry tleO -T402.12, Records,Creation and Retention' - Location and Placement' 004(J) Labeling of ingredients' 5-204.11- Conformance with Approved Procedures 5-205.11 Accessitnhft.Operationand Maintenance Supplied with Soap and Hand Drying 3-502.11 lHACCP Plans Devices S�eciafized Processors.Mcrllod�- _ 6-301.11 liondwashn R Cleanser, Availabilitt 3-502.12 Reduced lack tc I at 8-103.12 Conformance with Ar roved Procedures" i6-301.12 Hand Drying Provision Del),jos cl ic,11 jaill in the tedej?j 1999 Food Colic or 1017,CNIR 590.000, CITY OF SALEM BOARD OF HEALTH Establishment Name: a / 5w Date: 3-/- O�l Page: cs?_ of �. Item Code C-critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date t No. Reference R—Red Item Verified PLEASE PRINT CLEARLY s�' inie / / ,fo / a } a vn - - 221ate"9 t?AIDi l /rvo i .5 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 Ll Voluntary Compliance LI 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 1 your food permit. ) � �'4'/ht f'Tml�s ❑ Voluntary Disposal ❑ Other: 3-501 14(C) PH Fs Received atTetnperatw'as Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 4P'F145`F Within 4 Horns. PROTECTION FROM CHEMICALS 3-501_15 Cnolina Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501-16(B) ColdPHF,�Maintained at or below 3-202.12 Additives* 590.004(F) !1"145'F° 3-30214 Protection from Unat.toved Addauves=o 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 40'-F 7-101.11 klentContainers* lniorntation-Original 3-501.16(A) Roasts Held at or above 130°F. Containers` 7-102.11 Common Name-Working Containers" 20 Time as a Public Health Control 7-201,11 Se oration-Stool c' 3-501.19 Pune as a Public Health Contrat* - -- 590.004(H) Variance Requirement 7-2t)211 Restriction-P,resc ice and Lyse` 7--202.12 Conditions of Use* �- 7-203.1 I "toxic Containers-Prohibitions"' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizeis.Croeta-Chemicals* _ POPULATIONS{HSPS 7-2U4.13 Chemicals for Washing Produce,Criteria* �- 3-80L11(A) Unpasteuziaed Pre-packaged Juices and 7-204.14 Drvmg Agents,C.ritedi ` Bever t as with W¢uin�Labels* 7-207).11 Incidental Food Contac, Lubricants* i-801.11(,6) Use of Pasteurized 7-206.11 Reitrieted Use Pesticides,Criteria" 3-801.11(D) Raw at Partially Cooked Animal Food and Rau Seed Sprouts Not Served. 7-206.1.2 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-20(1.13 Tracking Powders,Pest Control and Monitorin¢" CONSUMER ADVISORY TIMEffEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption o1' I6 Proper Cooking Temperatures for Animal Foods That are Raw, Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens,* 3-4(l1.11A(1)(2) Eel 155'F 15 Sec Eggs-Immediate Service 145'FlSsec" 3-302.13 Pasteurized F,�s Substitutes for Raw Shell 3-401.1 I(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec. "' u' SPECIAL REQUIREMENTS 3-401.11(6)(1)(2) Pork and Sect Roast-130F 12'1 min* SPECIAL of Section 590.009A ( 3-401.11(A)(2) Ratites, Injected Meats- 155`'17 15 ( )--D) in sec. * catering, mobile good, temporary and 3-401.11(A)(3) Poultry,Wild Game. Stiffed PHFs. residential kitchen operations should be Stuffing Containing Fish,Meat. debited under the appropriate sections Poultry or Ratites-I 65'F 15 sec. above ifrelated to foodborne illness 3-401.1 I(0(3) Whole-muscle.Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to goal retail 3-401.12 Raw Animal Foss Cooked in a - practices should be debired under f129- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHF.* -145'1715 sec. '' 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing Critical acrd non-critical violations, which do not relate to the Time* foodborne illness interventions anti rick factors listed above, can be 3-403.11(C) Commercially Processed I2TE Food- foamd in the follon•ing sections<f the Food Code and 105 CWR 140'F* 5.90.006. 3-403.1.1(E) Remaining tinsliced Portions of Beef Item ! Good Retail Practices IFC 590.000 Roasts* ImoI_23. Management and Personnel FC-2 .003 ig Proper Cooling of PHFs 24 Food and Food Protection FC-3 .004 25 Ew ment and Utens Is— FC 4 .005 _ 3-501,14(A) Cooling Cooked PRFs from 14WF to 26 Water.Plumbinq and Waste _ FC--5 --,-(Y66-_ 70"17 Within 2 Hours and Front 70"F 27. Ph sical Facilit IFC-6 .007 to 41'-F/450F 4ktthin 4 Hours. '* 28 Poisonous or Toxic Materials FC-_7 .008 3-501.14(6) Cooling PHFs Made From Ambient 29 I _Special Requirement .009 _ Temperature Ingredients to 41'F145`F 36 UOther Within 4 Hours* SStpm,in .cub zn�� *Denoras critical itern in the tidem]1999 Food Cvdc or 105 CMR 590.000. S "Ma!`JS chusetts Department of Public Health Salem Board Health Department 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 Date T e of O orations) T e of Ins ection Ile ss ! J 2 % 9 a 3 Food Service Routine Address2Risk �-etail [IRe-inspection 90 r^/a �"" Level ❑ Residential Kitchen Previous Inspection TelephoneElMobile Dater-1,,�-e3 ^- 7W 1651'4 YM 1771 Temporary ❑ Pre-operation Owner HACGP �.0 ❑ Caterer ❑Suspect Illness ❑ Bed&Breakfast ro❑ General Complaint Person in Charge(PIC) Time f' r! In: ❑ HACCP Inspecto YPermit No. ❑Other U-3 �r$C(S Out: Each violatfon`chelk�"requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-comptiance,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 I�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, - TIMENEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling El 19. Hot and Cold Holding 'PROTECTION FROM CONTAMINATION [18. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and SanitizingREQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 21. Food and Food Preparation for HSP 17110. Proper Adequate Handwashing CONSUMER ADVISORY _ ❑ 11. Good Hygienic Practices [122, Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions I �i immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): I of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days es 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 .0 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)(59o.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:SWOVs 'IFOm 44.do Inspector's Signature: 14 Print: PIC's Signature: G Print: ro l r n 9 / Cr Page ofPages I r R Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Cross-contamination 1590.003(A) Assignment of Res onsibillty* 3-302.1l(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge" Cooked and RTE Fools* 2-103.1 1 Person in charge-duties Contamination from Raw ingredients 3-30211(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other- 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require tt;porting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Ve,*etables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Otensils* Char te* ConfamfnsFe from the Consumer 590.003(6) Re carting by Person in Chm ee* 3-306.14(A)(B) Returned Food and Reservicc of Food" 3 590.003(D) Exclusions and Restrictions* Disposition ofAdufteratedorContaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discm�ding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food" L4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tet11aeratures* 3-201.13 Fluid,Milk and Milk Products* 4-501.112 Mechanical Warewashim Hot Water 5-202.13 Shell Eggs* Safiltl Zation Tem eratnres* 3-202.14 ,Eggs and Milk ProduGs.Pasteurized* --T501 114 Chemical Sanitization-temp., pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-1.01.11 Di inking Waterfront an Approved System* 4-60111(A) Equipment Food Contact Surfaces and 590.006(.x) Bottled Drinking Water* Utensils Clean" 590.006(13) Water Meets Standards in 310 CMR 22.0* 4-002.11 Cleaning Frequency of Equipment Food- Sheilfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreat ovally Caught Molluscan Food Contact Surfaces of&ai ntent* Strelli'ish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1Q Proper,Adequate Handwashing Regulatory Authority Game and uMushrooms Approved by 2-301.1 1 Clean Condition-Hands and Anus* 3-202.18 Shellstock identification Present* 2-301.12 Cleaning,Procedure* 590.004(C) Wild Mushrooms- 2-301.14 When to Wash* 3-201.17 Game Animals* L 11 Good Hygienic Practices g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.,11. PHFs Received at Proper Tem erattnes* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 package Integrity, Month* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastur 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Eng Imces" Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.f I Numbers and Capacities* 590.0040) Labeling of Ingredients' 5-204.1 l location and Placemeat* 5-205.11 Accessibilif Operation and Maintenance 7 Conformance with Approved Procedures .-_. __ /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 HandwashinK Ciean_ser, Availabflit 8-103.12 Conformance with A. roved Procedures* 6-301.12 Hand Drying Provision --Denotes critical item in the federal 1999 Fwd Cate or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH y Establishment Name: � S5 L �CP��ss eis/ P Date: Q-/3-0 Ll Page: ;2. of o2 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - Verified .; PLEASE PRINT CLEARLY r'. N k et Ire 61e-(w L/ n / l ISI • ol � Llmqr / Z2 dC 67 11 X „ WW/-74 O 0. f 2 9 — P Sa6L , r / /A✓ F Qe7` a dam / :, v e- e7( / /3 G/ - Gal s o� �� /moi i Yd /2tiG1, /O A,4V Af o d pd /d/ 4Ge- /3 C S .P�� //✓�S/ e � U� j- /� 7/L� q� c L .,Lo- aS .res Cddet�d 6 e e.,fl�'r,�� PGJdSB f /SP Si -2 -1-Ii Cyzr /� G5_e. CZE ? CLI 9 PPJt l Iy f cLS O !fP P / ( (� P CIy 7J/h2 ©F /r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension nomply 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 El Embargo El Emergency Closure z /i. your food permit. —5 s �� '� ❑ Voluntary Disposal 0 Other: - 3-501.1.4(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Lain Cooled to Factors(items 1.22) (Cont.) 4 'FI45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-SOL 15 C'txthng Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41'!45°F* 3-302.14 Protection front Unapproved Additives'( 3-501.16(A) foot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F * 7-101.11 Identifying Information-Original 3-501.16(A) _ Roasts Held at or above 130'F. ^` Containers' - 7-102.11 Common Name- Working Containers* 20 _.. Time as a Public Health Control 3-501.19 Tont is a Public Health Control)' 7-201.1 I Separation-Storage* e" 7-202.11 Restriction-Presence and User ( 590.004(FI) V anance Rec uirEment 7-202.12 Conditions of Use` R HIGHLY SUSCEPTIBLE ENTS FOR O 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS NS(HSP) _ 7-204.11 Sanitizeis.Criteria-Chemicals 7-20412 Chemicals for Washing Produce,Criteria* 21 3-801.1.1(A) Unpasteurized Pre-packaged,Juices and 7-204.14 Drying)Agents,Criteria* Beier t;es with Warnm La'tbels* ?-205.11 Incidental Food Contact,Lubricants` 3-801.11(B) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1 !(D) Raw ar Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 7.206.12 1 Rodent Bait Stations3-801.11(C) Unopened Food Package Not Re-served. " 7-206.13 Tracking;Powders, Pest Control and Monitoring` CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.,11 Consumer Advisory Posted for Consumption of Animal Farads l hat are Raw. Undercooked or l6 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs r -o,» guar 3-401.11A(1)(2) Eggs 155'F In Sec, Patho,cnti E'-s-Immediate Service 145'F 1 5sec, 3-302.13 Pastelnutd Eggs Substitute'fin Raw Shell 3-401A 1(A)(2) Comminuted Fish.Meats&Game Animals- 155 F 15 sea. * 3-401_1 l(B)(1)(2) Pod:and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- L55°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game-Stuffed PHFs, residential kitchen operations should be StufFine Containu ,Fish,Meat, debited under the appropriate sections Poultry or Ratites-165F 15 sec. " above if related to foodborne ilhress 3-401.tl(C)(3) Whole-muscle-Intact Beef Steaks interventions and risk factors. Other 145"F"` 590.009 violations relating to gatd retail 3-401.12 Raw Animal Foods Cooked in a practicesshould be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145'F 15 see. I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-4011.1(A)&(D) PHFs 165F 15 sec. " (Items 23-30) 1-403.11(B) Microwave- 165'F 2 Minnie Standing Critical and non-critical violations, which do not relate to the Tune" foodhorne ilhtess interventions and risk f(actma listed above, Calc he 3-403.11(C) Commercially Processed RTE Fond- found in the following sections of rhe Food Code and 105 ChIR 140'F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef 1 Item Good Retail Practices FC 590.000 Roasts` 23. Management and Personnel FC-2 .003 �- 1g Proper Coaling of PHFs 24 Food and Food Protection _ Fr.-,; .004_ 3-501.14(A) Cooling Conked PHFs from I4t70 F 2� Physical Facility . FC 5 .007 25. _Equipment ment and U ensils FC 4 005_ 26 Water Pumbin and Waste FC-5 006 70'F Within 2 Hours and Front 70'F 3-�01.14(B Cool�tg PHFs Made From 2S Poisonous uToxic Materials FC 7 .008 to 41°F'/45'F Within 4 Homs. �� _ ' m Arabian[ f 22 S 30 Othera,R�ulremenis _ .009 Temperature Ingredients to 41"F/45"F - g._.....-_ ------ � Within 4 Hours* """°""""`'2d- "D notes critical item in the federal 1999 Foo(!Code of 105 CNIR 590.000. co rr CITY OF SALEM, MASSACHUSETTS v`6� .(`� BOARD OF HEALTH a'c 'e 120 WASHINGTON STREET, 4TH FLOOR n � SALEM, MA 01970 a �s9 ' ....... TEL. 978-741-1800 Bp,�� 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 : Amerada Hess Corp. Name of Establishment : Hess Express 21519 Address of Establishment : 90 North Street Type of Establishment : RETAIL FOOD Application Date : 12/20/2002 Restrictions : Permit for Food Establishment 129-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 32-03 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 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • • 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 979-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT_ 00 S Z-.KW55 Oq t5�l'9 TEL# �R�I "�(993 ADDRESS OF ESTABLISHMENT _qQC3� ` 44-41' MAILING ADDRESS (if different) Amerada Hess Corporation OWNER'S NAME i Hess Piaza/J Flaherty TEL# �"k'$Q Woodbridge,NJ 07095 ADDRESS CITY CERTIFIED FOOD MANAGER'S NAME(Sj CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON �� ' HOME TEL#�I Ola S HOURS OF OPERATION: Mon. a u� Wed. Thu. Fri. Sat. Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE ES 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 BED/BREAKFAST YES NO $1q0 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVENO —. TOBACCO VENDOR E� NO 3 ALL NON-PROFIT(such as church kitchens) YES (TD $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, Improviments,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knd Lief � , have filed all stat tax returns and paid all state taxes required under the law. Gu�� talalc?2 t3-`iG1�1t'�C9a, Signature Date -�`7T'-� Social Security or Federal Identification Number sed Revi11/25102 F000AP2.WM Checw a oate...G, l ��/ f'--r/r'C' 0 rf'•w.e»-�e.*vr�.rr+r��..,.rr-"r..qy.^-+..nw-sT,.-.y.�w't^a?�.r+-.'r./ si�Y.,.'4+y+M+..ri6q�•,d�•�..v;,�.,,-rw:+a.rr""„' '--'"„i"""'-.'r--� ;v THE 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 Date Type of Ooeration(s) !Y-gQ of Ingpection /YES S c�/S 9 /02-03 E] Food Service © Routine Address Risk [ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone / �y _ q� 2 ❑ Mobile Dat%%_ G-Oo2. Owner '/ HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time El Bed&Breakfast E] General Complaint Sq In: El HACCP Inspector V, 1Vl �.V / Out: ` ' Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking 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 El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements [1 17. Reheating El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling ❑ 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 ❑ 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 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 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: Inspector's Signature:; Print: PIC's Signature: ' - - Print: Page of Pages FORM 734A HOBBS&WARREN -BOSTON f tr Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(I) Raw Animal Foods Separated from 1-171 590.003(A) I 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 i 590.003(C) Responsibility of the Person in Charge to 3-302.1 I(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting 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 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 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* 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 Shelistock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* Il Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 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* i12 Prevention of Contamination from Hands F-6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* F1-3 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(J) 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 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. t - CITY OF SALEM BOARD OF HEALTH Establishment Name: ffEss /S79 Date: e, -/� i 3 Page: 2 of �_ Item „ Code C-Critical Item DESCRIPTION OF VIOLATION /PLAN OF CORRECTION s Date No. .�„' ReferenceR-Red item r. ' ' s - �'" " a - Verified ,.. '. a PLEASE PRINT CLEARLY .. ne�dic T r� /vsrh / isc nh �i/ir � iG ✓C1rrr,Pr�/cr/o _ . . _ A>n / ALS �f._ r //,.S /� i.-/mI Or n d01"li s i v / �AAll Ae� „r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ 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 ID Re-inspection Scheduled ❑ Emergency Suspension result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure .y ❑ Voluntary Disposal ❑ Other 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 41°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs i4`` 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/45°F* 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* 1120 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* 3-801.1 l(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(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 TIMEITEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Etleolve 1/1/2001 3-401.11A(l)(2) Eggs-155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.11(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(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.* 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 S 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 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18.: Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 to 41°F/45*F Within 4 Hours.* 28, Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. t , IMPORTANT MESSAGE FOR CJD p DATE � '�- � TIME /�/U'S A P.M. OF� �A� PHONE 6 /7- Z221P- 396 Q AREA CODE NUMBER EXTENSION O FAX O MOE3ILE 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 r SIGNED FORM 4009 ��111 MARE IN U.S.A. NOTES I CITY OF SALEM BOARD OF HEALTH Establishment Name: 7 / Dater/,z /Y y A 3 Page: of V Item Code C-Critical Item No. OF VIOLATION!PLAN OF CORRECTION Date No. Reference R—Red Item Verified � PLEASE PRINT CLEARLY t ce- ,n_4 /lNsc_. ``f ,f-14 r Gc�lt-u� l� t_ ArisJt:� 4 S E F i Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P LI Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. IIuunderst nd that noncompliance may result in daily fines of twenty-five d II 0x-s6spension/revocation of LiEmbargo Ll Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501,14(0) PHFs Received at Temperatures Violations Related to Foodbothe Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont:)_ 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMIC ALS 3-501.17 Cooling Methods forPHFs 14 - Food or Color Additives 19 PHF Hot and Cold Holding ---- 3-501,16(,B) Cold PHFs Maintained at or below 3-202.12 AdACC110 # 590.004(F) 410/451 F` 3-302.L4 Poiso nus or xic Substances tiscs* 3-501.16(A) Hot Pl-IFs Maintained aria above 15 Poisonous or Toxic Substances I40°F 7-101.11 Idenhtymg Information-Original 3-501,16(A) Roasts Held at or above 130`F. * Containers" 7-102.11 ' Corrlrnon Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storages, 3-501,19 Time as a Public Health Control*_ 7-202.11 Resfriction-PresenceandUse'" 590,004(H) VananceRequirement 7-202.12 Conditions of Use* 7-203.11 Toxic C.orneriness-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPUL 7-204.11 Sanitizers.Criteria.-Chemicals*' IONS(HSP) 7-204.12 C'henticals•tor Washin,Produce.Criteria* 21. 3-801.11(A) Unpasteurized Pre-packaged auices and 7-204.14 Dry n*A e its_(rrteiia* Beveia g es with Warning hibe�ls* 7-205.1.1 Incidents!Food Contact,Lubricants` 3-801.11(B) Use of Pasteurized Fens 7-206.11 Restricted Use Pesticides, Criteria` 3-801.1.1(D) Raw or Partially Cooked Animal Foot(and Raw Seed Sprouts 7-206.12 Rodent Bale Stations'` Not Served _ ing Powders, Pest Control and 3-801.1.1(0) Un .ocoed Food Package Not Re-served.Track Monitoring* CONSUMER ADVISORY _ TIME(TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw. Undercooked or PHFs- Not Otherwise Processed to Eliminate 3-401.71A(1)(2) Eggs-.1$5°F 15 Sec. Pathogens.' Legs Irirmodfat©Service 145"i'Lsec" 3-302-13 Pasteurized Eggs Substitute for Ravv Shell 3-401.1 I(A)(2) Coimninuted Fish,Meats&Game Eg r°* Animals- 155`F 15 sec. SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork arid Beef Roast- 13WF121. minr' 590.009(A){D) Violations of Section 590.009'11)-( )19 in 3-d01.11(A){2) Ratites, Injected Meats- 1$5°P 15 ( _ sea * catering, mobile food, temporary acid 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be Stuffing containing Fislt,Meat, debited under the appropriate sections Poultry or Ratites-IWF 15 sec. * above if related to foodborne,ilhiess 3401,1.1(C)(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145'F* i 590.009 violations relating to good retail 3-401.12 Raiv Anunal L'ocds Cooked in a practices should be debited trader#29- Microwave I TWF* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1.1(A)&(P) PHFs 165°F 15 sec. " (Items 23-30) 3-403.1 t(B) Microwave-165°F 2 Minute Standing Criticaland non-critical violations, which do not reline to the Toric* firodborne illness interventions and risk factors listed above, can be 3-103.11('0) Commercially Processed RTE Food- ,bund in the following sections of the Food Code and 105 CMR - 14WI7- 590,000. _ 3-403.11(E) Remaining Unslieed Portions of Beef Item Good Retail Practices 590.000 Roasts* 23. i Management and Personnel FC-2 .003 1g Proper Cooling of PHFs 24, 4_Food and Food Protection_ _ FC-3 .004 - --- 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water,� bin and Waste 'QFC 5 006 - - 25. E ui ment and Wang FC_ 4 00 - 6 I 70'F Within 2 Homs and From 70°F 27. Ph sical Facilit FC-6 .007 to 41°F/45°17 Within 4 Hours. 28. Poisonous or Toxic Materials FC-7 .008 3-501.I4(B) Cooling PHFs Made From Ambient 29._ j Special Requirements_ .009 - - - Temperature Ingredients to 41°F/45`F 30. J Other j ...... _ Within 4 Hours'" 11)11'„oensdon 'Denote,critical item in the tederal 1999 Ftxwd Code or 105 CMR 590.000. l e EYAMINATION FORM NO : 2001 CERTIFICATION NO : 2797691 DUPLICATE Serv.Safeo Certif ication TO MICHELLE BOUTIN for successfully completing the standards set forth by the National Restaurant Association Educational Foundation for the ServSafe Food Protection Manager Certification Examination, which is recognized by the Conference for Food Protection (CFP). Presented hp the National Restaurant Association Educational Foundation 10/4/2001 DATE OF EXAMINATION 10/4/2006 DATE OF EXPIRATION Check with your local health department for their specific requirements. MARY M. ADOLF PRESIDENT AND CHIEF OPERATING OFFICER NATIONAL RESTAURANT ASSOCIATION EDUCATIONAL FOUNDATION National Restaurant Association mzaesaakarnAssooaw�te�amu oloa EDUCATIONAL FOUNDATION 020729M V0919 www.nraef.org �ti�;k� � �,r � � �*ma CITY`O �.SA�-EM; MASS�C USE'TS, ,.•w rt�y i � ,-i�,.'�. � w u IV M '^` �'6aARooF " AL-I�T.. P v."' ' i 4�. • '�. ; i ' 'tis s 120fWA5HINGTaON,.,�STREE'fnT4TLOG » "F% y 1� JOANNE 1`__,� r n ,Ici.� d.HEALTH�'AG`4ENTK ��i.3 1' ..r �a� 1,4, i�• '� -: ,.� L' '� �. �h� s F h +I:� x y�i'/��r�n n w xdY �1 S��LL�}. ',COMMONWEALTH: OFSSACHUSET;TS4` " 52 a � s 3PERMIT TO OPERATEA [FOOD-ESTABLISHMENT , $ j . W � Tn hccordance w�sth ,regu ladons promulgate unaff cr oritjtof Chapt� Q s 94, Sections 3051A anM-LC to{r IT1I Sectrion of the} Genesi Laws, to operate' s ,r a +t Food Establsshment�in the ICi o saiem ixs here y gran ed tc -xrN. . a ✓ 8� K p }� a r- O �eYs Name r�Amerada Hess Corps Na'meof Establipshment eq _W___ s e ��kr�„, *llddress ofEstab'�lishme-lishmen`� RE�_ aL' FOpD t �” '�A 1 -cation ate:: f Res rictins ` x - ermi{at'`� or, F od sta 1 is mens < 7 , �� , rozen Desserts/ =cg r--gam ^fin- Permitfo'r�the Sale of#'Tobacco"�Productse{r '8- � heseP�erm�is EXplr ee`ember ' 8 f _ This, exmit ssnottraas eiabl'eand�mustibs„reass ed upon change of , .r3-n K +Af mux• , ownersb�p orlocation` ' Tyhew perau t must bei posted n romxnent location+ tx-is�w S' r•� fi+ sfA. 7;k+ •w �'�, • aia t establishment ki ,. u '”tie �, �°. �F3,-�icA• s .F ts'&. 5 ^�i � 'a . ... r .uli In accordance, with the StatetSaaitary Code°, before as ° renovations, , improvements, o, eq uipmentTchangescare made, all 1Naas for such at. be ^s K s.s ,ts#�4- y i s• k "' i an�d��approued�y* the�SalemBoard'�of�,{Health�' 1,- � } ax"a4 x � t HEAL GENTI& -*0 6 ;YIN9h T ' �. �W �:�31��. � � Mme. rY ��aii.Y '�X A�.,.• Xrl�+�l Y.S" 31' �'�+ 1 1'�1" •�{t L *4 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • • 120 WASHINGTON STREET, 4TH FLOOR _ . • SALEM, MA 01974 .,y3 TEL. 978-741-1804 FAX 978-745-0343 rv, STANLEY USOVlCX, JR. JOANNE SCOTT, MPH, RS, CHO Lit L. MAYOR HEALTH AGENT Cij-y'� . PA, HEALi 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT f�S &QC 'SS 9 019 TEL# `19-Q.(oo�13 ADDRESS OF ESTABLISHMENT 10 M ml� MAILING ADDRESS(if different) Amerada Hess Corp I Hess Plaza1J, Flaherty OWNER'S NAME Woodbridge,NJ 07095 ADDRESS CITY JIRtt ZIP _ CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON t _HOME TEL#A7S 52)'UIa5 DAYS/HOURS OF OPERATION: Mon. �Wed._T u.yFd.—Sat.,Sun.— TYPE OF ESTABLISHMENT �F check only RETAIL STORE NO 6(� <90D RESTAURANT YES 1 $40 BED 8 BREAKFAST YES $40 ADDITIONAL PERMITS MAKE ICE CREAM,YOGURT SOFT SERVE YES 40) $5 TOBACCO VENDOR NO �b.Z j NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPT FORM 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. dy� tt��aolt'�t l3-,A*Q\C)Oa SiDate Social Security or Federal Identification number Revised 1111141 foodap2.adm Check#&�� r f 517 7— IMPORTANT MESSAGE FOR QZEE6 A.M. DATE-6%2 TIME M�/�NV/r1od,5 OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE DUMBER TIME TO CALL TELEPHONED If PLEASE CALL CAME TO SEE YOU WILL.CALL AGAIN WANTS TO SEE YOU RUSK RETURNED YOUR CALL WILL FAX TO YOU MESSAGE E: S 0,641fl� Ab,6%64 /?/Z/A/ —so-m e e-- L(I//Nq, SLEP Oj�q /n/ S/r1UGG /JLC✓ �iyo fcrTc—i�4�`i��,�s7)is �1 e•ee /yp-Gc� t SIGNED lorOps FORM 4009 MADE IN U.S.A. NOTES _ _--- --__-- - -- - _-- n "•'W^v.+. .�...ti!.r'^y..!./-�.r ..:.�s _ ..ev �-v ... v.`.w'tlYF-i.'gorYf�4 Nv. . y.. _." i ,THE-.COZMMONWEALTH OF MASSACHUSETTS CITY . OF SALEM Address: 9 North Street Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (9781740-9705 Name Date Type of Operation(s) T3Me of Inspection h5.5 a/Si9 Da06-pa. ❑ Food Service /P" Routine Addressf Risk � Retail El Re-inspection 9d, ko/VarA sf Level Residential Kitchen Previous Inspection Telephone yy' q�� 11 Mobile Date: �2-e,?-0/ ❑ Temporary ❑ Pre-operation Owner HACCP Y/N 11 Caterer El Suspect Illness �� S Person in Charge(PIC) Time 11Bed&Breakfast ❑ General Complaint A l/ed'-ter/ ❑ HACCP Inspector In: ❑ Other ra 81 S Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) { violated. Non-compliance with: RED Violations (1-22) 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. 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 4 ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 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 ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations (23-30) 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(RED Items 1-22): of Health. Non-critical (N)violations must be corrected immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C 'N 590.000/Federal Food Code.This report,when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member.or its agent constitutes an 24. Food and Food Protection (FC-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:5Sw�WtFr c w.mo Inspector's Signature: Print: PIC'sSignature: / Print: ( ✓0.a Page of cZ Pages (� n Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT 8 Cross-contamination I 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2, 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* i l applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char e* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 ! 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003E Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ _ Food* 4. Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing- Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness* 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensilsand Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by lU Proper,Adequate Handwashing Regulatory Authority 1301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* =11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges from the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 11 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands `3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Ta s/Records:Fish Products13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records Creation and Retention* 5-203.11 Numbers and Ca acities's 590.004() Labeling of Ingredients` 5-204.11 Location and Placement* 7` Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 1 Conformance with Approved Procedures* 6-301.12 1 Hand Drying Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. THE COMMONWEALTH OF MASSACHUSETTS Sup err Establishment Name / ! SS , !9 Date oo9-66'6L�- Address 9.12 Ne eI4 yr Page--L2-of Item No. In the space below describe all violations checked on front page. /(16 4yA z lD :7� X7'5,�7.�T'f?•";.. �,�71^/�l,64,N 1 Ai /d' GG191a1TiYL#7 iazr �i�l�Of�' SfA%P�.�� r--z /! n�o . /n.S'C✓iN7 -5 90 6' F U Z Z W K K Q ac p x r m - � a w n f 0 O LL Discussion with Management r t �� Iva a......Far'. -.,,.�t+�r�0'�� 'rw.A rs�`.�a.. �.,*,.....r'w.s w.e.+a^;�..,...f.N� �.e+rv.•_."...r�T.t"v.r..r:w.:^vJ..,.,yf,.a6it�.r-^+iw..Ho..'K".✓F'c-r^v%✓vw°`.. ,•... a THE;COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 9 North Street Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 740-9705 Name Date Type of Operations) Type of Inspection 5��/ ai ❑ Food Service V Routine Address Risk [91 Retail ElRe-inspection Level ❑ Residential Kitchen Previous Inspection Telephone 7 vv_ ��0� Z ❑ Mobile Date: Owner El Temporary ElPre-operation C1r/L/ Py$ �Oi HACCP Y/N ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed &Breakfast ❑ General Complaint ❑ HACCP Inspector In: ❑ Other Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) Violated. Non-compliance with: RED Violations (1-221 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. 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 ❑ 16. Cooking Temperatures ❑ 5. Receiving/Condition ❑ 17. Reheating ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 18. Cooling ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 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 ❑ 21. Food and Food Preparation for HSP E110. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations(23-30) 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 (RED Items 1-22): of Health. Non-critical (N)violations must be corrected immediately or within 90 days as determined by the Board Official Order of Correction: Based on an inspection of Health. today,the items checked indicate violations of 105 CMR C N 590.000/Federal Food Code.This report,when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-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)(590.009) 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: Inspector's Signature: Print: 7 PIC's Signature: Print: G / Page of.+�Pages sm "V 'K Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT j 8 Cross-contamination f1'x590A03(A) I Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* ,2 590.003(C) Responsibility of the person in charge to Contamination from the Environment E require reporting by food employees and 3-302.11(A) Food Protection* r • applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Chare* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-30614(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003E Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* '. 4 Food and Water From Regulated Sources F-9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 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 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness* 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22A* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Molluscan 4-702.11 Frequency of Sanitization of Utensilsand Shellfish* Food Contact Surfaces of Equipment* 3-201.15 Molluscan Shellfish From NSSP Listed 4-703.11 Methods of Sanitization-Hot Water and Sources* Chemical* Game and Wild Mushrooms Approved by F11_0 Proper,Adequate Handwashing Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5-, Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges from the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* ^6_`! Tags/Records:Shellstock 112 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Ta s/Records:Fish Products ;13' Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. THE COMMONWEALTH OF MASSACHUSETTS �> City of Salem Establishment Name ` s S p1/s-/C/ Date Address GIS �� ¢. Page Z of.Z Item No. In the space below describe all violations checked on front page. A(n) // Fiv inspection of this establishment was conducted in accordance with the State SanitarV Code for Food Establishments,Chapter X, 105 CMR 590.000.The following violations were observed: Discussion with Management I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection,to observe all conditions as described,and to comply with all mandates of Chapter X. I understand that noncompliance may result in daily fines of twenty-five dollars. ae44 oawa' n CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT,MPH, RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740-9705 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 : Amerada Hess Corp. Name of Establishment : Hess 21519 Address of Establishment : 90 North Street Type of Establishment : RETAIL FOOD Application Date : 04/20/2000 Restrictions: Permit for Food Establishment 230-00 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 54-00 These Permits Expire December 31, 2000 This permit is not transferable and must be reissued upon change of ownership or location. In accordance with the State Sanitary Code, all plans of renovations, improvements, equipment changes must be approved by the Health Department. HEALTH AGENT Apr 04 00 10: 55a Joanne Scott Salem BOH 978 740 9705 p. l HF FAX APR 1 9 WID3 CO: _ FROM: CITY OF SALEM FAX/- DATE:�� DATE:-, HEALTH DEPT. �ciy CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3928 JOANNE SCOTT, MPH,RS,CHO NINE NORTH STREET HEALTH AGENT Tel:(978)741-1800 Fax:(978)740.9705 2000 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 4fSS 2d'-QI TEL# q-)8_1q+� LP23 ADDRESS OF ESTABLISHMENT- 90 N chr�'�S�- MAILING ADDRESS (if different) I V�e9S ��AzaISFlal er l uuoocllbt lege,n�o7ogd OWNER'S NAME '' mec`UA0. )r e Cor P TEL# "1307-150"(0350 ADDRESS \ �SQIAza U-)oo&rAge n-S 0-109 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)__-•.. (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON S �OUgI0.5,OPera�Ons (Ylgc. . TEL# 7139-7,'VWD0 12,46 _ LSTALiLISHIM ENT'S DAYS A HOURS OF OPERATION All, TYPE OF ESTABLISHMENT 0Z t�U FEE check only RETAIL STORE YLS NO S4 RESTAURANT YES NO #seats_ #nonsmoking_ $40 ADDITIONAL PERMITS MAKE FROZEN DESSERTS Y NO TOBACCO VENDOR ES NO 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 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, Sectinn 49A, I certify under the pains and penalties of perjury that I, to my best knowI d e a d belief, have filed all state tax returns and paid all state taxes required under the law. -1'11,7100, /3-AP00W Signa ur Date Social Security or Federal Identification Number -------V............................. ----------------------- �TT !/ 1 ------------ Revised 10/20198 f3ddap2.adm Check#8 Dete6 �a�/ 1`"` Y'�c+ 'ev RPR 04 2000 12:04 978 740 9705 PRGE.01