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HESS EXPRESS 21334 - ESTABLISHMENTS HESS EXPRESS #21334 295 DERBY STREET t N v l ii I� II` f r� 0 p I l a CITY OF SALEM, MASSACFIWSE� S BOARD OF HEALTH �`� , � ,ll n. PublicHealth 120 WASHINGTON STREET,4 FLOOK nevem Promote Protect TEL. (978) 741-1800 FAx(978) 745-0343 V`�� KIMBERLEY DRISCOLL Ixatndin(n.salem.com l! it,\AIDIN,RS/RHI IS,CI fO,(T-FS MAYOR HiSlm:r IA(,FNT 207JfAPPLICATION FOR PERMIT FOR SALES OF TOBACCO & NICOTINE DELIVERY PRODUCT PERMIT FEE $135 NAME OF ESTABLISHMENT �S TEL# 'It4q -&N I3 ADDRESS OF ESTABLISHMENT 2a S 1�i eir6A. FAX# DEPARTMENT OF REVENUE APPLICATION NUMBER: Yea Ratan Gpedens,LLC 3 Here Plaza/J Flaherty MAILING ADDRESS(if different) 1_illo9do,119e,W 07095 / 732-750-6350 EMAIL-Business': Websit$: 732.352-6623(fax) \j 7FlA"ERTY®5FtWWA1r.wm OWNER'S NAME TEL# ADDRESS STREET __`` CITY STATE ZIP / EMERGENCY RESPONSE PERSON��r-eo✓S Foola– Mr V2- HOME TEL# �7S' Type of Products Sold: Cigarettes— igars I-,' Chewing Tobacco—'Pipe/Cigarette Tobacco 'Nicotine Delivery Devices_ Other Tobacco Product(list on additional Sheet) DAYS OF OPERATION I Monday i Tuesday Wednesday I Thursday Fdday i Saturday Sunday I ! i HOURS OF OPERATION Please write in time of day. (For example 11 am-1lpm) *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';n 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. 22-2462225 ;Z_- ialaliv Signature Date Social Security or Federal Identification Number Updated 723/12 TOBACCO.doc Check#&Date $ i I 2602450254 (800)926-7784 Hess Retail Operations LLC Ann Accounts Payable Dept DATE.December 4,2014 One Hess Plaza CHECK NUMBER:0201656681 Woodbridge,NJ 07095 VENDOR NO 0000540402 00024 CKS 6A 14338 - 020165668E NNNNNNNNNNNN 3365100006004 %860131 C CITY OF SALEM BOARD OF HEALTH 120 WASHINGTON ST., 4TH FLOOR SALEM MA 01970 Invoice Date Invoice Number Purchase Order Divl Loc Gross Amount Discount Net Amount 12/04/14 120214135 0590 $13500 $000 $135.00 CIG RENEWAL 21334 TOTALS $136.00 $0.00 $136.00 a PLEASE DETACH BEFORE DEPOSITING CHECK R195 43273. OEC 0 2 2014, CITY OF SALEM Q MASSACHUSETTS/ p„blicHeaUh V� BOARD oP HEALTH 120\NASI IING,rON S 11iEET,4T"FLOOR �! � KIMBERLEY DRISCOLL Tm-(978)741-1800 FAX(978)745-0343 �i-' (� L\RRY RAMDIN,RS/RISI IS,CI IO,CP-F5 MAYOR ITamdin(nA salernxom HiiAI,ri-I AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: r�,4-ess 6i33 y II 12) Establishment Address: pl-t! be Y 1 13) Establishment Mailing Address(if different): / 14) Establishment Telephone No: y q- Hess Retail Operatione t I r I 1 Hess Plaza/3 Flaherty 15) Applicant Name&Title: Woodbridge,N3 07095 ` ioc-iau-o»u 6) Applicant Address: /j 732-352.6623(fax) rr ]FIAHERTYCSPEEDWAY,COM 17) Applicant Telephone No: 24 Hour Emergepcy No:-TP--n-"Email: 18) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or/artnership,give name,title and home address of officers or partner. A- association Name Title Home Address A corporation An individual A partnership Other legal entity Andrew Bernstein,Assn Sec I AR S � lI 12) Person Directly Respon-ible For Daily Operations(Owner, Person in Charge,Supervisor,Manager,etc.) I Name&Title: m Address: Telephone No: � 7 -/ 0 Fax: /� Email: Emergency Telephone No: -7 �P-7SO'006 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#dolZ V Date: I V I I I 1q Amount* I D Food Establishment Information 141 Water Source: 15) Sewage Disposal: CC DEP Public Water Supply No: (if applicable) C`�y CAL, I 16) Days and Hours of Operation: Ay 11 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) O Retail( Sq. Ft) ❑Caterer Permanent Structure 0 Food Service-( Seats) ❑ Frozen Dessert Manufacturer Mobile O Food Service-Takeout ❑Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments (check one) RETAIL STORE RESTAURANT ... . ......................... Annual Ef Less than 1000sq.ft. $70 ❑Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑Residential Kitchens $140 ❑More than 10,000sq.ft. $420 ❑25.99 seats $280 ❑More than 99 seats $420 Temporary/DatesMme: -------------------------------------------------$100-------- ❑ Bed&BreakfastlChildcare Services!Nursing Home - - ------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURTISOFT SERVE $25 O PASTURIZATION $25 ❑ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare&private club 23) Food Operations: Definitions: PHF—potentially hazardous food(time/temperature controls required) Non-PHFs—non-potentially hazardous food(no time/temperature controls required) (check afl that apply): RTE—ready-to-eat foods(Ex.sandwich=s,salads,muffins which need no further processing ale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of l Non-PHF and Non. Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date .70 or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec.49A,I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 22_2462225 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: ugss Retail 6perations, LLC 2602450255 •(8001926-7784 1 Hess Retail Operations LLC Alin:Accounts Payable Dept DATE December 4,2014 One Hess Plaza CHECK NUMBER 0201656682 Woodbridge,NJ 07095 VENDOR NO 0000540402 III.....,Ill�lrrl�rrlllrr�r�llr�lrirr�lrl�rllrllrrrtlrrlrllrrl -o 001325 CKS 6A 14336 - 0201656682 NNNNNNNNNNNN 33651000136004 %06081 C CITY OF SALEM BOARD OF HEALTH 120 WASHINGTON ST , 4TH FLOOR SALEM MA 01970 Invoice Date Invome Number Purchase Order Div l Loc Gross Amount Discount Net Amount 12/04/14 12021470 0590 $70.00 $0.00 $70.00 j FOOD RENEWAL 21334 TOTALS $70.00 $0.00 $70.00 I PLEASE DETACH BEFORE DEPOSITING CHECK R19543274 . \ - OOND$ �� City of Salem, Massachusetts e� f • �: i Board of Health 10 a 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PublicHealei Iramdin@salem.com Prevent. Promote. Protect. Kimberley Driscoll Larry Ramdin RS/RENS, CHO, CP-FS Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM-15-144 Permit Type: Retail Food 1000-10000 sqft Goods &Services: I Retail Food: 1,000- 10,000 sq ft Name of License Holder: Hess Corp. Name of Food Establishment Hess Express#21334 Address of Food Establishment 295 Derby Street Salem, MA 01970 Restrictions: This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: $280.00 Issued: 1/1/2015 / City of Salem, Massachusetts Board of Health ., 120 Washington Street, 4th Floor, Salem, MA 01970 PnblicIieatth Fm m,.Pr moa.Pmaea. Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin RS/RENS, CHO, CP-FS Mayor Iramdin@salem.com Health Agent TOBACCO SALES PERMIT Permit# TO-15-13 License For : Tobacco Date of Print 1/29/2015 Granted To: Hess Corp. Permit Issued 1/1/2015 Address: 1 Hess Plaza/ J. Flaherty Woodbridge NJ 07095 Permit Expires 12/31/2015 Location of Establishment: 295 Derby Street Permit Fee $135.00 Restrictions: Late Fee $0.00 Notes: #21334 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12131/2015 , unless sooner revoked or suspended. Health Agent Wssachusetts Department of Public Health Salem Board of Health 120 Washington Street,4s'Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town Of 04,p /y\ Address: G 7� FOOD ESTABLISHMENT INSPECTION REPORT Tel.glyw ' 1 � �} Name atG� Typ of Operafion(s) Type of Inspection nt 1r-{�_ Ll.'F Service outine Address /`']j 1 �L Risk etail E]Re-inspection Telephone A Level El Residential Kitchen Previous Inspection Tele p CA 1 2- ^� (�( / / ❑ Mobile Date: Ownerr HACCP YIN ❑ Temporary [IPre-operation ,�f Q,, (per I ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Ti e ❑ Bed&Breakfast ❑General Complaint _ ��( In�Qj(/� ❑ HACCP Inspector ��iV)V),p ( ^ Out: w •1 Permit No. ❑Other Each violation checked requires a e lanation on the narrative pages)and a citation of specific provision(s)violated. Noncompliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Tobacco 590 Violations marked may pose an imminent health hazard and require immediate .009(F) ❑ Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. L000 PROTECTION MANAGEMENT [112, Prevention of Contamination from Hands J�yl. PIC Assigned/Knowledgeable/Duties i� EMPLOYEE HEALTH ❑ 13. Handwash Facilities ' PROTECTION FROWCHEMICALS ❑ 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(PotentlMly Hazardous Foods) F1 4. Food and Water from Approved Source ' ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY-SUSCEP.t16L&POPULATIONS(HSP). El21. Food and Food Preparation for HSP 17110. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR cf Health. 590.0001federal Food Code.This report,when signed below C 23. Management and Personnel (Fc-2)(500.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc-a)(Soo.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Si lure:' ) \ Print: ^.(„ I�.�� (_,-,( PICS Signature: `�^ �/y 1 I Print: �+ kffi fAl'I'-I-{JL Page of ages h • ' Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION Cross-contamination FOOD PROTECTION MANAGEMENT 8 o 1-302.11(,Al(i) Raw AnimalFoods Separated from I 1 590,003(A) Assignment of Responsibility* ( Cooked and RTE Fcxxls* 590.003(3) Demonstration of Knowledge* � � Contamination from Raw Ingredients 2-103.11 Poson in charge-- dude:: 3-302.11(A)(2) I Raw Animal Foods Separated front Each Olhcr EMPLOYEE HEALTH Contamination � ( Contamination from the Environment 2 590.IH)3(C) Responsibility of the person in charge to - - 3-302JI(A)� Ford require ioporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants* 13-304.11 Food Contact with Equipment and - --- 1 59(003(F) Responsibility Of A Food Employee Or An I Gtcnsils* - - -- --I Applicant To Report To The Person In Contamination from the Consumer Charge.* 1 3-306.14(A)(B) Returned Food and Reservice of Food*-- 59(11X)3(0) Reporting by Person in Charge* 3 590.003(D) Exclusions andRestrichons* Disposition Ra 590.003(E) Removal of Exciu,vions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD F IOM APPROVED SOURCE I I Food+` - 4 I Food and Water From Regulated Sources ') Food Contact Surfaces k 590.004(A-B) Compliance with Food Law" i 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization'rentperatures* 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 Fgks and Milk Products.Pasteurized'^ 4-501.114 Chemical Sanitization-temp., pH, 3-202.16 tee Made Front Potable Drinking Wawr° concentration and hardness. '" 5-101.11 Drinking Water from an Approved System* 4-001.11(A) l^-tluipntent Fad Contact Surfaces and Utensils Clean- _590.006(A) Bottled Drinking Waict°' - 4-6 590.006(B) Water Meets Standards in 310 CMR 22.04' 4-702.11 Freque02.11 C Contact nta t Surfaces and Utensils* Frequency of Equipment Food- 590.006(B) I Shellfish and Fish From an Approved Source Requency ofSanitization of Utensils mrd I 3-201.14 Fish and Recreationally Caught Molluscan Forai Contacl Surfaces of Equipment* Shellfish* 3-201.15 Molluscan Shellfish from NSSP Listed 4-71)3.11 Methods of Sattitizatinn-Hot Water and Chemical* J Sources* i Game and Wild Mushrooms Approved by to Proper,Adequate Handwashing Regulatory Authority 2-301.11 Clean Condition-(-lands and Arms- 3-202.18 Shellstock identification PresemA 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.1.1 Wheat toWash* 3-201.17 GamcArtimals' { 1 t Good Hygienic Practices s g Receiving/Condition 2111,11 Eating,Drinking or Using Tobacco* 3-202.11 PHIrs Received at Proper'Ienipf;ratures' 2401.12 Discharges From the Eyes,Nose and Mouth* Package e mid Unn3-301.12 Prevemm�b Contamination When Tasting^ 3-101.71 Fund Safe mid Unadulterated * I - 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands- 3-202.18 Shellsntck Identification* I 1590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employee;:* Tags/Records:Fish ProductsI ( 13 Handwash Facilities 340111 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retemnpn* 5-203.11 INumbers mid Capacities* 590.004(7) Labeling of Ingredients* ( 5-20, Location and Placement* 7 Conformance with Approved Procedures I -'-US.I l Accessibility,Operation and Maintenance: IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing MethodsDevices * --- 3-502.12 Reduced oxygen vackagim, criteria* 1 6-301.11 Handwashing Cleanser, Availability _ 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Drying Provision *Denoiec critical item in the(euparal 1999 Food Code or 105 Cbtlt 59o.0oo. t CITY OF SALEM /� BOARD OF HEALTH / �Q Establishment Name: n�v n/ J Date: �� _�`� Page: ( of Rom code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION -Date No. Reference R-Red Hem Verlfled t ° ASE PRINT CLEARLY _ QQ'en ��n O. y 3 I u C,1, P,^AO �,�� n ✓To a V- Ay\ roc'a'v kms/ <zv - - v t-)�d-� Pia Pa Discussion With Person in Charge: Corre ve Action Required: I ❑ No 43' fes I have read this report, have had the opportunity to ask questions and agree to correct all I `-Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit �N/� / ,��J �yt �l" 0 Voluntary Disposal ❑ Other: 3-301.14(C) PHR Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41°F/450F Within 4 Hours. CHEMICALS I 3-501.15 Cooling Methods for PHFs PROTECTION FROM 14 ( I 19 PHF Hot and Cold Holding Food or CA Additives 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 1 590.004(F) 41°145°F* 3-302.14 Protection from Unaporaved Additives* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances J 140°F * 7-101.11 Identifying Information-Original 1 3-501.16(A) Roasts Field at or above 130'F. Containers* f ( � rime as a Public Health Control J 7-102.11 Common Name-Working Comainers* i i 3-501.1.9 Time as a Public Health Control* 7 201.11 Separation-Presage" j 590,004(H) Variance Requirement J 7-202.11 Restriction-Presence and Use" 7-202.12 Conditions of Use* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals* ( 21 1-801,11(A) Unpasteurized Pre-packaged Juices and 7-204ges with Warning labels* 7-204.14 Drying Agents.Criteria* 3-801.1 i(H) Use of Pasteurized Eggs* J 7-205.11 Incidental Food Contig,Lubricants* 13-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides:Criteria* Raw Seed Sprouts Not Served. " j 7-206.12 Rodent Bait Statiuns* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEIfEMPER4TURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked of 18 Proper Cooking Temperatures for { PHFs Not Otherwise Processed to Eliminate Pathogens.*`"Bc3°'"2wf 3-401.11A(1)(2) Eggs- 155F 15 Sec. Eggs,Immediate Service 145'FISsec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell 1 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155'F 15 sec. * SPECIAL REQUIREMENTS 3401.1l(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3401.11(A)(2) Ratites,Injected Meats- 155°F 15 catering,mobile food,temporary and sec.* 3-401.1I(A)(3) Poultry-,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3-401,11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145T* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding 1 VIOLATIONS RkATED TO GOOD RETAIL PRAC77CES 3403.11(A)&(D) PHFs I65°F 15 sec.* (Items 23-30) 3403.11(B) Microwave- 165°F 2 Minute Standing Crittcal,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can be 3-403A I(C) Commercially Processed RTE Food- i found in the following sections of the Food Code and 105 CMR 140°F* ( 540.000. 3403.11(E) Remaining UnslitedPortia¢%ofBeef Rem I Good Retail Practices FC , 590.000 Roasts* 123. j Management and Persona I FC-2 , .003 1 1$ Proper Cooling of PHFs 1 24. i( Food and Food Protection I FC-3 1 .004 i J 25. Equipment and Utensils FC-4 I .005 i 3-501.14(A) Cooling Cooked PHFs from 140°F to J 26, 1 Water,Plumbing and Waste i FC-5 .0W 70'F Within 2 Hours and From 70`F 1 27. Physical FaclNty . FC-6 1 .007 j to 410F/450F Within 4 Hours. * 128. Poisonous or Toxic Materials FC-7 .008 j 3-501.14(B) Cooling PHFs Made Froin Ambient 29. ( Special Requirements I .009 I Temperature Ingredients to 41°F/45017 130' 1 Other J Within 4 Hours* *IJenot"critical am in the federal 1999 Food Code or 105 CIMR 5901X10. CITY OF SALEM (� BOARD OF HEALTH Establishment Name: o'-- Date: Page of ' Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Ohio No. Reference R-Red Item Ver f ed (!' PLEASE PRINT CLEARLY I ✓ „ I J J�t/l nn APj A AQ AI n _ I I ✓ \r Gk— ✓s— I ✓� � eat til I _ 0,V- `-h`-hT)nl,,�A nem n1�A I ✓ — ./_ /LCCA It,n _ __ I it-, ✓ \ /%V1 J -.6'T/X/1 4zi'(.E.i I1 J OAC' �I�t'YYY•t e.u./1� JYY/•JLiJ /i Q � CA riy�ix I 7 I I i Discussion With Person in Charge: Corrective Action Required: I ❑ No e/fea I have read this report, have had the opportunity to ask questions and agree to correct all 0/Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollar r suspension/revocation of C3Embargo E) Emergency Closure your food permit. ` _ / - — `n/; / ❑ Voluntary Disposal ❑ Other: L 3-i01.14(C) PHFs Received at Temperatures 17otabons Related to Foodborne(/mess.interventions and Risk According to Law Cooled to Factors(ftems 1-22) (Cont.) 41'F/45°F Within 4 Hours. ' PROTECTION FROM CHEMICALS 3-501.15 C m1iaR Methods for PHFs 14 ( Food or Color Additives 19 PHF Hot and Cold Holding (` 3-50L16(B) Cold PBF•s Maintained at or below 3-202.12 Additives* } 590.004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above e Poisonous or Toxic Substances 15 � 1400F. * 7-101.11 Identifying lnfonnation-Original 3-501.16(.A) Roasts Heid at or above130°F. * Containers* ( 20 Tithe as a Pitting Health Control 7-102.11 Common Name-Working Containers* 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* � 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals* 21 3-801.11(A.) Unpasteurized Pre-packaged Juices and 7-204.12 I Chemicals for Washing Produce,Criteria* Beverages with Warning labels* ( 7-204.14 Drying Agents.Criteria" 3-801.]1(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact, ,Criteria*lAtbricantsj 3-801.11(D) Raw or Parially Cooked Animal Food and 7-206.71 Restricted Use Pesticides.Criteria* Raw Seed Snrons Not Served.* 7-206-12 Rodent But Stations° 3-801.11(C) I unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME(TEMPER4TURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of ( 16 Proper Cooking Temperatures for Animal Foods That are Raw•undercooked or { PHFa Not Otherwise Processed to Eliminate 3-401.I1A(t){2) Egg- 155°F 15 Sec. Pathogens,'E"ecava 1`1 Eggs-Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Egg Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Creme j Egg* Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 ntin* 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 590.0W(A)-(DI Violations of Section 590.009(A)-(D)in sec * catering, mobile food,temporary and 3-40111{Ax3) Poultry,Wild game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish Meat, debited udder the appropriate sections Poultry or Ratites-165°F J- sec.* above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F s 590.009 violations relating to good retail 3-401.12 Raw Animas Foods Calked in a I practices should be debited tinder#29- Microwave 165°F* Special Requirements. 3-401.1 t(A)(1)(b) All Other PHFs-145'F 15 sec. 17 ReheOng for Hot Holding VIOLATIONS RELATED TO 0000 RETAIL PRACTICES 3403AI(A)&(D) PHFs I65°F 15 sce.* (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* _ foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Ford- found in the following sections of the Food Corte mrd 105 CMR 140°F* 590.000. 3403.11(E) Remaining Unsticed Portion.%of Beef 1 item I Good Retail Praodees FC 5W.Ow � Roa%fs* 1 2& i Manattement and Personnel I FC-2 .003 18 Proper Cooling of PHFs 24.. 1 Food and Food Protection FC-3 .004 3-501.14(A) CoolingCooked PHFs from 140°F to 26 1 Equipment and Utensils FC-4 .005 � Z6. i Water,Plumbitnp and Waste I FC-5 .0Q8 70'F Within 2 Hours and From 70'F 1 27. 1 Phvsical Facilitv FC-6 .007 to 41°F/45°F Within 4 Hours. * 128. Poisonous or Toxic Materials ! FC-7 .008 1 3-501.14(B) Cooling PHFs Made From Ambient 129• I Special Requirements .009 1 Temperature Ingredients to 41°F/45°F 1 I Other 1 Within 4 Hours' *D2nntcs critical iters.in the federal 1999 Foci Code a 105 CMR 5901001. CITY OF SALEM r� _ � BOARD OF HEALTH '' �/ `r (� Establishment Name: 4!Il�yy _Q� Date: o—aN, t Page: l of Item ' Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Vedfled PLEASE PRINT CLEARLY N 4:�5 0 -3 _-1. an I(L J A K%0 L5 o.4 Discussion With Person in Charge: C:r7ecIvaAction Required: ❑ NoI have read this report, have had the opportunity to ask questions and agree to correct all untary Compliance Cl Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. /j � '/� 13Voluntary Disposal ❑ Other: v M. 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS i 3-501.15 Cooling Methods for PHFs 14 Food w Color Additives I 119 PHF Hot and Cold Holding 3-501.16(B) Cold PHFa Maintained at or below 3-202.12 Additives* 590.(H>hn 41°/45°F* 3-302.14 Protection from Unapproved Addiuves*Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above I 15 � 1400F. * 7-101.11 Identifying Information-Original 3-301.16(.4) Roasts Held at or above 130'F. Containers* I20 Time as a Public Health Control 7-102.11 Common Name-Working Containers* I 7-201.i.l Separation-Storage* } 13-501.t9 Time as a Public Health Control* I 7-202.11 _ Restriction-Presence and Use* i 1590.004(H) Variance Requirement 7-202.12 Conditions of Use* } REQUIREMENTS FOR HIGHLY SUSCEPTIBLE i 7-203.11 Toxic Containers-Prohibitions* i POPULATIONS(HSP) 7-204.11 Saniriurs.Criteria-Chemicals' I 7-204.12 - Chemicals for Washing Produce,Criteria* 21 3-801.11(.4) Unpasteurized Pre-packaged Juices and I.Beverages with Warning Labels* 7-204.14 Drying Agents.Criteria* 3-801.11(B) Use of Pasteurized Eggs* I 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and i 17-206.11 Restricted Use Pesticides.Criteria' Raw Seed Sprouts Not Served 7-206.12 Rodent Bait Stations* ( 3-801A](C)1(C) Unopened Food Package Not Ro-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 ' Proper Cooking Temperatures far I Animal Foods That are Raw.Undercooked or PHFs I Not Otherwise Processed to Eliminate 1 3-401.I1A(1)(2) Eggs- 155F 15 Sec. Pathogens.*F e mw rn o0 Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-40J Al('A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 see. * SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 catering, mobile food,temporary and 3-401.1 t(A)(3) Poultry,Wild Game,Stuffed PHFs, I residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3-40Lll(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F+' 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a I practices should be debited under#29- Micmwave 165°F* Special Requirements. 3-401.11(A(1)(b) All Other PHFs-145°F 15 sec. i 17 Reheating for Hot Holding VIOLATIONS R=LATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PRFs 165°F 15 sec.* (Items 23-30) 3401.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3.403.11(C) Commercially Processed RTE Food- ' ' found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3403.1 t(E) Remaining Unstioml Porticos of Beef I !tern I Good Retail Practices I ,FC 530.000 I Roasts* 23. Management and Personnel FC-2 .003 I 1S Proper Cooling of PHFs 24. Food and Foci Protection FC -3 .004 ! 125. Equipment ana Utensils FC-4 -005 i 3-501.14(A) Cooling Cooked PRFs from 140°F to 1 26. Water.Plumbinq and Waste FC-5 .006 ! 70°F Within 2 Hours and From 70°F 127. Physical FadAty FC-6 .007 to 41°F/45'F Within 4 Hours. * 1 28. Poisonous or Toxic Materials FC-7 .006 4 3-501.14(B) Cooling PHFs Made From Ambient I 1 320, i Special pecOthe�Requirements .009 1 Temperature Ingredients to 4PP/45°F Within 4 Hours* *U,,4,,cYifcal ttem in the tedernl 1999 Fnai Code ix 105 CMR 390.000. \ t SUITE 2700 G R A Y R O B I N S 0 N 401 E.JACKSON STREET (33602) BOCA RATON P.O.Box 3324 FORT LAUDERDALE ATTORNEYS AT LAW TAMPA, FLORIDA 33601-3324 JACKSONVILLE TEL 813-273-5000 KEY WEST FAX 813-273-5145 LAKELAND li MELBOURNE �^ MIAMI 813-273-5161 NAPLES ANCELA.ROTELLA-GARZON[l GRAY-ROBINSON.COM ORLANDO / TALLAHASSEE July 14, 2014 TAMPA Health Department City of Salemq � q R J Attn: David Greenbaum Optif< 4o 120 Washington Street �<T 41h Floor y Salem, MA 01970 Re: Hess 1334—Located at 245 Derbv Street, Salem, MA cense for Permit to Operate a Food Establishment and Permit to Sell Tobacco Products Notice of Change of Licensee to New Hess Entity Dear Mr. Greenbaum, GrayRobinson, P.A. serves as national regulatory counsel for Hess Corporation (NYSE: HES), a publically-traded corporation. The current licensee, Hess Corp d/b/a Hess 21334, will be changing to a new entity, Hess Retail Operations, LLC("HRO") d/b/a Hess 21334,FEIN 22-2462225. In accordance with our recent telephone conference with you, our office was advised that a letter of notification of this change to your office would be sufficient. The business will remain the same and there will not be any structural or employee changes. The officers for HRO are: Name Title Patrick McAndrew Vice President Kristy Cunningham Vice President David Goodes Vice President Steven Kemps Vice President& Secretary Andrew Bernstein Vice President& Assistant Secretary Stuart Steigerwald Treasurer The mailing address for the license will remain the same, which is: Hess Retail Operations LLC, 1 Hess Plaza, Attn: Janice Flaherty, Woodbridge,NJ 07095. www.gray-robinson.com GRA1'ROBINSON PROFESSIONAL ASSOCIATION July 14, 2014 Page 2 If you have any additional questions, please do not hesitate to contact our office. Thank you. Very trul o /If( Angel . otella-Garzon, FRP Licensing Specialist ARG/pmb \10\2192-9 5210748 v I 0 Zm -,q ;k _Z_ Ak City 0- 1 Salem Board of Health °3 ss.fes " tt -1Qffibbdey-Drh§6o'11 120 Washington----s- 4th.-Floor * 14v -7 41, SALEM,MAS 01970 _7 .a 4, 'MAC;; n fobdMitiff sitablighbietif g u4 -'DATE PRINT' W rz SS z7F. 1 r KKK t4, A w go ESTABLISHMENT-NAME11iss Eioieis#21334 A, 1-Hoss-Pliza/J.-Flaherty file NumberuHF200"uu 154 A_ woodbri 4 At:, _ST 42 LOCATED -6295 DERBY. REET 0 N 2-k 4 g A�� SALEM, MA 01970-,,r-,:, Z,,'�� ypc NO' .' _.� Ornt Issued rejfi,Expires R strittons:fNiteS Permit T fi RETAIL FOOD--YA,-Z,�BHP-20.14-0149,;'_�,� 4amil'2014" DO' $70 0 0- c 3 1;2014 e Notal Fees- _7 q -q q- g Z 47- K ?z X-C M f, J* 21- PERMIT EXP uU *1kPermitig.itot.tiransferableand-iiiiii;beieissiid'upo-iii'chaitge"'o'f,6w-ne-rship�orlocittion.-The,peifidtmiis�t-be posteU- - in a'pronfinent Ideation in the'Establishment; In accordance`with the State Sanitary Code-,benfre-any.'revolin-uons,improvements' -eq':*or mpmen':* t changes are made; all Ilins for SUch4 iniRt be stibiiitted to and,ipprioved-b'y'thii'Salem 116aid bfIfenit Page 1 5u ,- • t �� CITY OF SALEM, MASSACHUSETTSwpEge , BOARD OF HEAM11 /� V n •" 120 WASl[INC,'I'ON S'tzaaET,4°1 F].oOR dI(j e 11 KIMBERLEY DRISCOLL Tru..(978)741-1800 F1,C(978)745-0343 DEC LAI �Is�\b1DIN,RS/KEPIS,CI IO,(:P-1 MAYOR lcamdinGsalcm.com Ty OF EALTHAGENT "HDD OF HEALTH I- HEAL7y Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: �t NesS s Fxpr s ommq I2) Establishment Address: 0195 6t?(-1>4 G� 3) Establishment Mailing Address(if different): c 4) Establishment Telephone No: -Iqi. y)3 HES3CORPORATION 1 i neaa F'a&a 1-J.Fla:.::1i 5) Applicant Name&Title: Woodbridge, NJ 07095 731-7UB•ti4aa 6) Applicant Address: 7) Applicant Telephone No: 2 Hour Emergency No:-7_-V--LrV-&CM Email: 8) Owner Name&Title(if different from applicant). 9) Owner Address(if different from applicant): J I �0) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address ✓A corporation An individual A partnership R.1. Lawlor VP 1637 Thistlewood Dr Other legal entitv Washington Crossing, PA 18977 12) Person Directly Responsible For Daily Operations(Owner, Person in Charge, Supervisor, Manager,etc.) Name&Title: Sd�eeS OL Address: Telephone No: ol-jSr-q Iga,5&0 Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: / c7 Check#:_ 6 Date:la/`� Amount: ( D * , Food Establishment Information 14) Water Source: 15) Sewage Disposal: i~ 'DEP Public Water Supply No: (if applicable) C��1 c,4-Li 16) Days and Hours of Operation: au{ I 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑ Caterer ✓Permanent Structure ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments,,,,,,,,,,,,,, REMAIL STORE RESTAURANT ✓Annual (check one) l7Lessthan 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq:ft. - -$280 ❑ Residential Kitchens. - $140 13 More than 10,000sq.ft. $420 ❑25-99 seats $280 ❑ More than 99 seats $420 Temporary/Dates/Time: ------------- ------------------------------ ---------- - - --------------- --- --------- ❑ Bed&Breakfast/Childcare Services/Nursing Home $100 i ADDITIONAL PERMITS ------------------------------- -----.---- ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑9ASTURIZATION $25 ff TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare 8 private clubs) 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperature controls required) (check all that apply): RTE-ready-to-eat foods(Ex,sandwiches,salads, muffins which need no furtherprocessing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held ✓ Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs I Juice Manufactured and Packaged for Prepares FoodiSingle Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date I 690-7,or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: v Pursuant to MGL Ch. 62C, sec. 49A,I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under la'/w. 25) Social Security Number or Federal ID: 13-7 9alt � 26) Signature of Individual or Corporate Name: /y Co!{> T,' Q 1, 4; .I� A i0l )g Ww" s"I q jai onQ�tii -Ve,ovum, IS, 7 W! tY-of'swein s� o Board6f.HiilthKipy D Z V. C- Woo tlscoll x ' Www". 1W 17- ............ 12U -UbMHgtonlature V=s, -SALEMMA'l 01970 x - z tl Z n) v4'1 ":�' `TOBACCO PERMIT- W -q- -DATE PRINTED! .4, �--��--'IM8/20,13: M&N no nX �W, AI _e- W. . 21 . AWWW � — A,: 4 - z �gmpn, ESTABLISHMENT-NAME 1334 s� Lm-, WIP 'is W Flaherty 'raw Ang". File Nmba-BHF-2004-000154 QHCSS flaz -N &W 53, R 4� Woodbridge - T 0A, I......... LOCATED AT 029� -DRUY.-STREET"- off , Ilk! SAILE*M-`&W-�Ofh 6��'WEQ" 1"'A- f� R 11nut Expires-4 Fke Restrictions/-Notes nz, NZ: jql� f TOBACCO VENDOR ;BHP! 014D1GW ..... Jan n 1'�,2 014 D i�c-3-1 2 0 113 5'0 0 g qAq mol- . . jTotal Te6i. $135'.00 T`V'-� , Q W sn. V . Qg, 1 2 a 0A p CL -AWT W.* 0- n; fie-W W My WAMAU how- X -7 Ar" " M 'I','o a .1-0 0 j�41� -7 V, ------- -_t �-��`Board of Realth-,,,,i., X t IVA, 11 r s, miss .?W WmWa 17=y It" -mm. �g. W ON low z Z NJ W , W- Phil j In, xy 050 Q., SKY,& W Un 1 A&A r` • a LJ Crime OF SAl.>✓nr, MAssAcHUsrTTs r BOARD OF HEALTH 120 WASHINGTON STREET,47 FLOOR PiublicHeaIth TF.I... (978) 741-1800 Fat (978) 745-0343 KIMBERLEY DRISCOLI. lramdinnsalcm.com Lr\RRY 1L\h1UIN,RS/IU SI-1 ti,0-10,CP-IS NL\Y`0R HEAL i,i-I AG L+NT 201_APPLICATION FOR PERMIT FOR SALES OF TOBACCO & NICOTINE DELIVERY PRODUCT PERMIT FEE $135 NAME OF ESTABLISHMENT 1 SSS &cpresS a 133 TEL# -1 LILT-%q 13 ADDRESS OF ESTABLISHMENT �)ert Li FAX DEPARTMENT OF REVENUE APPLICATION NUMBER: 53'9% MAILING ADDRESS(if different) EMAIL- Business: He55Corp6ration ebsite: 1 Mess r'iaia y 3• FUnet" OWNER'S NAME Wnndbridae,_NI 07095 TEL# ADDRESS 732-750-6350 TSTREET 1Ful'c("`I CITY STATE ZIP EMERGENCY RESPONSE PERSON 4eeS HOME TEL# 0(y4-a5,0 Type of Products Sold: Cigarettes ✓ Cigars '� Chewing Tobacco / Pipe/Cigarette Tobacco Nicotine Delivery Devices Other Tobacco Product(list on additional Sheet) DAYS OF OPERATION i Monday Tuesday Wednesday i Thursday Friday Saturday Sunday i HOURS OF OPERATION 1 I� Please write in time (For example 11 am-11 pm) '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. JANICE FLAHERTY z II6113 LICENSE CO""7 1NATOR 13-ypjalooa Signature Date Social Security or Federal Identification Number // '—'-----------^--,-----------' .�51—��----------------- Updated 723/12 TOBACCO.doc Check#&Date d"0&/1,,W d/y�� $l� f°" Form CT-3T 01098 Massachusetts Department of Revenue 2012 - 2014 Cigarette Excise Unit Retailer License for Sale of Cigarettes and Cigars and Smoking Tobacco 0 This License must be posted and visible at all times. Sales to persons under 76 years of age are prohibited by law. Application Number: 53896 License Number: Date of Issue: Federal Identification or Social Security Number: 134-92-1002 01098 09/13/2012 Mailing address for license: Retail sale locafloh(if different than mailing address) HESS CORP HESS 21334 1 HESS PLAZA J FLAHERTY 295 DERBY ST WOODBRIDGE, NJ 07095 0961 SALEM, MA 01970 0961 This certifies that the taxpayer named above has paid the required license fee and is licensed to sell at retail at the address shown above until September 30,2014. This license Is not transferable,and is subject to suspension for failure to comply with the law. CITY OF SALEM, MASSACHUSETTS HOARD OF H::ALTH KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4r"FLOOR MAYOR TEL-(978)-41-1900 FAX(978)745-0343 LARRY RAMDIN,RSIREHS,CHO,CP-FS LRANIDIN07,SALFM.CONA HEALTH AGENT COMPLAINT INTAKE FORM Date: !P 1\4 Time: Received By: D (� Complaint Number: 0787 Complainant 11G�N�jdK3oJ.S Address: Phone: Investigated By: J IZq Date: Property Owner/Occupant Name Telephone#: ►araSC'�.veier' C�aesSoGt'�� Ste. 7L�G'�N\ ��q� Z.' �7',� II 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 HESS CORPORATION ATTN: JANICE FLAHERTY 1 HESS PLAZA WOODBRIDGE NJ 07095-0961 II 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 HESS CORPORATION ATTN: JANICE FLAHERTY 1 HESS PLAZA WOODBRIDGE NJ 07095-0961 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name p [fie I / T�TyppeofOperation(s) Type of Inspection p(//y//7 jFoLService Routine Address Jv�I j Rikk' Retail Reinspection Telephone ^/ll �r .Ccs?i;��l7�try',/ Qy/. Level ❑ Residential Kitchen Previous)nspeeytioon/ ''G ~ y� L' ❑ MobileTemporary ❑terve re ation/ Owner i (��/ ` 1 HACCP Y/N ❑ Caterer ❑Suspect Illness Person-in-Cha1rgle(PIC) /, Tip�tpQ ❑ Bed&Breakfast ❑ General Complaint ^j In:oC�J/ ❑ HACCP Inspector n `1 lolnC¢J�P Outwe1[ Permit No. L]Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provisions)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors-(Red Anti-Choking 590.009(E) ElIViolations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) [3 t F006PROTEC' MANAGEMENT _ ___.. _._ . _ < ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties � -"`_� ❑ 13. Handwash Facilities iEMPLOYEEHEALTH, -- - ;PROTECTION FROWCHEMICAL$ ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded _ �_� _ ❑ 15.Toxic Chemicals F1 4. Food and WYE from ApE,AT- ,z _ __ ---__, !TIMEIrEMPERATURECONTROLS(PoteiittallykaikZt-tiF.oas) < �_y ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling PROTECTION FROM CONTAMINATION1_u --•_ _ ❑19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FORHIGHLY-$USCEPRTIBLE-POPULATIONS:(HSP)`_ 9 ❑ El 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP El11. Good Hygienic Practices �CONSUMERAD-SORY_ ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR cf Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection FC-3X590.004) order in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FcsX590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: ., b1aex _ Inspector's Signature: Ip,(��SI>n/� erint: .� iJ ✓ r' p PLCs Signature: Print: v Page, oi,�ages rc� 111 i .-.....s..,x....... _-._ r ..t.. - sem" Violations Related to Foodborne Illness " Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT I J, 3-302.11(A)fl) Raw Animal Foals Separated from f I 1 590.003(A) Assignment of Responsibility* I Cooked and RTE Foods* J 590.003(B) Demonstration of Knowledge* I I Contamination from Raw ingredients 12-103.11 Person in charge--duties I 13-302.1 l(A)(2) Raw Animal Foods Separated from Each EMPLO"EE HEALTH Other* 2 590.003(C) Responsibility of the person in charge toI _ I Contamination from the Environment require reporting by food employees and I I 3-302.11(A) I Food Protection- 3-302 rotection 3-302 15 I Washing Fruits and Vegetables f applicants* 13-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Foul Employee Or An * Applicant To Report To The Person in Utensils Contamination from the Consumer Charge* 590 003(G) Reporting by Person in Chatez* 3-306.14(A)(B) Returned Food and Reservice of Food* f I 13 590d)03(D) Exclusionsand Restrictions* I Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions I 3.701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE I Fad* J 4 Food and Water From,Regulated Sources ( 19 I Food Contact Surfaces 590.004tA-B) Compliance with Food Law* ( 14-501.111 Manual Warewashing-Hot Water 13-201 12 ( Food in a Hermetically Scaled Container'' I Sanitization Temperatures" 13-201.13 Fluid Milk and Milk Products* I 14-501.112I Mechanical Warewashing-Hot Water 3-202.13 ( Shell Epgs* I Sanitization Temperatures* 13-202.14 Eggs and Milk Products.Pasteurized* I 14-501.114I Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water" I concentration and hardness. 4-601.I I(A) I Equipment Food Contact Surfaces and 15-101.1 l Drinking Water from an Approved System' � Utensils Clean* 1590.006(A) BottleWater Drinking Water" I ( 4-60'_.11 I Cleaning Frequency of Equipment Food- 1590.i)06(B) Water Meets Standards:n 310 CMF. 22.17* ( = q y El P I Shellfish and Fish From an Approved Source I Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.11 ( Fish and Recreatlonaliy Caught Molluscan 4-702.11 Foci Contact Surfaces of Equipment* She1L'ish* 14-703.11 I Methods of Sanitization-Har Water and 3-201.15 I Molluscan Shellfish from:" SSP L.i,ted Chemical* Sources* Game and Wild Mushrooms.Approved by 110 I I Proper,Adequate Handwashing Repu/atory Authority 123(11.1 I I Clean Condition-Hands and Arms- 3-20118 Sheilstock Ldentificatton Prescnt' 12301.12 Cleaning Procedure* 1590.004(C) Wild Mushrooms* I 12-301.14 When to Wash* 3-201.1' Game Animals* + i 11 I Good Hygienic Practices i s Receiving/Condition 12-401.11 Eating,Drinking or Using Tobacco* 3-202.11 ( PHFs Received at Proper Temperatures* ( 2-101.12 Discharges From the Eyes,Nose and 13-202.15 I Package integrity* Mouth* 3-10i.1 t I Food Safe and Unadulterated* ( 13-301.12 Preventing Contamination When Tasting* 161 I Tags/Records:Shelistock I 112 I I Prevention of Contamination from Hands 13-202.18 Shellstock Identification* I 590.004(E) Preventing Contamination from 13-203.12 Shellstock Identification Maintained* Employees* I Tags/Records:Fish Products i 113 Handwash Facilities 3-40"2.11 I ParasiteDcstruction" I Conveniently Located and Accessible i 3-402.12 Records.Creation and Retention* I 15-203.11 _ Numbers and Capacities* I 1590.01 Labeling of Ingredients' -I 15-204.11 Location and Placement* I, 7 I I Conformance with Approved Procedures I 15-205.11 Accessibility,Operation and Maintenance I /HACCP Plans I I Supplied with Soap and Hand Drying 13-502.11 Specialized Processing Methods* I Devices 3-SU2.12 Reduced oxygen packaging,triter a* I 16-301.11 I Handwashing Cleanser, Availability I 8-103.12 Conformance with Approved Procedures* I 16-301.12 I Hand Drying Provision •Denotes critical item in the Weral 1999 Paxl Code ur 105 CMR 590.000. I CITY OF SALEM BOARD OF HEALTH l l Establishment Name: t- (_ y Date: a/ r u//5( Page: o?-� of%� Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dete. No. Reference R-Red Item verified PLEASE PRINT CLEARLY z r I I_ I 4r�r_- tA UOA �o� I 4 rl tjzj� : �7' ! � Av --- I i I � I I I I I � Discussion With Person in Charge: Corrective Action Required: I ❑ No I10 f'Yes I have read this report, have had the opportunity to ask questions and agree to correct all ie_`V_�Oluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five Ilars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(0) PHFS Received at Temperatures Violations Related to Foodborne illness interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cont.) 4i'F/45'F Within Hours.* S PROTECTION FROM CHEMICALS 3-501.15 Cooliee Methods for PHFS 14 Food or Color Additives { � 19 PHF Hot and Cold Holding i 3-202.12 Additives'm ! 3-501.16($) Cold PIlFshiaintainedatorbelow 590.004(F) 41'/45°F* 3-302.14 Protection from Unapproved Additives" i 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances I 140'F. * 4 7-101.11 ldemdf ine Information-Original 3-501.16(A) Roasts Held at or above 130'F. " f Containers* 20 Time as a Public Health Control 1 1 7-102.11 Common Name-Working Containers* ( 3-501.14 Time as a Public menhir Control* 7-201.11 Separation-Staraue' 590.004(H) Variancet 7-202.11 .Restriction-Presence and Use* f Requirement 7-202.12 Conditions of Use' 1 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* 1 POPULATIONS(HSP) 7-204,11 Sanitizers,Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpastmdzed Pte-packaged Iuices and Beverages with Warning Labels* 7-204.14 Drvinfi Afients.Criteria' 1 3-$01.1 i(B) Use of Pas 7-205.11 Incidental Food Contact.Lubricants* 3-801AI(D){D} Raw or Partially Bally Cooked Animal Food and d Eggs* 7-206.11 Restricted Use Pesticides,Criteria* i 1 Raw Seed Sprues Not Served- 7-206.12 Rodent Bait Stations* ( ` ( 3-801.11(C) Unopened Foal Package Not Re-aerred, 7-206.13 Tracking Powders,Pest Control and ` i r Manitormp° CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIMEITEMPER14TURE CONTROLS Animal Foods That are Raw,Undercooked or 16 Proper Cooking Temperatures for Not Otherwise,Processed to Eliminate PHFs *�'.,nnvc, 3401-tIA(1)(2) Eggs- 155F 15 Sec. Pathogens. Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game Eggs* S Animals-155'F 15 sec. * SPECIAL REQUIREMENTS L 3.40LI1(B)(1)(2) Pori:and Beef Rout-130'F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D) in 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sea.* catering, mobile food,temporary and t 3-401.1 t(A)(3) Poultry,Wild Game.Stuffed PHFS, i residential kitchen operations should be Stuffing Containing Fish,Meat. C debited under the appropriate sections Poultry or Ratites 165'F 15 sec * above if related to foodborne illness j 3-101.11(12)(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail t 3-401.12 Raw Animal Foods Cooked in a i practices should be debited tinder#29- Micrvwave 165'F* I Special Requirements. 3-401.11(A)(1)(b) All Other PHFS-145°F 15 sec. ( 17 Reheating for Hot Holding I VIOLATIOAIS R.-LADED TO GOOD RETAIL PRACTICES 3-9)3.1 I(A)&(D) PHFS 165T 15 sec. * (Items 23-30) 3-403.11(13) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do nor relate to the Time* I foodborne illness inten entionr and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMF 140' 590.000. 3-103.11(E) REmainingUnslicedPortions ofBeef i item Good Retail Practices I FC5,90.400 Roasts" 1 m 23 . Management and Personnel FC-2 1 .003 1 1 Ig - Proper Cooling of PHFS 1 24. i Food and Food Protection i FC-3 .004 125 Equipment and Utensils ( FC-4 00.5 i 3-50J.14(A) Cowling Cooked Plffs from 140`F toWater.Piumbinq and Waste 1 FC-5 .006 70'F Within 2 Hours and From 70'F 1 27. i Phvsical Facii ty i FC-6 1 .W7 to 41`F/d5'F Within 4 Hours. * 128. ' Poisonous or Toxic Materials ! FC=7 .008 i 3-501.14(8) Coaling PHFS Made From Ambient 29. Special Requirements .003 Temperature Ingredients to41'F/45'F ( 130. dinar I Within 4 Hours* s 'Dean t&;C.ifi A:1wrain the L^detal W99 Food Cale,w 105 C.MR 590.000. A r Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4h Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. NameNP Type of Operation(s) Type of Inspection $ Food Service R Routine Address ( 3 C L �D Rik Retail ❑ v, us Ipection Telephone / I y 0 Level ❑❑❑ Residential Kitchen Previous I s coon ❑ Mobile Date: / Owner ❑ Temporary El Pre- per tion HACCP YM a� ❑ Caterer ❑Suspect Illness Bed&Breakfast ❑General Com Person-in-Charge(PIC) Time plaint In: a0ElHACCP Inspector �RlGonl��.�� out Permit No. ❑Other Each violation che6k6a requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate To590.009(F) ❑ Allergen Awareness 590.009(G) corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT _ �,� , [112. Prevention of Contamination from Hands El 1. PIC iEMPLOYEEHEALTFI/Knowledgeable/Duties Y _ _ '`� *3. ndwashFacilities -- " •-^�-y'PRO�TECTIONFROWCHEMICALS ❑ 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 4F06DFROMAPPR6VE6S0URCE �_� F14. Food and Water from Approved SourceTIMENEMPERATURE"CONTROL_S_(P_otentlaltyHaierdousF.00ds)-_� ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling '-PROTECTION FROM CONTAMINAT1oN ❑ 19- Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time as a Public Health Control Food Contact Surfaces Cleaning and Sanitizing (REQUIREMENTS FOR HIGHLY4USCEPTIBLE=POPULATIONS(H8P). 10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP _ _ ❑ 11. Good Hygienic Practices gCONSUMER`ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an in ection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2x590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc•sxsso.004)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4x590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC5x590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6x590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. s 30.. Other DATE OFRE-INSPECTION: a ,' t n /--, I! Inspector's Signature: Print: I PICS Signature: /� I Print: z`1 fol /))r�'G�IGr I Page (of Pages III I/ ' dCt X� Violations Related to Foodborne Illness Interventions and Risk Factors(Nems 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 18 Cross-contamination 3-302.1 1(A)(1) Raw Animal Foods Separated from 1 590.0031 A) Assignment of Responsibility* __ __ Cooked and RTE Foods* 590.003(6) I Demonstration of Knowledge" I I Contamination from Raw Ingredients I 12-103.11 Person in charge-duties 13-302 1 1(A)(2) Raw Animal Foals Separated from Each Otho EMPLOvEE HEALTH I I Contamination from the Environment 2 590.003(0) Responsibility of the person to charge to 13-302.11(A) + Food Protection* require reporting by food employees and 3-102,15 I Washing Fruits and Vegetables applicants* I P I304.11 Food Contact with Equipment and 590.W3(F) ResponsibilityOfAfoodEmi lloyeeOrAn 4 ( Utensils* Applicant To Report To The Person In I I Contamination from the Consumer Charge* 3-306.14(.41(6) I Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* 1 FoodDispion of Adulterated or Contaminated 3 590.W3(D) Exclusions and Restrictions* p� 590.003(E) Removal of Exclusions and Restrictions I ;701.3! Discarding or Reconditioning Unsafe I FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources I 19 Food Contact Surfaces j 590.0041A-B) Compliance with Food Law* I 4-501.111 Manual Warewashing-Hot Water 13-201,12 Foot ma,Hermeticalh Scaled Container* I Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* I 4-501.1 t2 Mechanical Warewashing-Hot Water 13-202.13 Shell Ems,gs* I Sanitization Temperatures* 13-202.14 Eggs and Milk Pr ducts,Pasteurized* ( 14-501.114 I Chemical Sanitization-temp.,pH, 13-202.16 I lee Made From Potable Drinking Water* I concentration and hardness. 15-103.11 I Drinking Water f nn an Approved System" I 14-601,11(A) I Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water" I Utensils Clean* 5W.006(B 1 Water Meets Standards in 310 Cb1R 210* I ( 4-602.11 Cleaning Frequency of Equipment Food I Shellfish and Fish From an Approved Source I Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan I Foci Contact Surfaces of Equipment* Shellfish* ( 4-703.11 I MetholsofSanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSF Luted I Chemical* Sources* Game and Wird Mushrooms Approved by 130 I I Proper,Adequate Handwashing Re uriatoryAuthorfty I 12-301.11 I Clean Condition-Hands and Arms* J 3-202.18 Shellstock Identification Present" 12-301.12 I Cleaning Procedure* 590.004(0) Wild Mushrooms* I 2-301.14 When to Wash* I 3-201.11 I Game Animals* l 11t Good Hygienic Practices 51 Receiving/Condition 12-401.11 Eating,Drinking or Using Tobacco* 1 3-202.11 I PHFs Received at Proper Temoeratures* ' ( 2-401.12 Discharges From the Eyes,Nose and 3-202.15 I Package hiteprity* ( Mouth* t +I 3-101.1 i Food Safe and Unadulterated* 13-301.12 Preventing Contamination When TastimZ* 61 TagstRarords:Shel!stock 112 I Prevention of Contamination from Hands 3-202.18 Shellstoek Identification* ( 590.004(E) I Preventing Contamination from 13-203.12 Sheiistock Identification Maintained" I Employees* Tags/Records:Fish Products I 113 ( Handwash Facilities 13-402.11 Parasite Destruction' I Conveniently Located and Accessible 3-402.12 Record,,.Creation and Retention* I 5-203.11 I Numbers and Capacities* 1 590.004(!) Labeling of Ingredients' I 5-204.11 I Location and Placement* 1 - . IAccessibility.Operation and Maintenance '7 Conformance with Approved Procedures 520511 I IHACCP Plans I ISupplied with Soap and Hand Drying 13-502.11 Specialized Processing Methods* I Devices 13-502.12 Reduced oxygen packaging,criteria* 16-301.11 Handwashing Cleanser,Availability I 18-103.!2 Conformance with Approved Procedures* I I6-30112 Hand Drying Provision •Denotes critical item iu the federal 1999 ro;A Cede of 105 CMR 5900000. CITY OF SALEM BOARD OF HEALTH Establishment Name: /ASS , /'3� Date: o�� fi/ �9 Pager of Item Code C—Critical Itemn DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item n PLEASE PRINT CLEARLY verified l ;( �S7nyictd biZCRnL� 73�e�•.—. �c7�c7Ti� o I A Jrg ably i o I VA--h6CD 1 rt 1. I Au.M-6n ij_�Jk anis-t ow 3Z 14 N6c I Cnca clo k rZpr 1 C,'-t- nTSp `::7A Atcl rn Wi <:TVH, 2a 0-2 4L�f 13 a-o7 Z-,l ! Ajokli c c tzb., I Discussion With Person in Charge: —' Corrective Action Required: I ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction Exclusion ,violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twent -five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. G>� 1/ q IJYh ❑ Voluntary Disposal ❑ Other: i 3-501.14(C) PHFs Received at Temperatures ' Viofaifons Related to Foodbarne Illness Interventions and Risk According to taw Cooled to Factors(Items 1-22) (Cont.) 41'F/45°F Within 4 Hours. ( 3-541.15 Cooling Methods for PRFs r PROTECTION FROM CHEMICALS ( 19 PHF Hot and Cold Holding ( 14 Food Color Additives 19 Cold PRFs Maintained at tx below t 3-202.12 Additives* ( 590.004(F) 410145"F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHBs Maintained at or above ( 15 Poisonous or Toxic Substances I I 1cF * 7-101.11 Identifying Information-Original Containers* 3-501,16(A) Roasts Held at or above 130'F. f ( 20 Time as a Public Health Control 7-102.11 Common Name-Working Containers* 3-541.19 Time ac a Public Health Control* -201.11 Separation-Stotaxe* 7-202.11 Restriction-Presence and Use* 1590.404{H) Variance Requirement 7-42.12 Conditions of Use* { REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* ( POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals* ( 27 3-841.17(A) Unpasteurized Pre-packaged Juices and ( 7-204.12 Chemicals for Washing Produce,Criteria* I .Beverages with Warning Labels* ( 1-204.14 Drying Agents.Criteria* t ( 7.245.11 Incidental Food Contact Lubricants* ( 3 841.11tB) Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and ( 7-206.11 Restricted Use Pesticides,Criteda* Raw Seed Sprouts Not Served { 7-206.12 Rodent Bait Stations* . f 7-206.13 I Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-sensed, 1 Monitoring* CONSUMER ADVISORY T1MEITEMPERAT URE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of 16 Proper Cooking Temperatures for I Animal Foals That are Raw,UndtTcooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(I)(2) Eggs- 155'F 15 Sec. 1 Patbogens.*�° " Eggs-immediate Service 145°F15sec* I 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155'F 15 sec. ( 3-401.11(B)(1)(2) I Pork and Beef Roast-134'F 121111112. SPECIAL REQUIREMENTS 3-441.11(A)(2) Ratites,Injected Meats-155`F 15 594.004(A}-{D1 catering, of Section temporary and in sec * catering, mobile food,temporary and 3-401.1 t(A)(3) Poultry,Wild Game,Stuffed PHF's, residential kitchen operations should be Stuffing Containing Fish,Nleat, debited under the appropriate sections Poultry or Ratites-165°F 15 see. * above If related to foodborne illness 3-401.11(C)(3) Whole-muscle,hand Beef Steaks i interventions and risk factors. Other y 145°F i' I 590.009 violations relating to good'retail i 3-441.12 Raw Animal Foods Cooked in a { practices should be debited under#29- 1r Microwave 165°F* ( Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. ( 17 Reheating for Hot Holding I VIOLATIONS R LATED TO GOOD RETAIL PRACTICES 3-943:11(.x)&(D) PHFs 165°F 15 sec. * {Items 23-30) 3-403.11(B) Microwave- 1650 F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- ] found in the follait ing sections of the Food Code and 105 CMR 1400P ! 590.000. 3403.1l(E) Remaining Unsliced Portions of Beef I Item ' Good Retail Practices FC590.000 Roasts* 123. i Manaoament and Personnel FC-2 .003 i I i8 Proper Cooling of PNFs ( ( 24. Food and Food Protection I FC-3 .004 I 1 25. I Et uipmern and Utensils FC-4 005 3-501.14(A) Coaling Cooked PHFs from 140`F to i 2E ( Water.Piumbinq and Waste FC-5 1 .006 ! 70°F Within 2 Hours and From 70°P 27. 1 Physical Facility FC-8 007 I to 41°F/45'F Within 4 Hours.* 1 28. ' Poisonous or Toxic Materials + FC-7 .008 I 3-501.14(B) Cooling PHFs Made From Ambient � 129. I Special Requirements i .009 1 Temperature Ingredients to 41°F/45°F 130' I Other 1 Within 4 Hours* "Denotes critical t=in the tederal 1999 FcaJ Cale or 105 C.MR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: q�� Date: �/�/�7 Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/FLAN OF CORRECTION YDate No. Reference R-Red Item Verified _ PLEASE PRINT CLEARLY 1� 0 IU 1, Lya:— c)7z 2 '/A r rtca-, c�c4nlo6yIVQ4�1'e IL fo r I �Qel—L7'.q-- r nIS�Y_ � Gls/Iku�a�lu-. _ ✓ O�.,E,e, isR Ire-0 JOE I LQ — nr 4 -- I 44tYe,P1- � A)UJ r4* OL- CU / 1 J Ni I 5�� Iden 7�JL ,k6j G ¢�¢ RFs- _ (a-c,.c�. — P,&O— �)a yi t� ,']A1 ! d6 1' ✓ 0, (J OAS_ - r T � � „ Discussion NX Person in Charge: �- pit �n, / /�h�H �j (c,� ,�p �, Corrective Action Required: I ❑ No r ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all I ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure yout food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(mems 1-22) (Cont.) 4t'Ff45'F Within 4 Haus, PROTECTION FROM CHEMICALS I 3-501.15 Cooling Methods for PHFs 14 f .Food or Color Additives ! 119 PHF Hot and Cold Holding { 3-501.16(B) Cold Pills Maintained at or below 3-202.12 Additives*' I 590.004(f-) 41'/45°F* 3-302.14 Protection from Unapproved:additives* I 3-501.16(A} Hot I'1iFs Maintained at or above { 15 Poisonous or Toxic Substances I e 14F. * 7-101.11 Identify3-SOi.t6(A7 Roasts Information-Original Containers* � a` field eld at or above 130°F. iners" * r 7-302.11 ContanName-Working Containers* ( Z0 Time as a Public Health Control { 3-501.19 Time as a Public Health Control* 7-201.11 Separation-Storage" 590.004(H) Variance Requirement 7-202.11 Restriction-Presence and Use* I { 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* I POPULATION (HSP) HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* ! POPULATIONS(HSP} 7-204.12 Chemicals fru Washing Produce,Criteria* 21 3-SOI.l l(A} BevUnperages w ti Pre-packaged Juices and 7-204.14 Irving Agents.Criteria* { Beverages whit Warning Labels* 7-205.11 Incidents]Food Contact.Lubricants* 3-801.1 I(B) Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria' 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served.* ` 7-206.13 Tracking Powders, Pest Control and 13-801.11(C) Unopened Fund Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMEITEMPER4TURE 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 3401.I1A(1)(2) Eggs- 155°F 15 Sec. , Pathogerrs.*`�c0re rn2Pnt t Eggs-immediate Service 145°F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell j 3-401.11(A)(2) Comminuted Fish.Meats&Game { Ems - Animals-155'F 15 see. SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* I 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155`F 15 sec.* catering, mobile ford,temporary and 3-401.1 I(A)(3) Poultry,Wild Game,Stuffed PHP's, i residential kitchen operations should be Staffing Containing Fish,Meat. ( debited under the appropriate sections t Poultry or Ratites-365°F 15 sec, * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks intetventions and risk factors. Other tl 145'F* 590.009 violations relating to goad retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- r Microwave 165F* Special Requirements. ( 3-401.11(A)(1)(b) All Other PHFs-145'F 15 sec.+ I j 17 Reheating for Hot Holding I VIOLATIONS R F1ATPti TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PRFs 165-F 15 sec. * (Items 23-30) i { 3-403.11(B) Microwave- 1650 F 2 Minute Standing +i Critical and non-critical violations,which do not,elate to the Thi* i foodborne illness interventions and risk factors listed above, can he 34,D3.11(C) Commercially Processed RTE Food- jbund in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef { Item ! Good Retail Practices FC 590.000 1 Roasts': 123. Management and Personnel ! FC-2 .003 i { 18 I Proper Cooling of PHFs I 1 24. i Food and Food Protection FC-3 .004 25 Equipment and Utensils FC-4 .005 3-541.14(A) Cooling Cooked PHFs from 140`F to 26, Water.Plumbing and Waste FC-5 .006 70'F Within 2 Hours and Front 70'F 27. i Phvaical Facility FC-6 .007 to 4I'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials 1 FC-7 .008 3-501.14(B) Cooling PRFs Made From Ambient 28. 1 Special Requirements .009 } Temperature Ingredients to 41'F/45°F 30. d Other ! Within 4 Hours* *Denotas cri icat nom in the federal 1999 Fuad Code a 105 C.MR 390.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: ( � t� (��L/ Date: eQ/=H�y Page: 'f of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified L PL ASE PRI T CLEARLY ( / ac�- G�9o�icG'I CO7Zo 6�Q tCT�Yc✓ I , u �C 124-L- M CA-R� 111-of",SCLCJS '5' LV i/(UY`Zn +?j,9 e- V-) odd v�j ,rl -R I12 t / I I / C(Q/°�t ,/L1. - ^ .St-z.r i �l,�j��.c /D7�T / rG : d�nok 7Ft A,n / �((AX O � ✓/ '1 LAO �irJ we, ((I, flow "'?)4— ii"ADV"A"— kwp Discussion With Person in Charge: Uo r �cw tt 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 _inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that r� noncompliance may result in daily fines of twenty-fffiiieQdoll rs or suspension/revocation of Ll Embargo ❑ Emergency Closure `,� your food permit. JY " Y� /� —� Cl Voluntary Disposal ❑ other: 3-501.14(0) PFIFs Rc=ived at Temperatures,, J Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to !=actors(items 1-22) (Cont,) 41'F145°F Within 4 Hatrs. PROTECTION FROM CHEMICALS 4 501.15 Cooling Methods tar PHFs I 14 I i Food or Calor Additives 149 PHF Hot and Cold Holding i -501.16(B) Cold PHFs Maintained at or below 13-202.12 Additives* 590.004(F) 410145'F* 3-302.14 I Protection from Unapproved Additiv;s* 3-501.16(A) Hot PHFs Maintained at or above 15 I Poisonous or Toxic Substances 140T. > 7-101.11 Identifying Information-Onginal 3-501-16(A) Roasts Held at or above; 130017. Containers* 120 Time as a Public Health Control 17-102.11 Common Name-Working Containers* i 3-501,19 Time as a Public Health Control* f 7-201.11 Separation-Storage* E 7-202.11 Restriction-Presence and Use* I 590.004(Hi Variance Requirement i 17-202.12 Conditions of Use* i REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 17-203.11 'Toxic Containers-Prohibitions* I POPULATIONS(NSP) 17-204.31 Sanitizers.Criteria-Chemicals* t 21 3-801.13(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals fru Washing Produce,Criteria' I .Beverages with Wanting Labels* 17-204.14 Drying Agents,Criteria* I 3-801.11(B) Use of Pasteurized Bags* I 7-205.11 Incidental Food Contact,Lubricants* I 13-801.11(D) Raw or Partially Cooked Animal Food and 17-206.11 Restricted Use Pesticides,Criteria* Rao Seed Sprouts Not Served.* ! 17-206.12 [rodent Bait Stations* I 3-801.11(0) Unopened Food Package Not Re-served. 7-206.33 Tracking Powders,Pest Control and l Monitating" CONSUMER ADVISORY r TIMEITEMPERNTURE CONTROLS 22 3-613•i I Consumer Advisory Posted for Consumption of I 16 Proper Cooking Temperetums for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.* 3401JIA(1)(2) Eggs- 155'F 15 Sec. Eggs-Immediate Service 145°Fl5sec^ 3-302.13 Pasteurized Eggs Substitute for Raw Shell ti 3-411.11(A)(2) Comminuted Fish.Meats&Game Eggs' k Animals-155°F 15 see. 3.401.11(B)(1)( ) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.5 l{A)(2) Ratites,Injected Meats- 155°F 15 541.009(A)-(D) Nidations of Section 590.009(A)-(IJ)in sec.* catering. mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be I ( Stuffing Containing Fish,Meat, debited udder the appropriate sections �r Poultry or Ratites-1650F t5 see. * above if related to foodborne illness ! 3401.11(C)(3) Whole-muscle,Intact Beef Steaks j interventions and risk factors. Other l I 145°F r` 590.009 violations relating to good retail f 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- SPf Microwave 165°F* Special Requirements, 3-401.11(A)(1)(b) All Other PRFs- 145'F 15 sec. I i7 Reheating for Not Holding VIOLA77ONS R-LATED TO GOOD RETAIL PRACTICES 3-403:11(.1)&(D) PHFs 165"F 15 sec.* I (Items 23-30) 3-403.11(B) Microwave- 165` F 2 Minute Standing Critical and non-crttfcal violations, which do not relate to the Time* fiiodbonte illness tmerventfoas and risk factors listed above, can he 3403.t 1(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.400. 3-403.11(E) Remaining Unsliced Portions of Beef Hem 1 Good Retail Practices 1 FC 530.000 i Roasts* j 23. i Management and Personnel ! FC-2 .003 i 18 Proper Cooling of PHFs f i 24. 1 Foal and Food Protection I FC-3 .004 1 125. 1 Equipmem and utensils 1 FC-4 .005 7 3-50L14(A) Cooling Cooked PHFsfrom 140`Fto ! 26, Water.Piumbingand Waste j FC-5 .006 t 70`F Within 2 Hours and From 70°F 27• j Physical Facility FC-6 .007 to 41`F/45'F Within 4 Hours.* 128. Poisonous or Toxc Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient ! 129. I Special Requirements 008 1 Temperature Ingredients to 41 017/4551T ( i 30. 1 Other ! I Within 4 Hour's* s.,mt-��,:•u e. 'De notea aiticaa mm in the federal 1999 Fuad Cate a'SUS CMR 590.000. ' s CITY OF SALEM BOARD OF HEALTH Establishment Name:__44" �7n�t2 ,1 t Dater Pager of Rem Code C-Crittcalltem - DESCRIPTION OF VIOLATION/PLAN 65 CORRECTION J Date No. Reference R-Red Item / verified PLEASE PRINT CLEARLY torte[ JAI MW-5 a trMA A 1 / o� ' 1( A,-r. t L)141-- `V*— Anne clt Ce-), ^t (41 rA 10 ,0120 r f J �- cCN o C — K �c�JPr� tno k Pl fid— j moo. nor k-A�s,4./, I I Discussion With Person in Charge: Corrective Action Required: I ❑ No hf fes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion p e-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-f ive dollars or suspension/revocation of I ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: r, w 3-501,14(0) PHFS Received at Temperatures via infians Related to Foodborne f iness Interventions and Risk According to Law Coaled to t Factors{items 1-22) (Cant) 41'F/45`F Within 4 Flours. i PROTECTION FROM CHEMICALS 3-501.15 Cooline Methods for PRFs 14 Food w Color Additives 19 PHF Hot and Cold Holding 1 3-501.16(B) Cold PIiFS Maintained at or below •i 3-202.12 Additives* 590.0(wlF) 410145'F* ? 3-302.14 Protection from Unapuroved Additives* ( 3-501.16(X) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140`F * 4 7-101A 1 Identifying Information-Original 3-501.I6(A) Roasts Held at or above 130'F. " 7 Contaiaers* ( 20 Time as a Public Health Control 1 r 7-102.11 Common Name-Working Containers* 3-501,19 Time as a Public Health Control* 1 7-201.11 Separation-Storage 1 7-202.11 .Restriction-Presence and Use* ( 590,004(H) Variance Requirement 1 7-202.12 Conditions of Use' 7-203.11 Toxic Containers-Prohibitions* 1 POPULATIONS NS(HSP) FOR HIGHLY SUSCEPTIBLE i 7-211 Sanitizets.Criteria-Chemicals* 04. 7-204.12 Chemicals for Washing Produtx,Criteria* 21 3-$01.17(A) Unpasteurized Pre-packaged Juices and Beverages with Warning labels* 7-204.14 Drying Agents,Criteria* ( 3-801AI(B) Use of Pasteurized Eggs* ( 7-205.11 Incidental Food Contact Lubricants* i ( 3-901.11(D) Raw or Partially Cooked Animal Food and 'r 7-206.11 Restricted Use Pesticides;Criteliaa r Ras,Seed Siccants Not Served- 7-206.12 Rodent Bait Stations* ( 3-801.17{C} ( Unopened Food Packare Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY C 22 3-603.I1 Consumer Advisory Posted for Consumption of TIMEIfEMPERATURE CONTROLS Animal Funds,That are Raw,Undercooked or 16 Proper Gookfng Temperatures for Not Otherwise Processed to Eliminate PHFS Pathogens.*� "n inxnr 3401.11A(1)(2) Eggs- 155F IS Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shei1 Eggs-Immediate Service 145'1715sec* 3401.11(A)(2) Comminuted Fish.Meats&Game Ems* %} animals-155'F 15 see. 1 SPECIAL REQUIREMENTS 3.401.11(8)(1)(2) Port:and Beef Roast-130°F 121 mW* i 590.009(X)-(D) Violations of Section 590.01 in 3-401.11(X)(2) Ratites,Ltjected A4eats-155`F 15 see.* catering, mobile fel,temporay and 340LI I(A)(3) Poultry,Wild Game.Stuffed PHFS, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections i 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 f 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under x`29- Microwave 165rF* Special Requirements. 3401.11(A)(1)(b) All Other PHFS- 145'F 15 see.* f 17 Reheating for Hot Holding I VIOLA17ONS R_LATED TO GOOD RETAIL PRACTICES 3-X03.11(,1)&(D) PHFS 16ST 15 sec. * ( (Items 23-36) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the Timm* foodborne illness inte"entiaw and risk factors listed above, can be ' 3-103.11(C) Commercially Processed RTE Food- found in the follonzng.sections of the Food Code and 105 CMR 1400F* 590.000. % - 3403.11(E) Remaining Unsliced Portions of Beef i, tient 1 Good Retail Practices FC 590.000 Roasts* i 23. 1 Manaaament and Personnel 1 FC-2 .003 18 Proper Cooling of PRFs ( 1 24. 1 Foal and Food Protection 1 FC-3 .004 1 25. 1 Equipment and Utensils i FC-4 r .005 3-501 14(k) Cooling Cooked PHFS from 140°F to ( Nater.Plumbing and`Naste FC-5 006 70'F Within 2 Hours and From 70`F 1 27. s Physca Facility FC-8 t .007 to 41`F/45°F Within 4 Hours. * 1 28. 1 Poisonous or Toxic Materials FC-7 .008 i R 3-501.14(8) Cooling PHFS Made From Ambient 1 29. 1 Special Requirements .009 1 Temperature Ingredients to 4VF/450F i 30. i Other i Within 4 Hours* 'Dernuec crinew rim in the I dml 1999 Food Cade or'105 CS1R 590.000. t v1 vl r e r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET 4"FLOOR Plib11CHP.alth STREET, VrO'enL I4mm�,c.P-1c0 TEL. (978) 741-1800 FAX(978) 745-0343 KIMBERLEY DRISCOLL Iramdinnn salem.com L,VtRt�It��NmtN,RS/aI?rts,(1110,(111-PS MAYOR Hv)u It-1 Ac,,i;N,I' July 1,2013 Hess 295 Derby Street Salem, MA 01970 Dear Owner: On Monday June 13,2013 at 6:49 pm 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 tobacco from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Hess is in violation of Section III (A)of the Salem Board of Health Regulation Affecting the Sales of tobacco to a minor. 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($100.00 Hundred Dollar fine)for the first offense. FOLLOWING THE THIRD(3110)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$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street, 4th floor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 978-741-1800. Sincerely yours �I Larry Ram itv Health Agent LR/hlp CERTIFIED MAIL: 70121640 0002 3312 9465 cc: North Shore Tobacco Control Program Barbara Poremba, Board of Health Chairperson and Members r4-� y 5 tT Su u4 `P. -.,4's .i15:.i.If.J^`"Ga.,°yn.. ..Y:(n;t<•;'° ' .�• V><olat><on Noflec Cown , 11 fa Board of Health y Public Health :.. 'Prevent Promote Protect' ' s - - .. :v ..'... ut`. ! -,d, a o Ax4x This,notice:is to'informyou'that your establishment,v�iotated the$oard of Health Sale of Tobacco Products ; &Nicotine�Deltver -Products and or Env'i'ronmental-Tobacco Smoke ETS, Re Mahon 4 Y ( ) 8t^s i•.. . i �/' 'i r i '' t,�ri ! t ' i4 , i`ti" n b:...,� r :x� xr�s, Name o'f es`tablishment IT f IT Address _ ,(e� jJ([ _ -5r ' .i�l\ f!i „`�yy k Date of violation Time of violation ,'I Mmor s age/gender s , Imps s ID# i Ir(Ordinance,Section,Regulahon� ' (Act Constituting Violation) N; r a Narrative information: ` ' �,•/ ,x ' ,,,111, • �I : �^./ w l IT of• • ., 5�`a i '� r t •\r/\i .�� 1 ` yV �. t•Y x 1 ,,' ! k 44. I affirm,under the pains and p neaties of perjury that the above report is true to the best,of my knowledge X. and belief. t IT Tr Inspector(Sagna ure)• r x —r (Print name) �' TT 'VENDOR S UMENT IacknoiJledge I received this Violation Noti&,e on. 20 at— S—. � 1M%PM nd•I am bemg'given a,carbon',copy of this nogce :I also acknowledge that I have b informed,that h Peabody Board,of Health 'will proyide,addttional,'follow-up'tnformation to this.violatio"n notice " s Tt t caner/Manager/Clerk(Signature) (Print name)' w . 'df vendor refuses this Notfce 6r4,the inspector feels unsafe m delivering it;an explanation must be t: written on a note attache'd'hereto.Mai ling of this Notice is thus rd:equireu ! ' w. + Contact the North Shore/Cape Ann Tobacco Aicohol'Pohcy Program at 781=586 6821 with questions' " Establishment-white. , NSTCP yellow $oard of•Health pink >.. q,ERTIFIE.' MAILT. RECEIPT Ln (Domestic Mail Only;No Insurance Coverage Provided) N OFFICIAL USE M Postage I$ M M Certified Fee M Postmark C3 RstemReceipt qulFee I I Here C3 (Entlorsament Reretl) O Restricted Delivery Fee O (Emi.mar ent Required) ' _a Totel Postage&Fees Sent To N C3 oireef,Ap(No; N orPCBox No. CIN Sime.ZIP+4.__.________________________________________________________________ rin 1:1414444.i.d.0 12,444 11 i::iiY:Yi: Certified Mail Provides: ■ A mailing receipt • A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mall may ONLY be combined with First-Class Mails or Priority Mails. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt maybe requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery'L ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530.02.000-9047 ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse XAdtlressee � so that we can return the card to you. B. �eceivedy(Printed Name) C. orelrvery ■ Attach this card to the back of the mailpiece, J� y.,� (�, I e�(R�D /� or on the front if space permits. -i D. Is delivery address different from item 17 Ll Yesr 1. Article Addressed to: If YES,enter delivery address below: 0 No ' �rtil P.♦n� 3. Service Type ❑certified Mail ❑Express Mail 0 Registered 0 Return Receipt for Merchandise 0 Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) 0 Yes 2. Article Number (fransferfmmservicef, L . 7p12 1640'_ 0002 3312 9465 0 PS Form 3811,Febru_, uomestic Return Receipt 102595-02-M-154D UNITED STATES POSTAL SERVICE I First-Class Mail 03 PS 1P® &Fees Paid l O n " 0� GIII • Sender: Please print your name, address, and il�t�t is bb' 0n N sv BOARD OF HEALTH� w SALEM, MA 01970 I I . I hlhilhdlllulld�l�ll�iilliw�l�ry�ll,.l.il��l�pllgl��l .• / ' ' ., :,, ,. " '"'•�YNCU9E�E�S. �%' .�,y"�,��'MBER� ��Y�S'�:'��':, • OR "YYOGZ � ''e` s • M{yam{ h 'y�•j�..�fj• r �y - -/ .• �?,A � "'* s#f:,r"i �� a' '� "UJ Cff•Y yY i •- / - 3s7�q+-t to ��' DA7fr fs6�''+ 0^ !a.' � `� . > 4•+ I p( t1`i � ;'"Sk ybin3 `�',a-X07'# 'f+� 3£tta'"a+' t��k• •�N -ati�, k4 l�Y'�Ck§vY K � '�.�t C� 1� y 1'fF j�i Y•,. ✓� Y fy ... If � :;� � ,.�Y iuS" !��T > ds*3'k y,��s-s'' �'V;�ss ! Y 1,�1 `'�e Y a u■ 6L8L3454 0 — n■ 2000 3 — — m � n CITY OF SALEM, NIASSACHUSI;TI'S 10 BOARD OF HEALTH 120 WASHINGTON STREET,4'""FLoOR PablicHealt I Ar<arni_1'inmme.Amlect. TEL. (978) 741-1800 FAX(978)745-0343 KIMBERLEY DRISCOLL lramdin(7Qsalcm.com L,N210"R,\11DIN,Rti/Rfi1I5,CI-IO,(;I)-I;ti MAYOR Hu',AI:t'I 1 A(;I',N'I' July 1, 2013 Hess 295 Derby Street Salem, MA 01970 Dear Owner: On Monday June 13,2013 at 6:49 pm 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 tobacco from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Hess is in violation of Section III (A)of the Salem Board of Health Regulation Affecting the Sales of tobacco to a minor. 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($100.00 Hundred Dollar fine)for the first 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$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4`"floor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 978.741-1800. Sinncerellyyours, Larry am i't]n Health Agent LRthip CERTIFIED MAIL: 70121640 0002 3312 9465 cc: North Shore Tobacco Control Program Barbara Poremba, Board of Health Chairperson and Members _ Violation.Notice CITown rf i.Y : Board,of Health Pt:!WHealth `•PtevenS Promote, Protect. -1 P rr. This notice.is toanformyou,that your establishment vjolated'the)oard of Healtli-Sale of_lobacco Produ4. cts ' Nicotine L)ehveiyP.roduets andlot;EnSirotrmental=Tobacco-Smoke(ETS)'Rggulation., r „ Name of�esta5lishment t ' ss Addie Date of.villahon Time of viol hon - : Minor sage/gender - -' icor s_ID71 , -- r (Otdinance,Sechon,QKegtllafxo a (Act Constituting Violation) ' Narrative information: r I affirm,under the pains and penalties ofpe-rjury,-that the above report is true to the best of'my knowledge and-belief_: _, l j r ry \i ( ..,� : _.T'l^:A 3f + f�t .' i, 1 '� z:,? -- `•...µ:,...w4 "y int" i '.;�'� Inspector(Sigpature) (PPMt name) VENDOR S "f�EMENT I acknowledge I received this Violation,Notice on 26 L -. at T /PMI and'I am being given a.carbott copy of this notice.I also a knowledge that I. have been inform'ed fiat the.Peabody Board,of Health,will provide,additional,follow-up information to this violation notice. ; 1 bwner/Iv Hager/Clerk(Sigtigtir ): (Print name) If vendor refuses this Notice or if the:inspector feels unsafeindelipering it,an explanation must be written on a note attached'hereto:hailing of this Notice is thus required',. _ to Contact the North Shore/Cape,Ann Tobacco.Aj'cohol PO(icy,Program at 781-586,6821 with,quest'ions' Establishment-white: NSTCP-yellow :BQard o£Health-pink`'', Commonwealth of Massachusetts ` City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor 11/18yor, SALEM,MA 01970 Food/Retail.Establishment Permit DATE PRINTED: 12/05/2012 - t ESTABLISHMENT NAME: Hess Express #21334,• File Number:BHF-2004-000154 - .1 Hess Plaza/J.Flaherty `Woodbridge . NJ 07095 LOCATED AT- 0295 DERBY STREET'' SALEM, NLA 01970 , a Permit Type Permit No.' Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD, BHP-2013-0068 Jan 1,2013, Dec 31, 2013 -.$70.00 TOBACCO VENDOR BHP-2013-0073 Jan 1,2013 Dec 31,2013 $135.00 Total Fees: $205.00 q 'PERMIT EXPIRES,, (December 31,2013 ` Board of Health - Z This Permit is not transferable and must be reissued upon'change of ownership or location.The permit must be posted 4 in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. page 1 { CITY OF SALEM, aC�� OHO :1jMASSACHUSKI TS C v > xe8itn DEC C �� r,;i�Z Bt},1RDt)�'''FIt'.,V:t1-i 120WmjIINCir(-)N ''1121i,fi'i',411,FIoott 1N, KENIBF,RLEYDRt��I:�' OFS-,_EM Til..(978)7411860F,ta(978)745-0343 MAYOR LARt21'R;lN4t> RtijRi:,iIS,t:i{<),C.t'-t�ti D OF HEALTy lxamdin(a saleni.coni I-IIN,I'l l AG ISN'T Food Establishment Permit Application y (Application must be submitted at least 30 days before the planned opening-date) 1) Establishment Name: ge-S5 4EXQfirss 2.133' 1 2} Establishment Address: a95 R e Ch,( r\ yr l 3) Establishment Mailing Address(if different): , 4) Establishment Telephone No: _?gq_2;LA13 HESS CORPORATION rless P11=1 j. 1 5) Applicant Name&Title: Woodbridge,NJ 07095 732-759-baba 6) Applicant Address: 1 7) Applicant Telephone No: 2 Hour Emergency No:-LV j—jM-(r(60 Email: l 1 8) Owner Name&Title(if different from applicant}: b 9) Owner Address(if different from applicant): J , 10) Establishment Owned by: ft} If a corporation or partnership,give name,title and home address of officers or partner. Am association Name Title Home Address A corporation „ An individual A partnership R.1. Lawlor VP 1637 Thistlewood Dr Other legal entity -- Washington Crossing, PA 18977 I) I l 12) Person [Directly Responsible For Daily Operations(Owner,Person in-Charge,Supervisor,Manager,etc.) l Name&Title: I :37af-CeS V_G_�0t, Address: Telephone No: I Q"(r� t {dd Fax: Email: Emergency Telephone No: 13) district or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: I Fax: Email: 1 Check#:J0) `}-{d`f.sq Date: U '�?/ I0 Amount— .� Food Establishment Information 14) Water Source: 15) Sewage Disposal: •p' '+' DEP Public Water Supply No: ( if applicable) CAA, 16) Days and Hours of Operation: aLl 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑ Caterer Permanent Structure ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments------------------------ ----------------------------------------------------------------------------- Breakfast Establishmentslish - nt (check one) REJAIL STORE RESTAURANT /Annual frrLess than 1000sq.ft. $70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑ More than I0,000sq.ft. $420 ❑25-99 seats $280 ❑ More than 99 seats $420 rTemporary/Dates/Time: - . . . ------------------------------------ - ------------------ ❑ Bed &BreakfasUChildcare Services/Nursing Home $100 ------------ -------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ pA STURIZATION $25 I TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare&private clubs) 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs-non-potentially hazardous food(no timeltemperature controls required) (check all that apply, RTE-ready-to-eat foods(Ex.sandwiches,salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held ✓ Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date a�� or Reconditioned Food Total Permit Fee: - Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. ///� 24) Signature of Applicant: ✓/( Pursuant to MGL Ch.62C, sec. 49A,I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 13-7 ?dl 26) Signature of Individual or Corporate Name: SCOtp Massachusetts Department of Public Health Salem Board of Health Divis'on of Food and Drugs 120 Washington Street,0 Floor 9 Salem, MA 01970-352q Tel. (978)741-1800LFax (978) 745-0343 City/Town of C M O/VY\ Address: `\ FOOD ESTABLISHMENT INSPECTION REPORT Tel. Q(,VQ- "),(.G,J If Q'/1h Name f ate T pe Operation(s) Type of Inspection A per) 4- � �� tL ��- i � ood Service ETRydine Addressr� O �� Risk- ElAetail e-inspection QG-05 ROn IT.4�' Level ❑ Residential Kitchen Previous Inspection TelephoneElMobile Date: ` 9' Owner q < '7) HACCP YIN [I Temporary ❑Pre-operation ❑ Caterer ❑Suspect Illness Person-in CharTime) /7, , T / ❑ Bed 8 Breakfast ❑❑General Complaint l I 1-1 ime� HACCP Inspector Ou : Permit No. ❑Other Each violation checked requires an la tion 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 Anti-Choking 590.009(E) ElItems ) Tobacco 590.009(F) ❑ Violations marked may pose an imminent health hazard and require immediate Allergen awareness 590.009(G) ❑ corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT_ El 12 Prevention of Contamination from Hands ❑ 1. PIC Assigned/Kno,(vledgeable/Duties 0 13. Handwash Facilities i.EMPLOYEE HEALTH - - OTECTION FROM"cHEMICALs, ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded _ F115.Toxic Chemicals FOOD FROM APPROVED SOURCE__ _ __ _ _ TIMEITEMPERATURECONTROLS(Potentlalty Haraidous F.oads) , ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18.Cooling „ PROTECTION FROM CONTAMINATION _ ��_ �, E] 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20. Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing J-REQUIREMENTSiOR HIGHLYSUSCEPTBLE=POPULATIONS'tHBP)'I ❑ 21.Food and Food Preparation for HSP ❑ '10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices r CONSUMER ADVISORY [122. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N 23. Management and Personnel (FC-2x590.003) by a Board of Health member or its agent constitutes an 1 f_ y) 24. Food and Food Protection (FC-3x590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4x590.005) cited this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC5)(590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6x590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7x590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other S< ` j_ .. SVI DATEOFRE-INSPECTION: s 8-w.dac Y�(i b Inspector's Signature: I Print: o't)vzp r �,,, P[Cs Signature: l _ ( 1 Print: � ' � ^ ' Page�ofges Violations Related to Foodborne Illness ti ' Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION ( FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 * 13-302.111,A)(1) Raw Animal Foods Separated from I i 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* 1 Contamination from Raw Ingredients 2-103.11 I Person in charge-duties I 3-302.1 1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH other* J 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment _ 13-3U2.11(A) I Food Protection" require reporting by to employees.md 3-302.l5 I Washing Fruits and Vegetables ' applicants* 13-304.11 I Food Contact with Equipment and 590.003(F) Responsibility Of Food Employee Or An Utensils* Applicant To ReportTo The Person in 1 1 Contamination from the Consumer Charge* 590.003(G) Repotting by Person in Charge* 3-306.14(A)(B) _I Returned Food and Reservice of Food* i 3 590.003(D) Exclusions and Restrictions* I Food donofAdulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions ;.701.1 1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* ' 4 Food and Water From Regulated Sources 19 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 Scaled Container* ( Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 1 1 4-501.112 I Mechanical Warewashing-HotWater 3-202.13 I Shell Eggs' Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 14-501.114 I Chemical Sanitization-temp.,pH, 1 3-202.16 lee Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Nater from an Approved System" 1 14-601_11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(B) Bolded Drinking dards i ,_ ( 4.60_'.11 Cleaning Frequency of Equipment Food- s>0.D06,(B Water Meets Standards in 310 CiviR_^.1, Contact Surfaces and Utensils* Shollfish and Fish From an Approved Source 4-70111 I Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught MolluscanShe]LI Food Contact Surfaces of Equipment" Molluscan 14-703.11 I Methods of Sanitization-Hot Water and 3-2G1.15 Molluscan Shellfish from SSF Listed I Chemical* Sources" Game and Wild Mushrooms Approved by 1 10P I Proper,Adequate Handwashing I RegulatoryAuthority 2-301.11 I i Clean Condition-Hands and Arms* 3-202.18 Shellsuck identification Present" 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 I When to Wash* 3-201.17 I Game Animals" I 1 11 I I Good Hygienic Practices 1 3 1 I ReceivingrCondition 2401.11 I Eating,Drinking or Using Tobacco* 1 1 3-202.11 1 PHFs Received at Proper Temperances* 12-401.12 Discharges From the Eyes,Nose and 3-202.15 i Package Integrity" Mouth 161 3-10i.1I Food Safe and Unadulterated" 1 3-301.12 Preventing Contamination When Tasting* I 1 Tags/Records:Shelistock 12 1 I Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 1 590.004(E) Preventing Contamination from 3-203.12 ( Shellstock ldentilicatiom Maintained* ( Employees* i TagsiRecords:Fish Products 1 1 13 Handwash Facilities 1 3402.11 Parasite Destruction" Conveniently Located and Accessible 113-402.12 Records,Creation and Retention` 1 5-203.11 Numbers and Capacities* I 1 590.0040) Labeling of Ingredients* _ 1 5-204.11 Locution and Placement* 7 I Conformance with Approved Procedures 1 5-205.11 Accessibility, Operation and Maintenance 1 /HACCP Plans I I I Supplied with Soap and Hand Drying 1 3-502.11 Specialized Processing Methods* 1 Devices 3-502.12 Reduced oxygen packaging,criteria* 1 1 6-301.11 Handwashing Cleanser,Availability 1 8-103.12 1 Conformance with Approved Procedures,, 1 16-301.12 Hand Drying Provision 1 `Denotes ctitial item iu the federal 1999 Faid Code of 105 CMR 590.0(N). CITY OF SALEM ,�� /� BOARD OF HEALTH Establishment Name: Flan- AQ 1 ��-Y Date: Page: �ot oC Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, No. Reference R-Red Item Verified fr) PLEASE PRINT CLEARLY rAli I AD L�?6d, I ►s) M�,y ✓ �,50" e/�>T lAA r1//L moi/ /�F S bJl t I ✓ Ate MAA, Z r1� �/�ULICZ- Mryn (J� �F A 7A I n l n� l�eIAA e A -Z (UjrOn ^ Pi _ �2arnn I f ori I tit u r - Discussion With Person in Charge: U Corrective Action Required: I ❑ No — , I have read this report, have had the opportunity to ask questions and agree to correct all tr Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next ins ection, to observe all conditions as described, and to p inAspe tion Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that X _tk( noncompliance may result in daily fines of twenty-five o tars or suspension/revocation of ❑ Embargo El Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: - I 3-501.t4(C) PHFs Received at Temperatures Violatlons Related to Foodborne Illness Interventions and Risk According to law Cooled to 'I Factors(ftems 1-22) (Cont.) 41 Fi45`F Within 4 Hours, PROTECTION FROM CHEMICALS I 3-501.15 Cooling Methods for PHFs 114 Food or Color Additives 119 PHF Hot and Cold Holding I 3-501.16(13) Cold P13Fs Maintained at or below 3-202.12 Additives*' 590,004(F) Hot 590.004(F) P 3-302.14 Protection from Unapproved Additives* ( °F 115 Poisonous or Toxic Substances I 1-501.16{A} HHot PHFs Maintained at or above ti 7-101.11 rdentifyingInformation-Original 140 . * • Containers* 3-501.16(A) Roasts Held az or above 330°E. * 120 Time as a Public Health Control I 7-102.11 Common Name-Working Containers* I 3-501.19 Time as a Public Health Control' I 7-101.11 Separation-Storage* I 7-202.11 i.Restriction-Presence and Use* I 590.004(H) Variance Requirement 7-202.12 Conditions of Use* ( REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 I Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria-Chemicals* I 7-204.12 I Chemicals for Washing Produce,Criteria* I 21 3-801.17(A) BevcrUnpasteurized ges w t Warning gad else and I .Beverages with Warning labels* 7-204.14 Drying Agents,Criteria* 3-801.1116) Use of Pasteuriml Eg*s* 7-205.11 IncRestricted Foal Csticid. ieriaLubricants* I 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* I Raw Seed Sprouts Not Served * 7-206.12 Relent Bait Stations* 1 7-206.13 Tracking Powders,Pest Control and 13-801.11(C) Unopened Food Package Not Re-served. * ! Monitoring* CONSUMER ADVISORY TIMEMEMPERATURE CONTROLS 22 3-6M.i i Consumer Advisory Posted for Consumption of 16 ( Proper Cooking Temperatures far Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.*a 1.7^ t 3-401.11A(1)(2) Eggs- 155`F 15 Sec. ° 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs-Immediate Service 145 Fl5sec* 3-401.11(A)(2) Comminuted Fish.Meats&Game E ¢s 'r Animal's-155°F 15 sec. 340111(B)(1)(2) Port:and Beef Roast- 130°F 121 min* I SPECIAL REflU1REMENTS 1 3.401.11(A)(2) Ratites,Injected Most;- 155°F 15 590.009(A)-(D) Violations of Section .590.009(A)-(D)in sec. * I catering,mobile food,temporary and 3-401.1 t(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'17 t5 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 Rods Cooked in aI practices should be debited under#29- Microwave 165`F* Special Requirements. ! 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 sec.* I f 17 Reheating for Hot Holding I VIOLA71ONS R_FLA TED TO GOOD RETAIL PRAC77CES ! 3-403.3 i(A)&(D) PHFs 165°F 15 sec. * I (Items 23-30) 3-403.11(B) Microwave- 1650 F 2 Minute Standing Critical mrd non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- � found in the following sections of the Food Code and 105 CMR 140°F* 590.000. t 3-403.11(E) Remaining Unsliced Portions of Beef 1 item Good Befall Practices i FC 540.00D l Roasts" ` 123. 1 Manactement and Personnel i FC-2 .003 1 1S Proper Cooling at PHFs I 1 24. i Food and Foal Protection I FG -3 .004 4 1 25. 1 Equipment and Utensils FC-4 .005 3-501.14(A) Cowling Cooked PHFs from 140`F to f 126. I Water.Ptumbinq and Waste I FC-5 .006 70°F Within 2 Hours and From 7017l( 27. I Physics FactIltV FC-6 .007 I to 41`F/45°F Within 4 Hours.* 1 28. j Poisonous or Trade Materials ! FC-7 .008 I 3-501.14(6) Coolutg PHFs Made From Ambient1 129. I Special Requirements .008 1 Temperature Ingredients to 41°F/45°F fi` 130. i Other ! Within 4 Hours* 5,.,a.m r,..•c: I 'Denotes critical lent in the federal 1999 Food Cade ut 105 C.MR 590.000. 04/03.2008 03:32 FAX R001/002 Al A-1 Exterminators pest control professlonals March 19,2013 Hess Corporation#21334 295 Derby Street Salem,MA 01970 Ann:Raja Based upon inspections and treatments please find our findings and recommendation.This inspection was performed by visual observation only. Interior& Cxterior Dates of neatments — 10/12/12, 11/1/12, 12/5/12, 1/3/13,2/6/13,3/5/13 i On 10/12/12 the interior and exterior of Hess, Salem MA,was inspected for the following: Insects and Rodents,rodent droppings,burrows and sanitation.At that time there was no evidence of insect and rodent activity on the interior&exterior of the building,multi-ketch traps were not disturbed. On 11/1/12 the interior and exterior of Hess, Salem,MA.was inspected for the following: Insects and Rodents,rodent droppings, burrows and sanitation.At the time there was no evidence of Insect and rodent activity or sanitation issues on the interior&exterior of the building.Traps were changed and re-baited as a precaution. On 12/5/12 the interior and exterior of Hess, Salem,MA.was inspected for the following: Insects and Rodents,rodent droppings,burrows and sanitation.At the time there was no evidence of insect and rodent activity or sanitation issues on the interior&exterior of the building. On 1/3/13 the interior and exterior of Hess,Salem MA.was inspected for the following:Insects and Rodents,rodent droppings,burrows and sanitation.At that time there was no evidence of rodent activity on the interior&exterior of the building,multi-ketch traps were not disturbed. On 1/3113 the Basement was inspected for the following: Rodents,rodent droppings,burrows and sanitation.At that time there was no evidence of rodent activity on the interior of the building,multi-ketch traps were not disturbed. 183 Shepard Street Lynn,MA01902-4597 701.602-2791• 800-525-4825 761592-7041 Fax C�002/002 04r0V2008 03:32 Pa e- On 216113 the interior and exterior of Hess,Salem,MA.was inspected for the following:Insects and Rodents,rodent droppings,butrows and sanitation.At the time them was no evidence of rodent activity or sanitation issues on the interior&exterior of the building.Traps were changed and re-baited as a precaution. On 315113 the interior and exterior of Hess,Salem,MA.was inspected for the following:Insects and Rodents,rodent droppings,burrows and sanitation.At the time there was no evidence of insects&rodent activity or sanitation issues on the interior&exterior of the building.Traps were changed and re-baited as a precaution, i ar i The above listed account is on a monthly IPM Peat Management Program, Sanitation continues to not be an issue on the interior or exterior of the Hess,Salem MA. This process will continue as an integral part of an effective I.P.M.Plan. Scott Weisber r Inspector A-1 Extertninat Direct Line 8 4243248 Office 781592 2731 Fax 781592 7641 Email: sweiaberaCa'latexterminators.com www,al exterminators.eom Commonwealth of Massachusetts F s City of Salem Board of Health Kimbedey Driscoll \, 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2011 ESTABLISHMENT NAME: Hess Express #21334 File Number:BHF-2004-000154 1 Hess Plaza/J. Flaherty Woodbridge NJ 07095 LOCATED AT: 0295 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2012-0188 Jan 1,2012 Dec 31, 2012 $70.00 TOBACCO VENDOR BHP-2012-0197 Jan 1,2012 Dec 31, 2012 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2012 Board of Health R n 1- This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made, all plans for.such must be submitted to and approved by the Salem Board of Health. page 1 CITY OF SALEM, MASSACHUSETTS r• BOARD OF HEALTH 120 WASHINGTON STREET,4T"FLOOR • TEL. (978) 741-1800 .KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR De,REENBAUMZasALEM.CONI DAVID GREENBAum,RS ACTING HEALTH AGENT APPLICATION FORPERMITTO OPERATE A FOOD ESTABLISHMENT U NAME OF ESTABLISHMENT -,S CII A133q TEL# Ry q S))3 ADDRESS OF ESTABLISHMENT-6M5 FAX# MAILING ADDRESS(if different) J�M., / ry�/� WopdbAdge,NJ 07095 EMAIL- Business':(N 2 t- 3q- Q SSS• COM -n7_7cn_#;irWebsite: OWNER'S NAME 1111111111111000111111KIIIIIATION TEL# 7 rreae r/J.n Mxy ADDRESS WeO 'W 07086 STREET n, "1:' $35_ CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) n, RGENCY RESPONSE PERSON �km Pqjrr� HOME TEL# —(fig 37d-IO�IID ;D . .`.OF.OPERATION°°;t. ;.`Monday'-` : .Tuesday'-�,I ,-,Wednesday.; t;'-<Thursday; ,:;�+„F.Adayf; ` _`:Saturday Vii; ; Sunday > -1 HOURS OF OPERATION Please write in time of day. (For example ttam-11pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. _$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ----- le ss than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 mora than 99 sects =$420 BED/BREAKFAST/ YES 1 ' $100 CHILDCARESERVICES/NURSING HOME------------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES ® $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES 25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid��arequired under the law I'a/6/i1 Signature DateII �-t �4L Social Security or Federal Identification Number Revised ionli 1 FOODAP201 Ladm Check#&DaIZ160411 $ rJ' CITY OF SALEM, MASSACHusErrs LICENSING BOARD A' 120 WASHINGTON STREET SALEM. MA 01970 DAVID J.SNEA.CHAIRMAN Sl �y ty TEL.978.745.9595 EXT.5648 JOHN H.COY FAX 978.74x46775 RICHARD C.LEE 5AR9ARA A.SIROiS KIMBERLEY DRISCOLL CLERX OF THE HOARD MAYOR HEATH DEPARTMENT NOTIFICATION FORM IF YOUR APPLICATION INCLUDES THE SERVING OF FOOD YOU MUST HAVE THIS FORM SIGNED BY THE HEALTH DEPARTMENT PRIOR TO SUBMITTING YOUR APPLICATION TO THE LICENSING HOARD. (this form MUST be signed and returned with your application). NAME OF BUSINESS N fAQteSS 1334 Corpomtename: Ness Grp d4da: y\es5 E,�pres5 a,33a LOCATION: TELE.# ,aa SMQ) TYPE OF LICENSE ACAI APPLICANTS INFORMATION Name:Hess c�1Yps ENtS Lt C HESS CORPORATION -- ifomi addressi 1 Heal Plaza 1 J.Flaherty City: State: Zi)y°Odbrldge,NJ 07085 Horne telc. # 732-750.6380 HEALTH AGENTANSPECTOR'S COMMENTS: t;e %6j4 Q T�� Muir lt;E el EJQ. 7r hAR bola$ e ( Ces Q DATE 130 , t "tom Health A en heal Ixm.nw;rEw,n [HE!!Jri I HePlazas CORPORATION Hess Plaza Woodbridge,NJ 07095 Janice Flaherty License Coordinator (732)750-8350 FAX:(732)352.8823 fohody®hew.com January 30,2012 Salem Health Department 9 North Street Salem, MA 01970 Hess 21334 295 Derby Street Dear Sir/Madam: Please be advised that storage in the building will not be affected by obtaining an alcohol license in the above store. We will cut back our 12-pack soda presence on the floor by putting 12-pack soda display in the window and stack beer where the 12-pack sodas were. In the event we need to increase our current extermination service because of increased activity in the store, we will adjust it accordingly. If you have any questions concerning this, feel free to call me at 732-750-6350. Sincerely, Janice Flaherty 233 L1 s�- Stn+ , A-1 _ MEN LmLrry HALL COOLER � - Hai WOMBS ` �� 3 ]R JR 3R 3R / 3 O D I NUTRITION I BREAKFAST $$ Two I HEWS ( � CANDY I CANDY 80� iCKIER MT I SNACKS / o 39 3R 3R 3El R / JR 39 / - �. SALTY I SALTY I ca O 22 T I GROCERY I AUTD PEPSI I o J 5rb R 3R / r �i turns CANDY PEPS pF 3•NAG .y.A, _ \ ® �3 a (CANDY K�� I VALUE POKER ATN RAJ I T SURA 12 PKS I r u - 1800 MADISON FF GTG /,To Gn lc2_ !J ca of e r A,00 -, o ZA it January 2012 Resets 1800 Madison FT! GOFP� [ate 'a:LN KpP FUJRTAIV UJu ( V 4REN5FR I CUFFR inCM GFP ,C4BAM CRL4 k GRILL P..ncus:Es PaEP+IR Hostess Bon APP 1 SR 7R C) _ IN w i I `i,--y'v I fhlvaRY � •Tr; I «� 1 a ;FF 1R :R 7R B •Eliminate Hershey Endcap ❑ ••Relocate HBA aR aR X15 11FEF9 2 LT 2�LT I I I TI R 3FF 7FT Ta—mw: PEPSI COKE TOWER _EW _.._ _ .._.... gFP4...� ._.COKE'"'. EfN eYwe FEM' FEM' '-'--_-' " , GDM72 GOM72 O11YE APE --- --� I ASi I--17 NNS ,15J .7 NHS fi 4'ALL -1A ?"'FOS4 weer covlel NEW! Commonwealth of Massachusetts ` c City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Hess Express #21334 File Number:BHF-2004-000154 I Hess Plaza/J.Flaherty Woodbridge NJ 07095 LOCATED AT: 0295 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0019 Jan 1,2011 Dec 31,2011 $70.00 TOBACCO VENDOR BHP-2011-0020 Jan 1,2011 Dec 31,2011 $135.00 Total Fees: $205.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health � ��✓� �LLltt�r f This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSES TT BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 1\1AYOR COM DAVID GREENBAUM,RS ACTING HEALTH AGENT 2011 APPLICATION` \ _ FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT i Sls �_APeSS, LaI33` TEL# rW q 9113 ADDRESS OF ESTABLISHMENT_O �? r �yd __.______ FAX#__MMTION MAILING ADDRESS if different0004M yyeodbtklge,NJ 07096 EMAIL- Business':(s�1a ►334 F1eSS. COl1t �-j_-rcn_szcWebsite: OWNER'S NAME TEL# i nese rnm��.�wrrtlrq W odbdd_ge,W 07086 ADDRESS STREET 9 CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) �y EMERGENCY RESPONSE PERSON c VAL)rrn HOMETEL# —l'1$'37�!-tDq)O DAYS;OFOPERATIONr ;'.I`; Monday `""•: Tuesday: �` Wednesday i'�:°^;Thursday t�::= :i , Friday; : _ < Saturdaya',:r aU: unday"v.,, � �K :;.:g HOURS OF OPERATION Please write in time of day. (Forexamplellam-11pm) TYPE OF ESTABLISHMENT FEE (check onlv2 RETAIL STORE YES NO less than 1000sq.ft. _$70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 RESTAURANT YES � less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 inore than 99 sects =$420 CHILDCARE SEF V-ICESINURS-I-N--G--Y-H--EO--S-M---E----- - $100-------------- --------------------------------------------------------------------------------------- -- ----- --------------------------------------- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES N $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES 25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. I 7i�-/-� ////S//o 13- 1/?0?/0C Signature Date Social Security or Federal Identification Number Revised 10/7/11 FOODAP201 Ladm Check#&Date� /% $ � mviroi c Environmental Services November 4, 2010 Dr. Barbara Poremba; Chairperson City of Salem Board of Health 120 Washington Street Salem, Massachusetts 01970 Re: 295 Derby Street ss Station 334 � p OV:N Salem, Massachusetts 01970-3632 MassDEP RTN 3-23131 Dear Dr. Poremba : In accordance with 310 CMR 40.1403(3)(d), notification is hereby made that a Release Abatement Measure (RAM) Plan has been submitted to the Massachusetts Department of Environmental Protection (MassDEP) for the above-referenced location. A copy of the RAM Plan can be obtained from Michael Matri, Hess Corporation, 1 Hess Plaza, Woodbridge, New Jersey 07095. If you have any questions, please call the undersigned at (781) 793- 0074. Sincerely, EviroTrac Ltd.z aw Robert H. Bird, LSP Principal Hydrogeologist cc: M. Matri, Hess Corporation 2 Merchant Street, Suite 2, Sharon, MA 02067(781)793-0074 Fax: (781)793-7877 www.envirotrac.com W 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 7448413 Handwash Facilities FAIL Critical RED Owner: Comment:Coffee observed in front handwash sink.Ensure"handwash sink only"sign is provided for this sink. Amerada Hess Corp. PIC: Jim Pyburn Inspector: Elizabeth Salandrea Date Inspected:Correct By: 517/2010 Risk Level: Permit Number: BHP-2010-0190 Status: SIGNED OFF #of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: All other violations noted in the 4/22/10 report have been corrected (see paper copy of previous inspection). 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 2010 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 10,2010 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2010 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 10,2010 ) Page 2 oft ! 0295 !'!ecs EXfflj s #21�3s Ji City of Salem RETAIL FOOD - Fond Establishment Item Status Violation Type Urgency PROTECTION FROM CONTAMINATION Address: 0295 Derby Street Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED /COMMENTS: Sanitizer bottle out front did not register as sanitizer when tested. Sanitizer Telephone: 744 8413 of proper concentration must be available at all times. Sanitizer was replaced at time of Owner: Amerada Hess Corp. inspection, Vsanitizer log maintained daily until approximately 2 weeks ago. Maintain sanidzer log daily. PIC: Tim Pyburn Inspector: Elizabeth Saiandrea Handwash Facilities FAIL Critical RED Date: 4/22110 ViOMMENTS; Coffee grounds observed in front handwash sink. Handwash sinks to be used for handwashing only. Risk Level; TIME/TEMPERATURE CONTROLS HACCP: No (Potentially Hazardous Foods) Correct By: Hot and Coll Holding FAIL Critical RED Permit Number: BHP-2010-0190 i COMMENTS: At time of inspection, pork tornados were measured to be 133'F.All Status: VIOLATION bz' potentially hazardous items being held hot must be held at a temperature of at least 1400F. Items were discarded at time of inspection. #of Critical Violations: 4 Violations Related to Good Retail Practices (Blue Items) i Food and Food Protection FAIL Critical BLUE Time IN: OUT: COMMENTS: The following outdated items were removed: v, I sprite Urgency Description(s): 1 nos energy drink BLUE: 5 Starbucks fra ppucinos Violations Related to Good Retail r } jci�ty of Salem Board of Heafth 120 WnsbhWon Streets 4th Fbor SALEM MA 01970 Phone:(078)741-1&10 Fm-(978)745-0343 4UDT tse coos Des Leuriem f4unkipai sONFd00%Inc. COMMONWEALTH OF MASSACHUSETTS n^^- "r 0295Def AK StnN t City ofSalem He"Expz= #21334 RETAIL FOOD - Food Establishment Item Status Violation Type Urgency 9 starbucks energy drinks Practices(Critical violations must be 2 hood light cream corrected immediately or within 10 8 tropicana melon soda days)(Non-critical violations must be 15 lipton pureleaf Iced tea corrected Immediately or within 40 6 soba iifewater days) 6 gatorades RED. 10 Pepsi Violations Related to Foodborne Illness 3 mountain dew Interventions and Risk Factors 6 red vault (Require immediate corrective action) 10 fantas3 boxes Jack links snack sticks 20 bags lays chips 15 bags cape cod chips 6 bags wise chips 7 bags doritos 3 boxes gummy savers PIC to closely monitor aU expiration dates. ,/The container in the cooler holding open packages of hot dogs was not closed properly. Clause containers properly so hat dogs are cohered to prevent contamination. ✓There were some food item stored directly on the floor In the cooler.All food items must be stared 6-8 inches off the floor. s 1,. l Chy of sake, seerd of Neagh 120 wauhlnpon Street.4*Flow MA 01470 Phone:(478)741-5800 Far.(9TB)745-0395 GeoTMS®2005 Deo Laurfem Municipal Solution,Im COMMONWEALTH OF MASSACHUSETTS Page 2 0295 DerbX Street He"Ex ma#21 City of Salem RETAIL FOOD - Food Establishment Item Status Violation Type Urgency Equipment and Utensils ` FAIL Non-Critical BLUE /OMMENTS: There is debris under the wire racks in the cooler- clean under the racks.. t//Milk trays in the cooler need general cleanings /counter under coffee machines and soda machines needs general cleaning. �� Provide a visible, accurate internal thermometer for the milk dispenser and the nantucket Hectare fridge. QInside bottom edges of cooler doors need general cleaning. JFountaln soda cup dispensers have buildup of grime and dust In them.Thoroughly clean R sanitize the cup dispensers./ /GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. /Please have last 3 months'extermination receipts available at the reinspection. -� T, /\A �p �y / _ 1 rSignature PI u CRr of Salem Board of Nee 120 wnnhh�iUon Street,4th Fhgr SALEM MA 01970 Pbone:(978)741-1800 F .(978)7 Oeo7MS®2005 Des tauriers Municipal soiutlens,Inc. COMMONWEALTH OF MASSACHUSETTS Page 3 L IMPORTANT MESSAGE FOR .. . I _1 7 DATE Ll- A K"TIME I —:D P.M. M OF PHONF AREA CODE NUMBER EXTENSION U FAX U MOBII F AREA CODE NUMBER TIME TO CALL TELEPHONED I PLEASE CALL CAME TO SEE YOU I WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR1II CALL WILL FAX TO YOU c' MESSAGE [ 0.ft< Q Cl (DO In cue S �a Pi1.I CCA 11A14, 7l ZAJ6-S SIGNE ol FOR 4009 MADE U.S.A. NOTES i r 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency =Telephone; TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 744-8413 Hot and Cold Holding FAIL Critical RED i Owner: Comment: Hot dogs were measured at temperatures of 126°F,133°F,and 136°F at time of time of reinspection.Hot dogs must be Amerada Hess Corp. held at 140°F or higher at all times;hot dogs were discarded at time of inspection. 'PIC: Establishment must begin keeping temperature logs of hot dogs,taken and recorded at least once every two hours.If temperatures e Jim Pyburn are off,corrective action must be taken and temperatures taken again to determine that product reaches correct temperature.Logs Inspector: must be available for inspectors to examine during inspections. Elizabeth Salandrea Date Inspected:Correct By: S 3/27/2009 _ 'Risk Level: Permit Number: I BHP-2009-0130 Status: SIGNED OFF :#of Critical Violations: � 1 .Time IN: Time OUT: Urgency Description(s): BLUE: All other violations noted in the 3/20/09 report have been corrected. Violations Related to Good Retail Practices (Critical Violations must be corrected immediately or within 10 iIays)(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 30,2009 ) Page I oft • Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 30,2009 ) Page 2 oft 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-8413 Handwash Facilities FAIL Critical ❑0 RED Owner: Comment: Handwash sink at front counter had empty soap dispenser.Provide soap at all handwash sinks at all times. Amerada Hess Corp. TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) PIC: Hot and Cold Holding FAIL Critical RED Jim Pyburn .Comment: Hot dogs were measured at a temperature of 121°F at time of inspection.Hot dogs must be held at 140°F or higher at all Inspector: times;the hot dogs were discarded at time of inspection. 13�• l Elizabeth Salandrea p40 125 . - D%* ( 6jr - Date Inspected:Correct By: 1 �, 3/20/2009 dv catidQ� Risk Level: iPermit Number: BHP-2009-0130 I Status: VIOLATION #of Critical Violations: 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 24,2009 ) Page I of ' Item Status Violation Critical Urgency RED: r 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 v/omment:The following outdated items were removed from shelves: immediate corrective action) 7 nestle vanilla milk 25 starbucks frappucino 23 starbucks doubleshots 3 tropicana twisters 4 lipton pureleaf iced tea 3 gold peak iced tea 8 nestea diet iced tea 7 aquafina flavor splash 4 dasani plus 6 gatorade fruit punch 9 gatorade lemon lime 25 gatorade g2 orange 8 powerade zero 21 propel water 5 no fear energy drinks 7 nos energy drinks 4 Pepsi 13 diet sierra mist 3 mug root beer 7 mountain dew 3 tropicana lemonade 7 brisk iced tea 9 diet coke 15 coke 8 barq's root beer 4 diet coke with lime 16 sprite 6 vault 9 orange fanta 3 grape Fanta 1 chex mix 1 ronzoni pasta 15 bags wise chips Owner to closely monitor all expiration dates. Equipment and Utensils FAIL Non-Critical BLUE ,116omment: Mop observed left in bucket at time of inspection.Mop must be hung to air dry to prevent cross contamination. *alk-in cooler needs general cleaning on the floor&under racks. V1futen's room had what appeared to be a laundry basket being used as a trash barrel.Provide proper trash barrel with cover for the men's room. 60060unter under soda machine needs general cleaning. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 I GeOTMS@ 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 24,2009 ) Page 2 of ' Item Status Violation Critical Urgency Milk racks in cooler need general cleaning. ✓Pepsi fridge at front counter needs general cleaning. hip racks need general cleaning/dusting. Reinspection in one week, all violations to be corrected. Please have January and February extermination receipts available at reinspection. w 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 24,2009 ) Page 3 of (IMPORTAW `MESSAGE ) FOP DATE TIME TIME M A? OF PHONE AREA CODE NUMBER EXTENSION 'U FAX t y)�l ` 4:'-q m /� O MOBILE l �jU M pRp/T AREA CODE UMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL fi WILL FAX TO YOU MESSAGE F-�Lk + SIGNED FORM 4009 MADE IN U 5 A. 9 ' NOTES •Hl�ax Series 900 Fax History Report for Plain t'a_pecFax./Copier Joanne_ScotLSalem1BOH 978 745 0343 Mac LL 2009 kT2 m Last Fax DAIt Tag- - iYwI lrlentifimtion Duration -_ Ea�oe, &_ Result Mar 11 4:25pm Sent 917323526623 0:38 2 OK I Result: OK-black-and white fax Commonwealth of Massachusetts s E City of Salem Board of Health ICmbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRI'NT'ED: 12123/2008 ESTABLISHMENT NAME: Hess Express #21334 File Number:B14F-2004-000154 I Hess Plaza/J.Flaherty Woodbridge NJ 07095 LOCATED AT: 0295 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1 Notes RETAIL FOOD BHP-2009-0130 Dec 23,200$ Dec 31,2009 $70.00 TOBACCO VENDOR BHP-2009-0131 Dec23,2008 Dec3t,2009 $135.00 'total Fees: $205.00 PERMIT EXPIRES (December 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 ti � CITY OF SALEM, MASSAC�IUSEM BOARD OF HEALTH �hrveo> 120 WASHINGTON STREET,4"`FLOOR TEL. (978)741-1800 KIMBERLEY I7RISCOLL FAx(978)745-0343 MAYOR ISMTrnr SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT \A- C S r-PwS5 9%13Y4 TEL# 7714`4"&L113 ADDRESS OF ESTABLISHMENT CLQ S ber" t.t l7d FAX# MAILING ADDRESS(if different) ;I`gg Ga7RF URATION EMAIL-Business I Nees PIsBel (WeFisheltily — Woodbridge,NJ 07096 OWNER'S NAME 1 _ TEL# ADDRESS ) STREETS CITY STATE ZIP CIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (We in an establishment where potentially\hazardous food is prepared) EMERGENCY RESPONSE PERSON i r r\ ?4�V n HOME TEL# DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday I Saturday, Sunday j HOURS OF OPERATION \ Please write in time at day. (For example 11 am-itpm) TYPE OF ESTABLISHMENT FEE (check oniv) RETAIL STORE YES NO less than 1000sq.ft. $70 1000-10,000sq.ft, more than 10,000sq.ft. =$420 _..-... ... - _...... - -...... ....... ... ... RESTAURANT YES O less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25.99 seats =$280 � OO more than 99 seats =$420 -_ - -- - - .... - ... --- ---- ---.............. - - -- -----------------_ .. - ------ .----...- ..----- .......-- BED/BREAKFAST! YES $100 CHILDCARE SERVICESL /------------ --------------------------------------------------------------- --------------------------*--------- ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE TOBACCO VENDOR (Y Q $135 ALL NON-PROFIT(such as church kitchens) €€s o J 5 `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 grik 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 I,to my best knowledge and belief, have filed all stale tax r u and paid all state taxes required under the law. r//("/m i3-Y90? a Signature Date — Social Security or Federal Identification Numher Revised 4/24/07 FO0DAP2008.adm Checkft&Date,7,�jIAVJ"3*.___ $ �� .1(r•p 7T"''' � t )Cy 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-8413 Food Contact Surfaces Cleaning and Sanitizing PASS Critical ❑d RED Owner: Handwash Facilities PASS Critical ❑d RED Amerada Hess Corp. Violations Related to Good Retail Practices (Blue Items) t}PIC: Food and Food Protection PASS Critical BLUE S Jim Pyburn Equipment and Utensils PASS Non-Critical BLUE Inspector: Elizabeth Salandrea Physical Facility FAIL Non-Critical BLUE Date Inspected:Correct By: Comments:There is 1 remaining water-stained ceiling tile in the women's restroom.Investigate source of leak and replace tile. 14/7/2008 IRisk Level: 1y Permit Number: i BHP-2008-0014 Status: SIGNED OFF #of Critical Violations: 0 ;Time IN: Time OUT: i Urgency Description(s): '' BLUE: tl All other violations noted in the 3131/08 inspection report have been corrected. ;Violations Related to Good Retail Practices (Critical Repeat violations noted on next routine inspection may result in monetary citations. 'violations must be corrected i immediately or within 10 days)(Non-critical violations I must be corrected immediately _ 'or within 90 days) E ! 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 14,2008 ) Page 1 of f t+V t Item Status Violation Critical Urgency 'RED: __--^--..�---°--, Violations Related to i Foodborne Illness Interventions] and Risk Factors (Require i immediate corrective action) I 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 14,2008 ) Page 2 oft f 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-8413 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: Leola ment:Sanitizer found too weak.Sanitizing solution of proper concentration(200ppm)must be available at all times. Amerada Hess Corp. PIC: bay sink found obstructed by various items.3 bay sink must be clear and accessible at all times and must be used properly to wash,rinse and sanitize all equipment and utensils. Jim Pyburn _ Handwash Facilities FAIL Critical RED Inspector: Elizabeth Salandrea t/omment:All handwash sinks including the restrooms missing paper towels at time of inspection.Paper towels must be available Date Inspected:Correct By: at all handwash sinks at all times. 3/3112008 Risk Level: Permit Number: BHP-2008-0014 Status: VIOLATION #of Critical Violations: 3 _ Time IN: Time OUT: I Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 02,2008 ) Page 1 of o' 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 1,Comment:The following items were removed,outdated: immediate corrective action) 40 nestle pure life waters 28 gatorades 20 caribou iced coffees 16 nestle iced tea 16 frito lay sunflower seeds 16 jack links pica sticks 16 starbucks double shots 9 quarts hood milk 9 amp energy drinks 8 tropicana twister sodas 7 starbucks frapuccino 6 tropicana grapefruit juice 6 1 L diet pepsi 6 vault sodas 6 orange fanta sodas 5 sobe energy drinks 5 diet mountain dew 4 1L mountain dew 4 planters heat peanuts 4 mug root beer sodas 3 tropicana of 2 lipton iced tea 1 1L Pepsi 1 gold peak iced tea 1 jim beam beef jerky 1 ruffles chips 1 fritos dip Owner to closely monitor all expiration dates. 66ome price labels covering expiration dates.Expiration dates must not be covered with price labels. Equipment and Utensils FAIL Non-Critical BLUE WGoommment:Walk-in cooler missing internal thermometer. Provide visible,accurate thermometer for this unit. vrays of Tropicana juices in cooler has accumulation of spills.Thoroughly clean these trays. Physical Facility FAIL Non-Critical BLUE Comment:There are 2 water stained ceiling tiles in the women's restroom and one directly outside of it.Investigate source of leak and repair; replace stained ceiling tiles. ' 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 Item Status Violation Critical Urgency GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. Repeat violations noted on next routine inspection may result in monetary citations. 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 3 of i - bF.:,..R'.` -�' r k.-`t..:, 'r��,T :. �-j;.a<ra.rer`,;., -.—vt..».: -n•.. +.x ..1'r .... -..-. ... y - _ Commonwealth of Massachusetts City of Salem • e Board of Health Iftberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Hess Express#21334 File Number:BHF-2004-000154 1 Hess Plaza/J.Flaherty Woodbridge NJ 07095 LOCATED AT: 0295 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0014 Jan 3,2008 Dec 31,2008 $70.00 TOBACCO VENDOR BHP-2008-0041 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved-by the Salem Board of Health. Page 22 of 28 A CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4'"FLOOR TEL. (978)741-1$00 - KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR ISCOTTna SALEM.CO D.j JOANNE SCOTT, HEALTH AGENT DEC 3-2007 y� CITY OF SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT , (�S C KDifeSS�LaI3 TEL# 71 L1 L1 2rgI ADDRESS OF ESTABLISHMENT aotS 1)e lea FAX# MAILING ADDRESSif different)) 1.urcrVKAIION EMAIL-Business': 1 MASS PI88et1 Jeflaherrlr Woodbridge, NJ 07095 OWNER'S NAME rpTEL# 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 \Yr\ 1q�Vr) HOME TEL# DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION \^ �� 1 Please write in time of day • , (For example 11 am-1 tpm) TYPE OF ESTABLISHMENT FEE (check or lvl RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. 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 $100 CHILDCARE SERVICES ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE )�F.§ TOBACCO VENDOR (Yo N $135 ALL NON-PROFIT(such as church kitchens) ES O 5 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have fled all state tax returns and paid all state t es required under the law. / � i//ak lay 13-y9aiWa Signature Date Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008 adm CheckN&Date.?w 5. ( IMPORTANT MESSAGE FOR h-�t�7fjrv2 DATF f TIME 'S P. OF--~/� (/ PHOI\lp 9 '20- AREA CODE NUMBER EXTENSION O FAX O MOBII F AREA CODE UMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU II WILL CALL AGAIN WANTS TO SEE YOU I II RUSH f RETURNED YOUR CALL I (I WILL FAX TO YOU MESSAGE a-� AL ////JJJJ i / r G ED I/� r -IAV FORM 4009 V MARE IN U S A NOTES _�Gv�'IAC.I{,)N� 15- p� S�vY CuPYrAN�vp UNITu►Jo yL IS Ha9l'o Th18_ v_0J"r mcaita� A��, ��a • THa Soaq t►+a- Fez a �Kg wfls rAmxbv V? i o "TN8 it0l�v�+p �o�A�cti tpr•c�LH t+o -tea �-nrn� Sy��@ ,�-�, ► in. Mtia S rat \H.G sIZ4bA% _ -37i`r-eP :. L i 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-8413 Handwash Facilities FAIL Critical RED Owner: Comment: Hand wash sink in back found completely obstructed. Keep hand washs sinks clear an accessible at all times. Amerada Hess Corp. Violations Related to Good Retail Practices (Blue Items) PIC: Physical Facility FAIL Non-Critical BLUE Joe Asamoah Inspector: 7i Comment:There are water stains on the ceiling of the front restroom. Investigate the source of the leak and repair. Replace all stained ceiling tiles. David Greenbaum Date Inspected:ICorrect By: 2/7/2007 GENERAL COMMENTS: Risk Level: All other outstanding violations cited in the 1/29/07 inspection report have been corrected. Permit Number: BHP-2007-0058 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®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 07,2007 ) Page I of? i p .- Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 07,2007 ) Page 2 oft 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-8413 Food Contact Su es Cleaning and Sanitizing FAIL Critical ❑d RED Owner: co ent:There is no sanitizing solution available in this establishment. Sanitizing solution of proper concentration must be Amerada Hess Corp. r dily available at all times. PIC: Jim Moran Handwash Facilities FAIL Critical RED Inspector: - Comment: Hand wash sink in back found completely obstructed. Keep hand washs sinks clear an accessible at all times. David Greenbaum TIM /E TEMPERATURE CONTROLS(Potentially Hazardous Foods) Date Inspected:(Correct By: Hot and Cold Holding FAIL Criticald❑ RED 2/5/2007 1 Co ment:The hotdogs had a temperature of 117°F. Hot potentially hazardous foods must be held at a temperature of 140°F or Risk Level: gher. Violations Related to Good Retail Practices (Blue Items) Permit Number. Equipment and ensils FAIL Non-Critical BLUE BHP-2007-0058 Status: oment:The Cool Point cooling unit on the counter is missing a thermometer. Provide a visible,accurate thermometer in this umt.m VIOLATION #of Critical Violations: Th stored in the bucket. Clean the mop and store upside down not touching any surface to air dry. 3 _ _ e walk in flooring needs a thorough cleaning including under all racks. Time IN. Time OUT: physi al Faality FAIL Non-Critical BLUE Urgency Description(s): Comment:There are water stains on the ceiling of the front restroom. Investigate the source of the leak and repair. Replace all BLUE: stained ceilin Iles. Violations Related to Good There a hoses hanging in the mop sink.Provide back flow prevention devices on these hoses or remove. Retail Practices (Critical violations must be corrected immediately or within 10 GENERAL COMMENTS: days)(Non-critical violations A final reinspection will be conducted on Wednesday, February 7, 2007 all outstanding violations must be must be corrected immediately corrected. 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 I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) I City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 05,2007 ) Page 2 oft 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-8413 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: - Comment:There is no sanitizing solution available in this establishment. Sanitizing solution of proper concentration must be Amerada Hess Corp. i o readily available at all times. PIC: The' scoops are stored improperly. Clean and sanitize the ice scoops and store in the ice handle side up or in a sanitized Joe Asamoah c tamer labeled"Ice Scoop Only" Inspector: Handwash Facilities FAIL Critical RED David Greenbaum C�bmment:The faucet at the counter hand wash sink is loose and in disrepair. Repair or replace the faucet. Date Inspected:Correct By: I (((/// 1/29/2007 T counter hand wash sink is missing soap and paper towels. Provide soap and disposable paper towels at this hand wash sink Risk Level: t all times. j T back hand wash sink is missing soap and paper towels. Provide soap and disposable paper towels at this hand wash sink at Permit Number: au times. BHP-2007-0058 TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Status: Hot and Cold Holding FAIL Critical EVII RED 1 VIOLATION -aC Comment:The hotdogs had a temperature o 20-/ Hot potentially hazardous foods must be held at a temperature of 140"F or #of Critical Violations: higher. 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 ' 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 Co ent:The following items removed outdated at the time of inspection: 1 rin lies immediate corrective action) 1 -Ot fat free milk 6-pints whole milk 3-Campbell's soup at hand Owner must closely monitor all expiration dates. Equipment an of nsils FAIL Non-Critical BLUE omment:The cappucino machine and the milk dispenser need a thorough cleaning. '^ The Cool Point cooling unit on the counter is missing a thermometer. Provide a visible,accurate thermometer in this unit. The mop is stored in the bucket. Clean the mop and store upside down not touching any surface to air dry. The walk in flooring needs a thorough cleaning including under all racks. Physical Facility FAIL Non-Critical BLUE Comment:There are water stains on the ceiling of the front restroom. Investigate the source of the leak and repair. Replace all stained ceiling tiles. ;,f There are hoses hanging in the mop sink.Provide back flow prevention devices on these hoses or remove. The�et paper dispenser in the back restroom needs to be replaced. GENERtKL 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®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 29,2007 ) Page 2 oft 2•('33`1 . gyp© CITY OF SALEM, MASSACHUSETTS BOARD OFHEALTH RECEIVED r 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 DEC 132006 FAx 978-745.0343 WWW,SALEM.COM CITY OF SALEv1 Kimberley Driscoll BOARD OF HEALTH Mayor JOANNE SCOTT, MPH, RS, CMO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ��53 TEL# r74°-8`1/3 ADDRESS OF ESTABLISHMENT �� Dti'�bH FAX# MAILING ADDRESS(if different) HESS CORPORATION 1 Hess Plaza t J.rtanerxy EMAIL--Business': yyp "'N,i_47095 OWNER'S NAME 732.750.6350 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 :!;7 1 rr, Moot h HOME TEL#W I DAYS Of OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday NOaOF OPERmo ,y J� Please sewriritelndmeaf tlay. �( I (For example.)tam-1tpml TYPE OF ESTABLISHMENT FEE (check onlvl RETAIL STORE (IEN✓� NO less than 1000sq.ft. $5 1000-10,000sq.ft. =roo more than 10,000sq.ft- =$250 RESTAURANT YES less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 - - --- ---- - - - 00 - . .--.-... --- - - _._. ....-_ .._._.. -- .. - --------- ----- BEDlBREAKFAST YES NO $10 _.......... ... ... — _ ...-...._... .-... .. ._- ...-... - ....._ ..... ..-._.....--... _. .. . -..... . ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YE NO $5 TOBACCO VENDOR YES O $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 unde,the pains and penallies of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes requited under the law G '1;�- \3-4 ia10oa. Signature Date Social Security or Federal Identification Number ------------ ----- --------------- ----- --- ------ ------------- ----- -------- -�- ------------ ----------- ----- ------ ------ --- ------- ---- - Reviseo 11113106 FOODAP2007 adm Y Check*&Date 14, er ",,'�Uommonwea 1twoumassac"nscui § Za of 01 oar�d of Hiilth'�O ;.1 Washington Street,4th Flooi,� Ddscoll SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: Hess Express #21334 File Number.BHF-2004-000154 I Hess Plaza/J.Flaherty Woodbridge NJ 07095 LOCATED AT: 0295 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions Notes RETAIL FOOD BHP-2007-0058 Dec 19,2006 Dec 31,2007 $50.00 TOBACCO VENDOR BHP-2007-0081 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 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 9 of 24 --�sl�'� -�� w.y �ml,"``` a �+fw+3°# nk,8",�eL""„y��rs�.yrt. .rdr P�}�' �a+.• ��' �as. ;Communwcalth',of Massachuset[s w�'•�:z t; ...irc•�,�z:. ` M`% <s�R`r'� C ty.Of Sal¢m� a `"ig ' �" +!'x 'A''>'. •'. `° °. '�u.e.. *' '_':,. ' QAr"rx ., Ai Maj , , :..A^a"k'-_"„/�-'t !',• L Si - r < n" y f. X f�i:"u • s,YA 4a :� r * ftF'`^'�r "c n;, ', •+ ,u .�µ' s^, _'* F'1,nW� � _ _� ,*��` '' r• �.;° Board of Health' iGmbetley Ddsooll 1`'120 Washington Street,4th Floor y' or , SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 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-2007-0001 Dec 19,2006 Dec 31,2007 $100.00 TOBACCO VENDOR BHP-2007-0027 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES December 31, 2007 , Board of Health 6d-o� V This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all plans for such must be submitted to and adproved by the Salem Board of Health. Page 12 of 29 f Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2006 WHO'S PLACE OF BUSINESS IS: Hess Express #21334 File Number BHF-2004-0154 I Hess Plaza/I.Flaherty Woodbridge NJ 07095 LOCATED AT: 0295 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0307 Jan 4,2006 Dec 31,2006 $50.00 TOBACCO VENDOR BHP-2006-0306 Jan 4,2006 Dec 31,2006 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location."Phe 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 4 of 20 " - CITY OF SALEM, MASSACHUSETT Pgav% , BOARD OF HEALTH • 120 WASHINGTON 'STREET, 47H FLOOR NOV 14 YQ�� SALEM, MA 01970 TEL 978-741-1800 CITY OF SALEM FAX 978.745.0343 BOARD OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS CHO MAYOR HEALTH AGENT 2007APPLICATION FOR P'EER-MIT TO OPERAT�tE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �4rS &Preto dratO3q TEL 0 1q -Sq 13 ADDRESS OF ESTABLISHMENT 99,:5- her6 II.�'1 MAILING ADDRESS (if different) AMERADA Of AZA 171 7 PCJrE TION 1 ..€SS . 4�+J-,-LAM€RTV r5- WOODBRIDGE,N 1 OWNER'S NAME ` >32 7 L ADDRESS 1 CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S)— CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON )af�ro, �4,n�yvr HOME TEL 4 HOURS OF OPERATION: Mor ' u TJeV Thu. Fri.—Sat. SuP% TYPE OF ESTABLISHMEKT fj� t t FEE check only RETAIL STORE YES NO Y fess than 1000sq.ft. -$50 1000-10,000sq.ft. = 0 • - more than 10,000sq.h. =$250 RESTAURANT YESNO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BEDIBREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT�SE^RVE Y N TOBACCO VENDOR 7:b(D � *25 ALL NON-PROFIT{such as church kitchens YES N 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 knowledgeancIbelief. have filed all statg to returns and paid all state taxes required under the law. _ 10/89/O.Y 0-•1Qi20Oo, Signature Date Social Security or Federal Identification Number ----------------------- ------------------------- - ? ------ --------------------- Revised 11103/03 FOODAP2.adm Check#&Dale 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-8413 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:The thermometer in the ice cream freezer is broken. Provide a ne visible,accurate thermometer in this unit. Amerada Hess Corp. PIC, A new thermometer has been ordered and should be delivered on 319/06. Sandra Kafker GENERAL COMMENTS: Inspector: 523:AII other violations cited in the 3/2/06 inspection report have been corrected. David Greenbaum Date Inspected. Correct By, 3/9/2006 Risk Level: Permit Number:- BHP-2006-0307 Status: SIGNED OFF #of Critical Violations 0 Time IN Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) Ci of Salem Board of Health 120 Washington Street 4th Floor SALEM MA 01970(978)741-1800 City 9 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 13,2006 ) Page / of 'lam Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) N 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 0295 Derby Street Hess Express #21334 City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone. FOOD PROTECTION MANAGEMENT 744-8413 PIC Assigned/Knowledgeable/Duties PASS ❑ RED Owner: Amerada Hess Corp. Non-compliance with: Anti-Choking PASS PIC Tobacco PASS Inspector: David Greenbaum EMPLOYEE HEALTH Date Inspected: Correct By. Reporting of Diseases by Food Employee and PIC PASS RED 3/2/2006 Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number _ Food and Water from Approved Source PASS ❑d RED BHP-2006-0307 Receiving/Condition PASS Q RED Status: VIOLATION Tags/Records/Accuracy of Ingredient Statements PASS RED #Of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev Mar 02,2006 ) Page I of s Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS ❑/ RED Foodborne Illness Interventions and Risk Factors (Require Food Contact surface;Cleaning and Sanitizing FAIL Critical 0 RED Immediate corrective action) Comments:There is no sanitizing solution available. Sanitizing solution of proper concentration must be readily available at all food-service'areas at all times. The ice scoops stored in container with other items. Ice scoops to be cleaned and sanitized and stored in a sanitized container labeled"Ice Scoop Only" The 3 bay sink found obstructed with many items. The 3 bay sink must be used to wash, rinse and sanitize equipment and utensils 0 Proper Adequate Handwashing PASSd❑ RED Good Hygienic Practices PASS - ❑Q RED Prevention of Contamination from Hands PASS RED HandwashFacilities FAIL Critical ❑�/ RED Comm Is:The handwas sinks in back and at the counter found obstructed. Handwash sinks must be kept clear and accessible at all es. PROTEC N FROM CHEMICALS Approved Food or Color Additives PASS Q RED Toxic Chemicals PASS RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS 0 RED Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS 0 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 02,2006 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Kotection FAIL Critical BLUE zComments: Food products stored in the restroom on the toilet. Food products must be stored in an appropriate storage area. Not in the restrooms. The following items found outdated: 4-Strawberry-milk 3-15.2oz OJ 9-32o i grapefruit juice. / 2Chips f1 -jar peanut butter Closely monitor all expiration dates. Price labels covering expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels. Equipment and Utensils FAIL Non-Critical BLUE - Comments:The thermometer in the ice cream freezer is broken. Provide a ne visible,accurate thermometer in this unit. Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: 508: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 3 of Aleve dL4 qk o •§ �^urre 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 #21334 Address of Establishment : 295 Derby Street Type of Establishment : RETAIL FOOD Application Date: 03/19/2001 Restrictions: Permit for Food Establishment 261-01 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 65-01 These Permits Expire December 31, 2001 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 Jan 04 01 12: 35p Joanne Scott Salem BOH 978 740 9705 p. 2 � v culrr 6 MAR 1 9 2001 71,100y/ IMFX077 ' CITY OF SALEM HEALTH DEPT. CITY OF SALEM BOARD OF HEALTH Salem, Massachusetts 01970-3926 .IOANNE SCOTT. MPH. RS.CHO NINE NORTH STREET HEALTH AGEN 1 Tel,(978)741 1800 r-ax.(9761740-9705 2001 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT I0SS s p \33L4 TEL# J`79-''qLlf QSZ ADDRESS OF ESTABLISHMENT 16er\ol-, si- MAILING ADDRESS (if different) ues5 ]AW-0, I� FlO,he� 1 dbr t�e nJ O"109 S OWNER'S NAME a()r\el1A0l \A2SS CDro. TEL# Ila-'150-Iy3SU ADDRESS It 3eSS 91012.0. CITY r'ke STATE fY.S ZIP D'1095 CERTIFIED FOOD MANAGER'S NAM (S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON -S ))0LY,&49 HOME TEL#� TYPE OF ESTABLISHMENT OZ F�FJcheck only RETAIL STORE YES NO 4 RESTAURANT YES NO #seats_ #nonsmoking_ $40 BED& BREAKFAST YES NO $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES NO Ct ) $ TOBACCO VENDOR ES NO / t NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF TAX EXEMPTFORM 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 bestknow e d lief, have filed all state tax returns and paid all state taxes required under the law. � 641, \3-4ga\W'A Signature tkSSWA\\0119 bate` Social Security or Federal Identification Number -----------------------------------------------------------.-..---------�--------------------------------------- Revised 11/21100 foodap2.adm Check#&oat ( JAN 04 2001 11:48 978 740 9705 PAGE.02 r„,-..y. ..r�.._�,;-.w:,..h,...i ' .:^..^-v4r�, �'4.��s..�°-.4+-T ^.�. r>..r.ss�".^:a'n,sYs•wnr„�:vG'.:..w-..:v.yb•.n�^�...tsyu...A.:..... . THE GbMMONWEALTH OF MASSACHUSETTS )CITY OF SALEM Address: 9 North Street Board of Health Salem, MA 01970-3928 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (9781741-1800 Fax: 978) 740-9705 Name / / Date TYoe of Ooerationls4 Tyne of Inspection ��9 ❑ Food Service P ;Routine (Address �9s � / Risk [4*`Retail ❑ Re-inspection J r Level ❑ Residential Kitchen Previous Inspection (Telephone ❑ Mobile Date: (Owner ❑ Temporary 71Pre-operation aj"_4 fJi l�nnpir� HACCP Y/N ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) � � �� Time ❑ Bed&Breakfast EJ General Ll HACCP Complaint 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 It-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 ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations 123-301 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 -f 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 5XIOS ar 14 me Inspector's Signature: / / //'� Print: PIC's Signature: Print: Page / of 3 Pages r i' Violations Related to Foodbome Illness Z Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT 8 Cross-contamination -1 590.003(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* 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* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* �.3 7 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FIOM APPROVED SOURCE Food* 4; Food and Water From Regulated Sources I; 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 110 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* Jill 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 1112 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) 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 1 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 w City of Salem Establishment Name ell Date Zlyl/jl Address a79S '_/J&�_�/ Page of Item No. In the space below describe all violations checked on front page. Air) EYP?/i/l sZ/JGo inspection of this establishment was conducted in accordance with the State Sanitary Code for Food Establishments,Chapter X, 105 CMR 590.000.The followinq violations were observed: 4nn�1/Y/ T/lewh� ✓ GS '4; X Discussion 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. 1 I •/ ^` .S .. ca r CITY OF SALEM;JMASSACFiIJSETTS,.. , BOARD OF HEALTH ' �v 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 a TEL. 978-74 1-1BOO ' 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 ^accordancewith regulations_spromulgated 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 #21334 Address of Establishment : 295 Derby Street Type of Establishment : RETAIL FOOD Application Date : 12/27/2001 Restrictions: Permit for Food Establishment 208-02 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 52-02 These Permits Expire December 31, 2002 This permit is -not transferable and must 'be-.reissued•Lupon, 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-,changeso are�made;,r.allaplans,.,for. such must, be submitted to and approved by the`�'Sal'em$Board of Health." " U HEALTH AGENT l A. CITY OF SALEM, MASSACHUSETTS .co • BOARD OF HEALTH p � s 120 WASHINGTON STREET, 4TH FLOOR PD SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 „ DEC 7 zui,i t. STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT CITY OF SALEM HEALTH DEPT. 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT —BtLISHMENT NAME OF ESTABLISHMENT f f�� 't cess a�33y TEL# ADDRESS OF ESTABLISHMENT orb beObLt SA- MAILING ADDRESS(if different) / Amerada Hess Corp 1 Hess Plaza/J.Flaherty OWNER'S NAME Woodbridge,NJ 07095 ADDRESS CITY `J`IAIt ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON .�oP� AmU-SOr\ HOME TEL# DAYS/HOURS OF OPERATION: Mon.—(ah*-::/-LrOl _Thu._Fri._Sat._Sun._ TYPE OF ESTABLISHMENT FE check only RETAIL STORE (EDNO 40 RESTAURANT YES 0) $40 BED & BREAKFAST YES $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES � �a_Q � $5 TOBACCO VENDOR QffSNO NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF 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. Signature Date Social Security or Federal Identification number Revised 11/1/01 foodapZadm Check#&Date io z5-1 26 7,c �i io 9a3 i 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 Tvpe of Ooerationfai Type of Insoection i/65S AxvPrss Y"�33'f e.2-0.,-op 1-1FoodService YS Routine Address a Risk Retail ❑ Re-inspection �9S2iS�1.�f Level •5 Residential Kitchen Previous Inspection Telephone 95 ❑ Mobile Date: 49- ?- O/ ❑ Temporary ❑ Pre-operation Owner c"�� HACCP Y/N 1 ❑ Caterer ❑ Suspect Illness PIC)PI ❑ Bed&Breakfast El General Complaint Person in Charge( hPanRpf ,/ Time ❑ HACCP Inspector �/�/J� in F-1Other V!lils(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 (1-221 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 O 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 [110. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories BLUE Violations (23-301 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): F -1 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 (FCw6)(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 50fns ,IFw 6-II Eoc 4^1„ Inspector's Signature: '� Print: PIC's Signature: / •� Print: ^;I ) Page L of Pages �ttW�{�aEt � Jc�r,l�f ncu��n(��/�uf( 1 J Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION AND MANAGEMENT 8 Cross-contamination I',1 590.003(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* 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* Charee* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 11 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a 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 Utensils*and 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 1110 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* Good Hygienic Practices II 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* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) 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 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 Establishment Name Dated.). Address \k Page—,�of Item No. In the space below describe all violations checked on front page. i? ,,r�itti•Ue. /�6'{'l/� {r1� •i 'TSS ��,'>nn /-I„'r_f . •.wy/./.r�ct . i �.S riY/�/•/{;Ilnllorr �,lir'i� f ��c0 .,C1�?,f'— %f�f! C!f�,o:f_ F:�,,/ �/J/L.N �P'!I A�5!J _-•.0, �',Iv�/aC •,S!r�//C �! r?/ hRs U Z Z W C K 3 p �f� if/nP lldF.fIA r� 7!J r��✓.lil-Gr4.!!r S m a n Z rc O n 7 Discussion with Management <}�,Yie)g1,l,..W:rrf!i:� 'ft .�.�ASYl.' �:•. . l= 'tom. - - , • - rt t/ c' K..:Y.E.^r:f.. 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L,. ..... x`c -.rrGf..n?air9i•''"5y;:• - ^N, „yf.k.x -saleciiYu^ i'E 1' aa ,.1, a.wa.t ,::•ua °.�iu1;Hr; -frv'?`:. .,d!p='.S_ _ _ _ _ �rr•�..�L51-a...,-=•:":•_. 007664n 1:OLL07531SOI: 3060004530311' :a ;liavrt%1;' .:Sjy,l „ .. •'i.' . . .gi. - mQ3- + z; if , K� • 't „ J , r.5 - n j ♦ 'i ...,'.'k ... }� y„�fj}sf.`v s A.i ,� 6” , . t r , •�' '1 .5, i Q I .,..i, ' ._,§.. 'mFdi3ev 9 - Sy' :A',CFS4LENtVASSAChUSETT;S�: .e r,': - '� BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR ” g 5.4tkE :MA'01970 ~61 Mb :> d : A W40 t.i. K, m . V3r°yq v .JS _r TEL-- '978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. s JOANNE SCOTT, MPH, RS, CHO MAYOR + , HEALTHrAG • +r. y ..x: .�: -4f March 8,2002 a$ ` i s Hess 296 Derby Street Salem,MA 01970 Dear•Owner, ` On February 21,2002,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 16-year-old male purchased cigarettes from a clerk in you_r'store3 Documentation is nowYon'file'at the Boaid of ;1.' regarding that sale. Hess is in violation of Section HI(A)of the Salem Board of Health Regulation Affecting the,Purchasing of x " Tobacco Products.' According to this section;the sale of cigarettes,chewirig tobacco,snag o'r any t46a7cc6 ` in any of its forms to any person under the age of eighteen_ shall be punished by a fine of one hundred dollars ($100)for the FIRST offense 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$100:00 for the violation stated above. A ctieck or,;money order payable to the City of Salem must be at the Board of Health 'office' 120 Washington-Street,4's floor within ten days of receipt of this notice. Should you be,aggrieved by this Order,you have the right to request,a heanng:iieforeie Board ofHealth. 'r - _w.. A r"_equestlfoi sdolia liearingmust bereceive$iirwritin in this-dffice_:oa they oazdzof Aealtk' "tliiri`sevenr -' ..r.,. -.sv a.H.E (7)days of receipt of this Older: At`said lieaiing you',will9ie given'fhe:opportunty to lie lireai present witness and documentary evideriee`as to why this'Order should'l e;modified or.withdiawri;Y.ou may, " be represented by an attorney. Please also be infomed that you have the righfto inspect and obtain copies of all relevant inspection or investigation repots,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. Sincerely yours, 'Lannc Scott Health�Ageini °t Cc: North Shore Tobacco Control Program Leonard Milaszewski, Board of Health.Chairman tt %fM • - 1 1�Rn � i4 • �i A$a y+' 1A 11 ,1 .�� ''' 1SY,f ilr £�.{ yf�k �'1 ` tq.i ,$';Y 1' ' � , tel- - j :�' ;3 y ,. .# ' } 3.l r'r e{ •� tt '?'. e: �.�'{'i'. I .. c - ' •1'.:i >�f'��:. Y ' i , ( ' : ..et' t.a$p"ss ;y ��. .gi.i= _ f' "}�:ft� �"1 d,'" ;'j. xi_b� � Jz*.c b",.Y'y. � v�..y�'r• .i#" ;.:-.y.:-,,:;s_+4•'e. j,�.�:`k!;; MAh.r�•v''ra' IA +t+� sx��at4` x✓�:':::.ii�.ia;vr' � r"S,'''-w - q .. :i ur"",. y �•" sOF'SALENI,° SSCHU' ��. BOARD OF HEALTH • • 120 WASHINGTON STREET, 4TH FLOOR SALEM MA 01970 .* . - 5 . - + .t�'�� ,�' a.3 Y%.5;3JF;�yni�:.w'.fi. s:ili�e:.:ri�°�ir k.;'::.i'ibT_^ti>'• - TEL. 978-741-1800 ` FAX 978-745-0343 STANLEY USOVICZ;JR. JOANNE SCOTT, MPH, RS, CHO MAY _e�*{:�� —; xy-a i HEA'LTH;F.GENT,,aea�`, 'M. ''h ,20 arch='8;2002 Hess~' 296 Derby Street Salem,MA 01970 6 %':w.s„..'': On February 21,2002,personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sella tobacco-product to a minor- A 16-year-old male purchased cigarettes from a cleiii in your store Documentation is'iiow.on'tile'at the Board of Health regarding'1haf We. ` ,Hess is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of ToliaccoProdticts.'' According•fo this sectiKthe sale of cigarettes,chewing tobacco, snnif or any to(ia6co' in any of its forms to any person under the age of eighteen shall be punished by a fine of one hundred dollars ($10,0)"for,theFIRST offense. 1t` v' The NorthFShore Tobacco Control Program and the Salem Board of Health have worked with you and your employees toAemonstrate methods to ensure compliance wiTh tlns'r'eguli tion. ' Tler�efore#,yo-u are.oyrdered.to pay a£mFe2o�f$ 00.x.00i;f.forLsthe' -.vt iol'aFhs.ti stated A check or money orde'r'payable to,the City-of Salem must beat the Board'of Health omee,120 Washington Street,4h - floor within ten-days of receipt'of this notice- - ..,e � �,,.>•. r Should you-be aggrieved by this Order,you have the right to request a hearutgbefortAe Board of-Health. . � t'. ' A request'for.sueh`alieanngimusteeceived`iri afiting in tlmis officb'b tlie% oard of;FIealtli''_ efi:' i .f'i r of recei t of taus O`rde% At satd�l ou w1ll be ven the o to be`�It-`�� ; �. present witness and documentary evidence as:to why this Order.shomild be modified or withdrawn You may be represented by an attorney. Please also be informed that you crave,the rightto inspecf'and obtain copies _ . of all relevant inspection or investigation reports,orders,and other documentary inforrnation 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. Sincerely yours, Joanne Scott ° Health Agent Cc:' North Shore Toba600'6ntr'ol Program gg : s'Leonard'Milaszewsid Board:of.Health,Chain=..;. ;. - ii r ` 1 :'3 :- k pi ';-.i e.. .a R•,Z'a. _ ^ "1' '1tYs” ifs 4 _p"A , _ a - . . � " % y j, ,7T;`C=P.'t.'�{:-J�'�r�?.:- �f,.'; .•y,{:y,,:; . 1+'r,*iit ,t .t,=brei $f= $rl$vatt,: #I<tx?:ai 3 g 'a %,, r4 IF $F .(('T nr. Flk4 s♦. .Yy l'd]$ ''-�,. ,,�'L r�t- , fzR ;'tq?J.p.a :�. �.Pt3.i.'. �tf .v _ f.'. 5 Si4r. Sl< F �i}E•{'Th}.,. ]�N - SrilRf� ;. " �r~, r l., i -,t�e S G� Y Y',.,= t .�a'.'.r. ;_,-.' .s.' �+5§`•-' Ci' a f :r+r ".i=s, n�,eP.a• er s,9v..d- ` :bf,� bl'•a5d .P. 'a+ r-1 m 5 v P i., •,r ua:dc'$In. �Yk3q .alive,;_. .,br<• _ = '� - :�.- . ,F=-:i: reign.,«. _ ..�.._..7.6 - �I, ,�•.; �. 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Geer✓h�ue?ao -/v Coe&Yn�, ( GMPt;RTANT MESSAGE ) FOR OATF �d�a`3� TTIM!31-2 "6 P.M. �F ,�o �- ��_ •�7f � OF AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBII F AREA CODE NU BER TIME TO CALL TELEPHONED SE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED Y imps MAAOREMIN 0009 NOTES _ , ,,fMP0RT\ANT MESSAGE ) FOR O a-,N-Q— DATE / i �/�7, TIME P.M. OF �'e SS - '1q �N <ST_C S- Op �y/ C PHONG `� OP !_ 6,7 ` a �7vs-- AREA CODE NUMBER EXTENSION O FAX O MOE311 F AREA CODE ' NUMBER TIME TO CALL TELEPHONED I PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU ' I RUSH RETURNED YOUR CALL ) WILL FAX TO YOU MESSAGE C,�� - SIGNED i laft�(� FORM .&AS Ira. MAGE W U.e.A. ate\ NOTES _a. - Inspectors List 06/20/2003 Zip Code I Owners Last Name Owners First Name Type of Establishment Date inspected 01970 Post (Christopher 01970 Brookhouse Home fo 01970 lBert;Kinder House Trust;J_ohn __.__..........._. .__ 0010 _ 01970 'Kinder Care Learning! 01970 Amerada Hess7Corp ; 000--- 7000— .. 01970 !Target Corporation (Target Corporation ! 01970 jSaini ;Jatinder S. _ 01970 Salem Mass. CVS, In! 01 -970 'Lam Debo-r-ah.......... ( 01970 (KB Toy of MA, Ina i- --16 70 ---- � .. 01970 (Leong jLisa � ---1111-- _ 01970 Davis & CaccavaroKaren & John _ — 7777... 07:00. 01970 ITaka -FGazmerd & Helen 1111 -0011-- ...... .----1111 -- - ----F--- - ----- 01970 01970 '.:New Mass Restaura i — � 01970 ;Salem Lodge of Elks i _ 01970 Chartwells _ 01970 V.F.W. Post 1524,lnci 01970iKantorosinski ;Stanley & Maria 01970_ Silva Debra _�..._._.. 0777; 7777 . i 1 /afa3`3cc,/% �G SGZc� Te. Ltou�d tier �e W/GG co Ll- o- Qa'` � CITY OF SALEM, MASSACHUSETTS is BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL, 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ. JR JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 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 421334 Address of Establishment : 295 Derby Street Type of Establishment : RETAIL FOOD Application Date : 12/20/2002 Restrictions : Permit for Food Establishment 130-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 33-03 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 3 120 WASHINGTON STREET, 4TH FLOOR -'SALEM, MA 01 970 TFL 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNF SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT t� NAME OF ESTABLISHMENT 55 Lr-PffPS5 Q13-3q q TEL# ADDRESS OF ESTABLISHMENT t9qS berll j MAILING ADDRESS (if different) Amerada bless Corporation OWNER'S NAME 1 Hess Plaza/J Flaherty TEL#-23 (tk � Woodbridge,NJ 07095 ADDRESS CITY CERTIFIED FOOD MANAGER'S NAME(S) w CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON 11: 006 AMUS0r} HOME TEL#~ISI 59 V(0933 HOURS OF OPERATION: Mon. -�Tue._Wed._Thu. Fri.vSat. Sun TYPE OF ESTABLISHMENT FEE check only RETAIL STORE ES NO �Q 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 $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE Y TOBACCO VENDOR ENO 331-0-,- $50 ALL NON-PROFIT(such as church kitchens) YES e $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 knowle e�f dp elief, have filed all state tax returns and paid all state taxes required under the law. ( - +a\y\G2 t3- \o1 t1% 0A Signature Date Social Security or Federal Identification Number Revised 11/25/02 FOODAP2.adm Check#&Date �.2(-9 -5y—/02 7f�yf 9,33x000// CITY OF SALEM / BOARD OF HEALTH Establishment Name: 4.1ss FAV" -'-s Date: I /— /9- o3 Page: / of / i . Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY _ t A P, „ o! Plo-.- ceGvvs o.] Oc ria,-_s-secc_ t" /-Y-4 `1-Zcc. T/G�; P ba, ASG/. . euw&1e 1 I I I t1��1 SfN� iS /0e?'f4P'4 04 nrPos/ /. Phi OF id I I 6-.0 A-,e.� `1d4 dowS• 7lca.�ol�vG / / s i9Dt ®S/(t, I I I L4 A& ro 1,-7 hcal A'97" "Ooa . I IPlea��I Ply 4tie-4 51 '44-'- ,cQ -kv I I Pt"_�' /Pl vHs�c� �cr�ss/tip /o cafia�/ �Co I I 14 &e Tom , oY uw,P vP . s a� r �� r�,-„/ o/ � vP u/ �t' I I y Discussion With Person in Charge: Corrective Actlad Required: I ❑ No I ❑ Yes v I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ElRe-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Cod V. I u ders an that noncompliance may result in daily fines of twenty- or s sion/revocation of LI Embargo LI Emergency Closure your food permit. �� 11 -03 ❑ Voluntary Disposal ❑ Other: }i f r 3-50t.WIC'; PHFs Rt c,lv:d at'1-e111pendure's Violations Related to Foodborne Illness interventions sod Risk Acoi dine to I,i ,>(', b.d to i Factors(Items 1.22) (Cont.) 41;7/4,FWithin 4 Flo:=.!s. ' PROTECTION FROM CHEMICALS j 3-501J5 f oofire htetho:ls : r PIIFs -, ( I•I I Food or Color Additives ( 14 PHF Hot and G.E4 Holding j 3-501.i6(H) Gdd PHF•s 7^ain+ninrd at or clow Addihoec,z 590.004(F) 4;; /45-F:1 1 c I13-362.14 Protection from Unapprr»rd Addih,ea'' I 3-50:.16(A) Hot PHFo-.Maintained at of above Poisonous or Toxic Substances 140-h 7-10115 Identrfyinglnfornu[hon Ori I, 3-50L16'A) Ib- :t a, Held al of obmc i3U'F l COnfatneLS'" I 7-102.11 Common Narne-Wo j 12ti rime as a Public tlea!ai Control rkin�Cantainen" ;-501.1•') Time e,.a Public Health ControP` ( 7-2(il.l I Separation-Storage" , 7-202.11 Rcatriction-Presence and Use* 15`%t).U0,4(:-I: y%m'i.:nr: Re;iu,rcnlant i 17-202.12 Conditions of tlsc" 11-203.11 toxic Containers-Prohibitions' ( REQUIREMENTS FOR HIGHLY SUSCEPTIBLE j 7?04.11 Sanitizers.Criteria-Cheoueats" I POPULATIONS(HSP) Produce r f 21 3-301.:?(.A) Unraci:urn.;ed Pre-packaged Juices and I7--„0411- Chemicals for R'aslan Produce. Criiena:� j 7-204.14 Divimp Agents, Criteda* ( ! Bever'a!tes •.virh Warnim, Iabel�" 3-801.14(B) Use of Pasteurized F, S" 7-105 11 Incidental Food Contact, Lubricants° :;_gO1.11iUi -Rats ca Partially Conked rlmma(Food and 7-206.1 I Re,tricied Use Pestwide.,Criteria' 7-20012 Rodent bait Stations ' j ;. Raw Seed Sprouts Not Se;eed g0111(C; UnunnedFood Packa r; Not R c-sQrved 7-206.13 Trackin^,Powders,Yugt Control and -loniu)r ngCONSUMER ADWSORY TIME/TEMPERATURE CONTROLS 22 3-603 11 Con;umei Advrsnry Posted for Conqutnption of .Animal Fo0d.1 That are kaw. Undercooked or 1b ( Proper Cooking Temperatures for Not Otherwise Processed n)Elinnnate PHFs Padw cs r g•cs.` 3-401.11 At 1)(2) Eggs- 155`FI5Sec Eggs-Immediate Service 145"Fl5co:x ;-302 13 Pas.iem-irrd Eggs Subattiule for Raw Site]] 3 40i IkA)(21 Comminuted Fish. Me-,,.Is&Game F•'''1'* Anintala- 155"F 15 sec. 3-401.11(BrI (') Pok andBtRoast - 130F I'_I min" I SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meals- I55-P 15 590.00`(AI-(Di v'olatins of Section.': SJO.ti9(:j)-i ) to sec. * catering, mobile food, temporary and 3-101.11(.4)(3) Poultry, Wild Game. Stuffed PHF. residential kiwiten operations should be Stuffin,Containm-,Fish, Ment debited under the appropriate sections Poultry or Ratites-I(u`F IS sec * above ii irlatcti to fliotlhorne illness 3-461.1 1(00) Whole-muscle, tinsel Beef'Steaks j intervention,and risk factors. Other 145'F" 590.009 Violations reiatuig W good retail 3-401.t2 Raw Aminal Foods Conked in a piactiocs should be.debited under ,429- Micinwave 165'F ^ Special Kequirernents, 3-401.11(A)(1)(b) All OtherPHFs; 145"F 15 sec. * j ( 17 Reheating for Hot Holding VIOLATIONS R�L4TED TO GOOD RETAIL PRACTICES 3403 1 I(A)&(D) PIIFs 165'F 15 sec. (Items 23-30) 3403.11113) Microwave- 165`F 2 Minute Standing Gihr ul and n<,n-cal cul violations, w/nch do xu;r.-late to the Time" ,/uodhurnc IYT,ess Two ioention,s and rick facrors l,sted uhurc, can be 3 103,11(C) Commercial h'Pnvecsed RTE Food- (ooud io tha jriLnrt»r,,ectia;a of o is Food tied( and 10(AIR 140°F` j `90.0(/(1. 3-40311(H) Remaining UnshcedPortions orBeCC Item Good Retail Practices FC 590.000 ! Koas[s': .3. Macaoernent and Persormel FC-2 .003 Iffi j Proper Cooling of PHFs j 24, Fxxr;end F:xrd Protection FC-3 25 Equipment and utirmis FC- 4 ,005 i-501.14(.A) CoolingCuokedPHFsfront i40'Fto1 26. Viater,Plu;T;bcr?and''Was:e FC-5 .006 70'F Within 2 Homs and From 70'F 1 21 j Phvsical Facili:y FC-6 007 ! In 41'F/45'F Within 4 Hours. ' 28 Poironous or'axic N-aterials FC - 7 ,008 3-501.14(B) Cooling PHF-Made Funu Arobieut L2`-' ! Speciai Requirements .009 Temperaturelnoredien[ait)4! ! O. Othet .j Within 4 Hours' `Denote,critical von in the federal 1999 Fred C(Nte of 105 CsIR 540.000. L CITY OF SALEM � BOARD OF HEALTH Establishment Name: H/P 4.S Date: ii/ri�3 Page: of / Item Code C-Critical Item ,7 DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified /�-- PLEASE PRINTCLEARLY l 1 I I 1 I I � I I � I 1 1 I I _ i 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ fes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. u� ❑ Voluntary Disposal ❑ Other: ?. 14(C) PHFS ?e,ered at Tetr:per.aurca Violations Related to Foodborne Illness Interventions and Risk According to L 4«7 C:v?cd F.p factors(Items 1.22) (Cont.) 41'F/45'F'Xithin 4 Hours. PROTECTION FROM CHEMICALS 1-601.15 Cooling&lcthr ds trot PA' Fs ( 14 I Food or Calor Additives ?-20i l7 ! ( l9 Plat-I?o2 ar:9!)old Holding 3-5)1.16111) `-old PH(';;l%la;m.tined a! o:betoe, Additives# 3-30114 Protection front Unappowed Additivuc* 59Ct.GU4(F) ; �I"-5"['.. st)1 Ifi(.q; Hot PI-lF: k4aura roiled at o: abc>e Is g Poisonous or Toxic Substances i 140°P '7 101.11 IdetdiNiue Information-Original ;-`_ Containers" � 01.16(9) i hoa-.ts Held at or above 110 F. 7-102 It (A nation Namnt e-Workins Cnainem" I `� i time as a Public,Health Control 7-201.1 l Separation-Storage'. i z,.5iil 19 Time:s a Pal,;;, Health Control" 7-20211 Restriction-Presence and (1se° z9o.004(i-li VauanceRcymrerrent 7-202.12 Conditions of U;el 7-203.11 Toxic Containers-- Piohibilioos* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 � Sanitizets.Criteria-C'henrir,8s` POPULATIONS (HSP) I I Tlnp-steurizad ?-201 12 Chermcals for Washing Produce,Criteria'. 21 -501.11(Ay Pae-packaged Juices and 7-204.14 Drying Agents C riteii;0 Beverages with Wanda,Labe Ls:: i 7-205 11 Incidental Fond Contact, Lubricant;`r 3-801 I i(B) Usc of Paeteurived B;,ps' 7-2(36.11 Rcctrictcd Use Pesticides,Criteria` '001 l ltD) Raw of fln'tiaily Cooked Anin al Food and j 7-20o.12 Rodent Bait Stations Rea:Seed roodSpryr.Package e Not . 1 3-801 I i(C) Unopened Food Pnekage Not Ru-served 7-206.13 `Cracking Powders,Pest Control an(] Monitoring* CONSUMER ADVISORY 22 3-b(1:i.1 1 Com'umer Advu.oi y Pasted tar Consumption of TIME/TEMPERATURE CONTROLS A.nuttal Food, I'ha; arc Rau'. Undercooked of 16 Proper Cooking Temperatures for I is rn !}then,dse F7ocessett to E'limitrtte PHFS =+•,rs,. nw 3-401.11A(1)(2) Eggs- 155`F 15 Sec Podyigen:,.T' 3-302.13 Pa;leuri.ed Egg.,Substitute for Raw Shell Eggs-Immediate Service ld:i"} 15sec E�ga* 3-401 1 1(A)(2) Comminuted fish, Meads A, Crams Animals 155"F 15 sec. " SFECiAt. REQUIREMENTS 3-401.tI(Hit I)(2) PorkandBeefRoast- IsOT 121 min" s90MOWA) (D. of section 590.009 A)-(I? in :, 401.11(A)(2) Ratites,Injected Meats- 155`'F 15 ( ) W: * ( catering, mobile food, ten.parary:uttl 3-401.11(A)(3) Poultry Wild Game. Stuffed PHFa. rrcidcnnal kitchen operations should be Stuffing Containing_ Fish"Meat debited under the appropriate sections Poultry or Ratites-165`F 15 sec above ii teated to fbodbornc illness 3401 11(C)(3) Whole-muscle, intact Beef Steaks interventions and rkk factors. Other 135'F* 590.00(1 vioiations relating to good retail 3-401.12 Raw Arnold Foods Cooled in a practice should be debited under ii29- Microwave 165`F" Special R qu re,nents. 3-401.1 UA)(1)(b) All 011ie, PHFS - 145`F Is sec. ' t7 Reheating for Hot Holding VIOLATIONS R=LATER TO GOOD RETAIL PRACTICES 3-403.1 1(A)&(D) PHfis 165'F 15 sec. 1, 1 (Items 23-30) 3-403 11(B) Microwave- 165' F2 Mmule Slandun, C,-incal and nn;; cr rlical r elations, which do not relair to the Tune* ocdhorne il'r;esintrrcurv..is and risk(Metol t lured ahorr, can he 1-403 11(C) Cornmetciall}Pr("ssed R" E Fund- /o;nm'w the%)iioa•in,t,• set lions gfthe Food t'ndr and 125('ASH 140`F* 590.u(10. 3-40111(E) Remaining Unsliced Portions of Beef Ham Good Retail Practices FC 590.000 Roasts": 23 Managemert alit:Fatsonnel I FC--2 .003 Proper Coolie of PHFS 24. Food and Focx;Ftote"'.ion FC-3 .004 ---- - --------_-- f8 P g 25 ! Equipmert ana Utensils ! F-C 4 .005 3-501.14(A) Cowling Cooked PHFS from 140"17 to 26. Water,Piumb:nq and Waste ! FC-5 .006 70'F Within 2 Hours and Front 70'F 27 Phy:sacel Facility 1 FC-6 .007 to 41'F14517 Within 4 Hours. 'i ii 28 Poisonous or Taxtc Materials ( FC--7 .008 3 501.14(B) Cooling PHFS Made Front Ambient ,, 29 __ I_Specie i-Requirements .009 Temper:uure ingredienta iu4l°F/4. 'F ; 0 Other Within 4 Hours' s v,,. J, ; 'Uennle+erilital dery in the lederal 1999 Faod Code ut 10h('kin;90.000. 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 Tyne of Oneration(.gj f In i n f/ESS t1Fbkv,Q.0 Al, 2/ 33 1 a V- 1,3 El Food Service outine Address Risk E etail ❑ Re-inspection A 95'-_17 aeP.d(J .fes Level ❑ Residential Kitchen Previous Inspection TelephoneElMobile Date: pa-O6-o2. 1778-) '7v IJ- 9.c-S/ Owner - HACCP Y/N ❑ Temporary ❑ Pre-operation 1,2 r ,o I@,2 doL /PSS I ❑ Caterer ❑ Suspect Illness Person In Charge(PIC) Time ❑ Bed&Breakfast El General Complaint Yn.N N /��rYJn - ?� In; ElHACCP �Ylnuev-,rk/S Inspector Out: Permit No. El V Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions) 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 E:12. Reporting of Diseases by Food Employee and PIC El3. Personnel with Infections Restricted/ Excluded Ll 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding , El 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection El 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below c N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 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: t Inspector's Signature: / ... %�. Print PIC's Signature: Print: �`'�D�. 1 M O S u A/ Page-of .2 Pages FORM 734A HOBBS&WARREN - BOSTON 47. Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 13-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.1 HA)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* 3304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B)l Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces 4 I 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-tem H, 3-202.14 Eggs and Milk Products, Pasteurized* p'P gg � Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22 0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* - - - 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing 2 Regulatory Authority 301.11 Clean Conduced-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 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* i 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 IJ Handwash Facilities Tags/Records: Fish Products 3-402.11 Parasite Destruction* I Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(1) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 COIR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: f/.-Ss X 1, C / 33 d Date: 62 - o4- 03 Page: ,�2_ of —1)_ t Item Code C-Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION Date No. Reference R-Red Item ,,,4A e�� ) ,/� PLEASE PRINT CLEARLY k ,�-- Verified _X1 54aiZ FYI.-j.,0 /.eJ.,;.OFf`�ifr,->. /w/ir.I /i✓ �'�OYi l7r,c /o iC /.0/T/1 .SAI/4 Y �Pr�P,Pd l In 4a/ Gln4S } I Th/ e �VP,t°f_ Nd T",i 1 {F I 1 k`{f �Srrl 17 L�.S/flll uin f- S�//s Ta'�'i�c`.+17�u/CP ir4nN/ecL surr7o/P y ,(jLci/ SP//.n/O �, Aae { / / 7- S (2 .4, /J s. Ao,-"C� /-/-s nr3 tic aRG, /,v /"n/ /L> ax'/Ywr/, �PC U/0/i14dwRn n, >le'y a Ala Te. 1 1 � I I i ` I I I Discussion With Person in Charge: Corrective Action Required: I ❑ No I LI Yes 6 have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / r i violations before the next inspection, to observe all conditions as described, and to comply Exclusion with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled El Emergency Suspension F result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure -- ❑ Voluntary Disposal ❑ Other k .i FORM 734B HOBBS &WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures to Factors(Red Items 1.22) (ContAccording to Law Cooled) 41°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives 19 PHF Hot and Cold Holding - 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/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* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.1l(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.* Eeectve 11112001 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* - 3-401.11(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.*I catering,mobile food,temporary and 3-401.1I(A)(2) Ratites,Injected Meats- 155°F 15 Sec.*I residential kitchen operations should be 3-401.1l(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* 3-401.1l(A)(1)(b) All Other PHFs- 145*F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 I Reheating for Hot Holding (Blue Items 23-30) 1 3-403.11(A)&(D) PHFs 165*F 15 Sec.* _ Critical and non-critical violations, which do not relate to the 3-403.1 l(B) Microwave- 165°F 2 Minute Standing foodborne illness intementiau 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 PracticesFC 590.00 J 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 41017/45°17 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. 11/18/2003 12:49 FAX 5084809080 BOHLER ENG. Q001/003 VUHLEK 6NQINEERING,P.C. SOUfHBORO EXECUTIVE PLACE 352 TURNPIKE ROAD SOUTHBORO, 1 503.480.9900(tt1 308-080-9080(Ta facsimile trMsmiffal NOV 7 8 2003 CITY OF SALEM BOARD OF HEALTH To: -1a&46- Fax: From: E).&A%_SjL Date: ii-19 OS Re: A6%% _ D�'t'6'� SY . Pages: at_ CC: t CC: Urgent 0 For Review ❑Please Comment 0 Please Reply - Notes: I�aAJ�J,E . {��C4t.Ll� 11 to s Cpm ,SF- -cq€_ �Cc MA- - 51 t�EPCETe.(E.YC�I V lq T�� JP20 cF �E4L�i \ ' pPP2,aVA``l- AaSJ�-tAY�1L� v.t ict.� -C1A� f>�oV 6i 1L.EFER-E.�c.Ed a�T4� �i-F nc C-Au` ASN I JtLrc_ 1�. JT El��.50 - 5aL3 . '�L;b olV 0 4 11/18/2003 12:50 FAX 5084809080 BOTTLER ENG. 002/003 CITY Oi SALEM, MASSACHUSETTS '� BOARD OF HEALTH +, • "•� 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 T EL. 978-74 1-1800 FAX 976-745-0343 FO 17 l� `-� STANLEY USOVICZ,JR. JOANNE SCOTT, MPH, RS, CHO �� MAYOR HEALTH AGENT I®� u A l O'1 lam( D Fri /.may +? i NOV 18 2003 Com 5' May 10, 2002 CITY OF SALEM Walter B. Power, III, Chairman BOARD OF HEALT8 Salem Planning Board 120 Washington Street Salem, Massachusetts 01970 Dear Mr. Power: At its meeting on April 9, 2002, the Salem Board of Health voted to approve the Special Permit for the Hess Gas Station, Amerada Hess Corporation, at 295 Derby Street, presented by Attorney Philip C. Lombardo, Jr. and Engineer Lucien M. DiStefano, with the following special condition: 1. Plans for the intended food establishment must be approved by the Health Agent prior to construction. And the following conditions: 1. The individual presenting the plan to the Board of Health must notify the Health Agent of the name, address, and telephone number of the project (site) manager who will be on site and directly responsible for the construction of the project. 2. If a DEP tracking number is issued for this site under the Massachusetts Contingency Plan, no structure shall be constructed until the Licensed Site Professional responsible for the site certifies that soil and ground water on the entire site meets the DEP standards for the proposed use. 3. The developer shall adhere to a drainage plan as approved by the City Engineer. 4. The developer shall employ a licensed pesticide applicator to exterminate the area prior to construction, demolition, and/or blasting and shall send a copy of the exterminator's invoice to the Health Agent 11/18/2003 12:50 FAX 5084809080 BOELER ENG. X003/003 5. The developer shall maintain the area free from rodents throughout construction. 6. The developer shall submit to the Health Agent a written plan for dust control and street sweeping which will occur during construction. 7. The developer shall submit to the Health Agent a written plan for containment and removal of debris, vegetative waste, and unacceptable excavation material generated during demolition and/or construction. 8. The Fire Department must approve the plan regarding access for fire fighting. 9. Noise levels from the resultant establishment(s) generated by operations, including but not limited to refrigeration and heating, shall not increase the broadband sound level by more than 10 dB(A)above the ambient levels measured at the property line. 10. The developer shall disclose in writing to the Health Agent the origin of any fill material needed for the project. 11. The resultant establishment(s) shall dispose of all waste materials resulting from its operations in an environmentally sound manner as described to the Board of Health. 12. The developer shall notify the Health Agent when the project is complete for final inspection and confirmation that above conditions have been met. If I may be of any assistance to your Board, please call me. Sincerely yours, For the Board of Health, oa�J nne Scott Health Agent cc: Philip C. Lombardo, Jr. Lucien M. DiStefano r r r r ' P f o RO�gR7(..E RIO br a+ccaoe4+11y mRplvtMra 6tR•ewaraRRrns eet try M we sj ism Edaemn by reo100 o9Pwuxte by the. 4w emv(iaFe/FaoO Profettlbn iwMice+ia �ixEC snM�aWntl FOOtl 36tcly t:oec � Rr:IrNroa RY tM NSI4esaaER Jf[eE4EYR)YMAaNeJaf/oN BmEu�mm 8671/91 _ o.��e ov c•wwvrn..r�ow �, ipY.M�a'abMM 4TeM1O bI#i AM G�di r qv�9 YMYaV VLMu W EyY yYtl! LEM MOORfi. L£wPNiRxO dNYs t_Ert Yf pNc�wTYON tliv l3thw W p�srNYvl'Y.nrMT.Y� I' I.. ,-�. �.-�.T.'a+�^^�.wse„Fwrs•.+w+4'•+-z.w.rrv+-^+•-w.r,raR,o:,l.-n'W'�Y'v"�v9+rl-vwT„....-+Y't.+l�«�.M�-(%•T�mdSFF'e"y.i'tigl..j'°v�'Yr'w.�w,-.rw..n" l ,TH 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 L/ Date Tvoe of Ooerationf Tvoe of Insneetinn, A �S-„f if '�( ,f�l�$S' 2. f//�0r ❑ Food Service ❑-R uo'`tine Address Risk E1 Retail El Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone.-?yy._ y j � till ❑ Mobile Date: OwnerHACCP Y/N ElTemporary E] Pre-operation #)4.14 4 0 )lK s e-o o-F' ❑ Caterer ❑ Suspect Illness Person In Charge(PIC)) fi Time E] Bed&Breakfast El General Complaint �+ ��+ In: ❑ HACCP Inspector ll AfC.6-Nd1vot4 /!.A rff o vxAiu-' 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 ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS ❑ 3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE EJ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures f El 5. Receiving/Condition 'El6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating ❑ 7. 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) 2 9. Food Contact Surfaces Cleaning and Sanitizing ElEl 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations rX 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-0(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: Inspector'sign 5ture: Print: �f�)}M=R^"-T / /i ✓.dfit f.-d.!� PIC's Signature: '�4/a. "� Print: - r) ( p d�� t;r1 r'K t` ,>_ Page of .Pages i FORM 734A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATIONL > 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH I Contamination from the Environment 11(A 2 590.003(C) Responsibility of the Person in Charge to 3-302. ) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* - 3.304.1 I Food Contac[with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B)l Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces 4 I 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 1 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing 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* 11 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* � 12 Prevention of Contamination from Hands 6 Tags/Records: Shelistock __ 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* J � 13 Handwash Facilities Tags/Records: Fish Products - Conveniently Located and Accessible � 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 I Conformance with Approved Procedures HACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* - 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: 9.S 4e-;e_6L1, Date: //- /- Page: �_ of 2— Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified v// � ✓/ �Y PLEASE PRINT CLEARLY I X14/G.S= I / - /C'f.' �SCG�'v^^,JJi/_iT/�✓.Si�.a7r .J12�"rL 9` 11,/(.1�211 /�J,Sr/� /CPIY/C/IPP ��'/l�L� 5%�i� /�_� '7,-s?o r14_ r&i_&--r a/GT rslP //Fr 1 EXYf,Fim;�t7'/� rz v '�_/r(477_-7 7/)< 71�Q /lc('trCx<"tl r Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ fes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that non compliance may result in daily fines of twenty-five dollars or suspension/revocationFof,,_ LlEmbargo ❑ Emergency Closure y food permit. lea � O Voluntary Disposal ❑ Other: , PHFs Received at'1'empen%tun � Violations Related to Foodborne Illness Interventions and Risk acccr:ling to I i, v Gx;led to Factors(Items 1-22) (Cunt.) 41'1`45'F With ,4 Hours ' PROTECTION FROM CHEMICALS j 3-5('E 15 Cayintg Methods for P111-s j 19 PHF Hot and Cold Holding j 14 1 Food or Color Additives ( }clil.lfi(B) ! Cold NlFs Main!:aned at or beiuw i 202.12 Addiuuesx j 590.004;F1, 41''Lt5°-r' 302.14 Protection frutu Unappio,ed Addil'n-es' j 3.50!. 6(,4) ! 'lot PI Ws..^.�iarnroi,ed at or above 15 Poisonous or Toxic Substances 14o-f'. ` j 7-I01.I1 Idmrtifyv)p,Information -Oni=ire,l ,-50!.!6(17.) ; kuastt. Held at r•r above 130T. Container;' ; t0 Time as a PuLlic Health Control j 7-102.11 Common Nance-Worl,ino,Contin aer',s' j 3-507. jj i 9 T:rte as :i ul)lic Fcalih Control_` 7-2U L ll Separation--Stouge" -90.0 11Varian., RWILInen ut7-Z2. ! . Ue. jj j 7 702,12 Condnions of I!se, j j 7-2'73 I I Toxic Containers-ProhibnioW ( REQUIREMENTS FOR H=GHLY SUSCEPTIBLE 7-204.11 Saniti-rers.Criteria--Chemicals* ( POPULATIONS(HSP) 7 ZCl 12 Cheuu(als for W'aahrng Produce; Criteria He\e j 21 13-301.!I(A) teuri rzd Pre-p:u:kaged.iuicas and Br�era«es wint u1%annng I..ibels* j 7-204.14 Dr}sng An?nts. Cntcri,)* j 3-1101.1 I(B) Use of Pastewi::rd Fgn:2 j j 7-2(75 I 1 Incidental Ford Contact,Lubricants" ( -3O1 I Ir,[i) Fun: of Partially C'rokerl Animal F:xui and 7-206.11 Restricted Uae Pe,ticides,Criteria" 7-'_U6.12 Rodent Bait Stations' ! Ka,,. geed Sprouts No! Served. 7-206.13 Tracking Powders,Pest Control and 5-3GL l 1tC) Unopened Fo(d Package tint Re-sorted. Ivlbmtonng* j CONSUMER ADVISORY TIMEffEMPERWURE CONTROLS 22 '-60? 11 ConsenterAdvitory P,:sted for Consumption of 16 Proper Cooking Temperatures for Anneal Ford, Firm are Rai., Ln&acuuked or PHFs Not Otherwise Fr:,eessed to Elirrnnate 9 Pmhagens_':r-v:.r: ;zuor i-101.1iAt1)(J Eggs- 155^F (S Sec Lgga- Immediate Scrv,re 145"F15sec• 3-3'72.1 3 Po:,teurizcd E-gs Substitut:for Raw Shell 3-401.1 I(A)12) Comminuted Fish. Meats&Gane " vsY Animals- 155'F I5 sec. ' j ;:SOLI t(B)(I)(^_1 Port and Beef Roast- 130°F 121 tele' SPECIAL REQUIREMENTS 1 5,),0r(0)9(A)-(U) Violations of Srrncnt 590,009tA - 1)) in 3-161.1 RArt2) Katitce, hgcctrd Meals- 155 F IS ) ( see. * cale:ing, mobile food, temporalp and ' 3-401.11(;)(3) Poultry,Wild Game. Stuffed PHFs, tesidenti:d kitchen operations should be Stuffing Containing Fish, Meat. debited under the in ronriatc sections ' Poultry or Ratites 165'F 15 sec .:bore if rc!ated tc•foodborne illness 3-401.11(C:)(3) Whole-muwte. Intact Beet Steaks interventions and risk faciors. Otter 135'F" 590.009 ciulatiun,, :elalrug to g(x)d retail 3-401.12 Raw Annnal Foods Cooked in a practices shrntld he debited ander#r'29 - Micinwave 165`F a Special Requirements. 3-401.1 i(A)(l y b) AI I Other PHFs - 14517 15 sec. j 17 Reheating for Hot Holding VIOLATIONS R--LATED TO GOOD RETAIL PRACTICES 1 40 1.11(A)&,W) PF1Fs 165'F 15 sec. (Items 23-30) 3--103.11(B) Ill icnnvace- 165 F 2 Almute Strau in,g Critical and a,-,v-ernicul violations, which do not relow to the T!nie°` t...Jbor,w d!ns JU,a-,r:rionc enc i4sk factma k.sted uhovc, cmc be 3-103.1 I(C) Corntnercialiy Processed RTE Food - bund in:heJnlLnring se(unrn qj the Pood Code a d 105 CWR 14WF1 590.000. 3-403 11(E) Remaining Lnsticed Portions of Beef Item Good Retail Practices FC 59alloo Roast:,` j 23. ! Utanagementand Personnel FC-2 _ 003 j 18 Proper Coaling of PHFs 14. rood and Food Protaciion FC-3 004 j_L`--_-- -`dv'pment and U:ensTIs FC-4 .005 - „3-501,14(A) Cooling Conked PHFs front 140=17 to Z6. ! %Nater.Plumbinq and Waste FC-5 .006 16"F Within 2 Hours and Froin 70'F 1 27, Phw;icar Facility FC--o .007 to 41"F/45117 Within 4}lours. " j 28 Posorous or Toxic Miateria!s 1 FC--7 .008-� 3-50 i.14(B) Gxtlinf:PHFs Made Ffum Andr�znt ='3 Special Requirements --009 ?'euperature Ingredients to I 'F7-}5'F �J. Other W ilhin 4 Hours:. " Drn,xe,critical acro in thu federal 1099 Kod Cude or 10;,CMR 591).000. / CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH a _ 120 WASHINGTON STREET, 4TH FLOOR �(p 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 #21334 Address of Establishment: 295 Derby Street Owner's Name: Amerada Hess Corp. Restrictions: Application Date: 11/26/2003 Permit for Food Establishment 44-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 011-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH " 120 WASHINGTON STREET, 4TH FLOOR ac 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 #21334 Address of Establishment: 295 Derby Street Owner's Name: Amerada Hess Corp. Restrictions: Application Date: 11/26/2003 Permit for Food Establishment 44-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 011-04 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 I CITY OF SALEM, MASSACHUSETTSq110 BOARD OF HEALTH • • 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 V NOV 2 4 2003 TEL. 978-74 1-1 800 FAX 978-745-0343 CITY OF SALEM STANLEY USOVICZ, JR JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE�2A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ti S Scprem (903q TEL# jyN Sal 13 ADDRESS OF ESTABLISHMENT (9q,--r her6u lS� AMERADA HESS XRPORAMON MAILING ADDRESS (if different) I HESS Gt AZA i 1 n AMPTy OWNER'S NAME `} WOODBRID73-2 7 GE N amp ADDRESS ) CITY 'STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) j,v �4 CERTIFICATE#(s) (required in an establishment where potentiallyhazardousfood is prepared.) EMERGENCY RESPONSE PERSON )ail�rA NWvr HOME TEL# HOURS OF OPERATION: Mor a'l'der/W�d. Thu. Fri. Sat. Su . TYPE OF ESTABLISHMENT 1 FEE check only RETAIL STORE (n5> NO less than 1000sq.ft. _$ 50 1000-10,000sq.ft. 0 more than 10,000sq.ft. =$250 RESTAURANT YES NO t� 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 SERVE Y N $5 50 ALL NON-PROFIT(such as church kitchens) 1TOBACCO VENDOR1�e� YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledndp lief, have filed all stale tax returns and paid all state taxes required under the law. f ,d„io3 )3- 199 OOa Signature Date Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------------------------------------------ Revised 11/03/03 FOODAP2.adm Check#&Date 473 CITY OF SALEMp MASSACHUSETTS BOARD OF HEALTH 6� 120 WASHINGTON STREET,4TH FLOOR r o 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 Address of Establishment: 295 Derby Street Owner's Name: Amerada Hess Corp. Restrictions: Application Date: 11/18/2003 Permit for Food Establishment __ 25-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 2 :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. ��71zr/1f.X.C� ✓L /HEALTH AGENT � u CITY OF SALEM, MASSACHUSEI-'f� Ibl✓✓] V BOARD OF HEALTH 3 s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 CITY OF SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Ne-55 Ex0resS TEL# 9�a- -)`/y- Sy)3 1n j ADDRESS OF ESTABLISHMENT ��- I MAILING ADDRESS (if different) I f (� OWNER'SNAME Ji Brio` Re-S5 IAEA, TEL# )3z ESQ- 6000 ADDRIF��SS OKe- 1+255 P Irti2c ' CITY ;1)AcAlor-,,kq2 STATE A)7' ZIP 67/715 CERTIFIED FOOD MANAG`ER'S NAMES)Arke Z iesIa CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Ed`k%e- �P�°� HOMETEL# Svc-37-6 - )4147 HOURS OF OPERATION: Mon.X Tue.__)� _Wed. X Thu. X Fri. x Sat. X Sun. TYPE OF ESTABLISHMENT-,, FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YESNO 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 SERVE YES NO $5 TOBACCO VENDOR YE NO $50 ALL NON-PROFIT(such as church kitchens) ES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursua t t pter 62C. Section 49A, I certify under the pains and penalties of perjury that I, to my best d belief, have filed all ate tax returns and paid all state taxes required under the law. i J 114-03 IpZ - 56 - 602-� Signature Date Social Security or Federal Identification Number --- --------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date 390 CITY OF SALEM MASSACHUSETTS BOARD OF HEALTH r _ 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978.741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, 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 Address of Establishment: 295 Derby Street Owner's Name: Amerada Hess Corp. Restrictions: Application Date: 11/18/2003 Permit for Food Establishment 25-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 25-04 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. ldaL� 44-t7(— HEALTH AGENT COURT DOCKET NO. 0 CITATION NO. CITY SALEM PD 0531} VIOLATION NOTICE r V iT NAME(LAST,FIRST,INITIAL) }'r E.-. S tix ? � 2t33y STREETADDRESS CITY/rOWN STATE ZIP ?—<?1; ?Y.2�`I ST SSn\i,Cw' n`� 01G"WI LICENSE NO LIC EXP.DATE DATE OF BIRTH OWNERS NAME(LAST,FIRST,INITIAL) (� STREETADDRESS CITY/TOWN STATE ZIP Zr),! D: 2 7-�, r ra " O qlm REGISTRATION NO STATE EXP DATE L MAKERYPE YEAR(COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PRRSIIIONu L, rp-I /^ 1� INJURY ZS 0A, l .LJ PM P � k C7�n []NO LOCATION OF VIOLATION ENFORCING DEPT. T4s OFFENSE �CHAP I SECC1T_ FINESII,1 875�`yr""� OFFICER I D.NO. T DUE LI OFFICER CERTIFIES COPY GIVEN TO VIOLATOR J/ �❑ IN HAND X /jIJr BY MAIL DO NOT MAIL-CASH!PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL - CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 ..0 x TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, 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 #21334 Address of Establishment: 295 Derby Street Owner's Name: Amerada Hess Corp. Restrictions: Application Date: 11/22/2004 Permit for Food Establishment 45-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 0012-05 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. HEALTH AGENT fCITY OF SALEM, MASSACHUSETT- (170 � BOARD OF HEALTH II�Ij) LA • 120 WASHINGTON STREET, 4TH FLOOR f `j;J/( SALEM, MA 01970 NGVI' j19 Z604 TEL. 978-741-1800 FAX 978.745.0349 CIT-`(OF SAL CM USOVICZ, JR JOANNE SCOTT, MPH, RS, CHO BOARD OF Ei� MAYOR l HEALTH AGENT ��L�8 200/APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT t erc, ExPrem r9133q TEL# lgq-Sq IJ ADDRESS OF ESTABLISHMENT 9q,!5r te['6A ",St MAILING ADDRESS(if different) AMERADA HESS SDR?GRA7TMN ' } WOODBRIDGEE OWNER'S NAME 732 -.r L OF ADDRESS CITY 'STATTE,q ZIP CERTIFIED FOOD MANAGER'S NAME(S)_..A , 11 CERTIFICATE#(s► (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Y-iaWVI- HOME TEL# 97S:ff-V-vq HOURS OF OPERATION: Mor ' u'i'tie�I-1X:"9Thu.—Fri. Sat' TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. 6$50 1000-10,000sq.ft. 0 more than 10,000sq.ft. =$250 RESTAURANT YES NO yf 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 SERVE ,Y N TOBACCO VENDOR 425) ALL NON-PROFIT(such as church kitchens) U�a-DS YES N Please pay total with one check payable to the City o1 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 n ellef, have filed all stale taxreturns and paid all state taxes required under the law. Signature Date/ Social Security or Federal Identification Number --------------------------- ----------•---- ------------ ------ ----•----------------------- - ---- ----- ---------------- Revised t 1t43103 FOOOAP2.adm Check#&Date 2ik"rS Wq U/!S)0 Y coxnir CITY OF SALEM, MASSACHUSETTS vQ' BOARD OF HEALTH e 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 s,� TEL. 978-741-1800 '0 FAX 978-745-0343 STANLEY USOVICZ. JR. JOANNE SCOTT, MPH, RS, CHO` MAYOR HEALTH AGENT ` COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT fi .robacecJ 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 21334 Address of Establishment : 295 Derby tre Type of Establishment : RETAIL FOOD Application Date : ±2 Restrictions : Permit for Food Establishment 130-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 33-03 These Permits Expire December 31, 200/y 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 00000557 375884 A 1 0050 01 00304011 0003 00001 A (732)750-6803 Amerada Hess Companies Attn: Internal Audit One Hess Plaza Woodbridge NJ 07095 CITY OF SALEM BOARD OF HEALTH 120 WASHINGTON ST., 4TH FLOOR SALEM MA 01970 YENDDR DATE CHECK N0, 0000540402 11/15/2004 0200810344 pTVli-0C NV©ICE NO. . ._.,..PATEP.O. NO,, GROSS AMOUNT. DISCOUNT RMDUNT NET AMOONP 0590 11/10/4-21334 11/10/2004 $100.00 $0.00 $100.00 2005 'ood permit for Hes# 21334 $100.00 $0.00 $100.00 • n .. -rnY-Y na n .. .. •�. �t'F ..• - �, � " .r 1. . art. rYa. P yf^ � v .ae .f rr '+ Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'" Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Dat�eer- ITvpe of Ooeration(s), Type of Insoection /dot SY' �L(l/tic r 2r 3 Y /?2�� 1 ❑❑� Food Service C �F outine Address Risk �ji'Retail C] Re-inspection 9a� ��R f Levelj•� I El Residential Kitchen Previous Inspection '? Telephone �`( I ❑ Mobile Date: N4 -P4i9 111 Owner HACCP YM El Temporary [IPre-operation /4v#j-".4 le*_n' Cwt/, I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time - ❑ Bed& Breakfast ❑General Complaint In: [I HACCP Inspector I)Av,O Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ,- tl� s Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS El2. Reporting of Diseases by Food Employee and PIC E] 14.Approved Food or Color Additives [:] 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE El 15. Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION D.Y$/. 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 El21. 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 Z 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 afCeaNh . 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-a)(sso.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 50InVWFCm 14 dx Inspector's Signature• Print: PIC's Signature: ; O n I Print: S�HV, Cq Page of 2 Pa esJ !/1 g Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-comaminndon 1 590003(A) j Assignment of Rean')nsibili[y" 3-302.110)(1) Raw Animal Pnrxis Separatcd f oro 590.003(B) Demonstration of Knowledge' Cooked and I2 FE Fea+ds" 2-103.i 1 Person in charge - datics ( Contamrratinn frorn Raw lnoredrents 't-302.1l(A);2) Raw Arine l Foods Separated from Each EMPLO"EE HEALTH Oth•:r' 2 590.003(C) Responsibility of the person in ch.nge to Con+aminaftoo from the Fowronme7t require reporting by food employees and 3-30211(,.) Food Protection" applicants' ! 3-3o2 1,5 Vvashing Fruits tad tire-ciables 596.003(F) Responsibility Of A Food Employee Or An 3.;04_i I Ford Contact with i:gmpment and Applicant To Report To The Person in Utemik' Chmpe* Cotxamiaatior,from the Consumer 590.003(G) Reporting Pelson to Charge( ) P 5 € ! 3 306.14(A)(H) Returned Food and Rcservicc of Facnl^ ! 3 590.00P3(D) Exclusions and Restrictions* I Disposition of Aoultemted or Conraminated 590.003(E/ Removal of Exclusiune and Restrictions I ( rood 3-701.11 Discarding errRc.couditiomngUnsafe FOOD F IOM APPROVED SOURCE Fc+ceP' 141 Food and Viater From Regulated Sources 9 Food Contact Surfaces ! 590.004(P.B) Compliance with Food Low' ( 4-501,111 Manual Waret,asirtnI-Hot Water 3-201.12 rood in a Hermetically Sdaled Container' ! Sanitiz a[ion'Femoerattres" 3=201 13 Fluid]vlilk and MilkProducts' ( 4-501 112 Mechanical 36 ar washmg:Hot Water 3-20213 Shelf Eggs' Sarittz<ntion Tepiperaaues 3-262.14 Eggs and Milk Fr(x4icts.Pasteurized" ( 14-501 1 14 Chemical Sanuizntiou-temp.,pH, concentration and hardness, 3-202.16 ice Made From Potable Drink rw Water" j " d-601.tl(A) Equipment Fcsw9 Contact Suflaces and 5-101,11 Drinking,Water from an Approved Systenr' ( I Dtenstls Clean" 590.00(0(,) &tl0cd Drinking Water' ( 4{612 11 Cleaning Frequency of Equipment Food- 1590.006(B) Water Meets Standards in 310 CMR 22 W Gmtact Surracel and Utensils" f Shellfish and Fish From an Approved Source 4-7(}2.i I Frapuzucy of Samtizahon of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan I Food Contact Sur•4t_es of Equipment* Shellfish* 4-70".11 Mzthrxis ut Scmftzatiur, - Hnt W'ut:r and 3-200.15 Molluscan Shellfish from NSSP listed Chemical^ Sources' I 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 C7ena C'onditioa- Hgnds and Arms" ! 3-202 18 Shelistock Identification Present` '_-301.12 C'iza[tin;;Frrxedmr* 590.0U4(C) Wild Mushrooms" 2-301.14 When to Wash"' I g ( 201.17 Game Animals" 11 good Hygienic Practices Receiving/Condition 1-401.11 Faring,Drinking or Using Tobacco' ! 3-202.11 P11Fs Received at Proper Tentperatures,t 2-401.12 Discharges Frorn the Eyes Nose and Month: 3-202.15 Package lntegxity" * 13-300.12 Prrvenfing Contami:whon )('hen Fasting' ! 3-101.11 Food Safe and Unadulterated Cr Tags/Records:Sheilstock ( ( 12 Pf<vention of Contamination from Hands 3-202.18 Sheilstock Identification'. 590.004(E) Preventing Contatmnation from Eniplovees* 3'03.12 Sheilstock Identification Maintained'" Tags/Records:Fish Products ( 13 Handwash y Loceies 3-402.11 Paasite Destruction* I Curnbcis ai tooted and Aocesstbie 3-402.12 Records,Creation and Retention" t .5-?R3.11 Numhcr:xnd Capacities ! 590.0010) Labeling of Ingredients* ' 15-204.!: Location and Plac:irtmt' 7 Conformance with Approved Procedures I 5-205.11 Accessibility, Operation and Mmntenmtce /HACCP Plans I Supplied with Snip and Hand Drrmg 3 502.11 Specialized Processing k4eduni0- i oevres ! 3-502.12 Reduced oxti,een packaging,criteria' 6-301.11 Handwashine C'cin:,er.Avaihilulav 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Drying Provit ion hanote.critical nem m the federal 1990 F+oi Cole or l t)5 CNIR`-090.000 CITY OF SALEM BOARD OF HEALTH Establishment Name: fr&rT C RAR-rT-i'S 2/32 q Date: Q /�d� Page: Z of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date I No. Reference R—Red Item Verified PLEASE PRINT CLEARLY � �� " �7Y-,e �n tc a ti✓trri- f f73rnt E6tJl.re iA.X-,n.�Rs11 1 I r- jr I l' iX c,e 1 3-RA*+r0_,E D,czrr.,✓� I AA.rrc_v .A.r.s.,r/'ya au e3IV-/uw„s.r rlr�s 1 l fA r Ko.,L^ « ,roe,J4 IPWKbc ra c,r,re r. Ae✓rn aar /Jt I/os fvSt rw: /,t!'fS t !'De eoc%s I /�yAtt C'7�wat 4 I � c �- � stivrl�t c-..✓,� f-,r� dn/�,+r /�,n.+�..-s/_.� S,w�n¢�N,>r- sOc�rnU,v st �.�./�r or arc I arar Oag-T #4-0 0 CW-4A /P Of- /2f�� . .e..,e..-r./nfi, iR!(' � er�r *+r- .o- rLEL-10 dA 1We eu� rrf AAr.s I �1�tRSI ., AntTia .,. .. 3rt+r,t�,r✓b 1 Discussion With Person in Charge: Corrective Action Required: I ❑ No I ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance 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 or suspension/revocation of ❑ Embargo ❑ Emergency Closure E� your food permit. (,��•67 ( Q ❑ Voluntary Disposal ❑ Other: r PHFs Rec�ned a!Tempt-, ttm'c.s Violations Related to Foodborne Illness Interventions and Risk According to Uw Cooled to Factors(items 1-22) (Cont.) 41`F/45'FWithin 4Houis. PROTECTION FROM CHEMICALS 3 501 15 Cooling Methcol!.for PHFs 19 PHF Hot and Cold Holding 14 Food or Color Additives 3-501.iwti) Cold PF-IF,, Maintained at or below 1-201-12 Additivcs'> Syf10Q4'F) 41"t45"r" 3-302.14 Protection from unapproved .Additive,k 3-501.I5(A) IIon ibiaintained at ur;tbave � 15 Poisonous or Toxic Substances I 1-:0'F'F.. " 7-101.11 Identifying tnformdttun-Original I 3-501,lb(A) Ruas!sHe•Idatorabovel3U'A " Containers" Time as a Public Health Control 7-102,11 Cormnon Narnc-Working Containers" 2(? 13-50; q Time as a Public Health Control' 7-201.11 Separation-Storage' " ' _,0(LOpa(H) v'afienCC Rcyu;rcnu:nt 7-2(,r n 11 1Lstriction-Pic;ence and Une'� 7-202.12 Conditions of Use, 17 '_1}3.11 'toxic Containers-Prohibitions"' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 17-204.11 Sanitizer,,Criteria-Chemic:is" POPULATIONS(HSP 7-'_03.12 Chen)ie•als for G'v ashmg Produce;l'ritetia°` 2i 3-801.11(P.1 Chfatsizunzccl Pit-purkoged 7utecs anti 7-204.11 Drying Agents,Criteria" ( rievetages wish kkainingLabels^ -Sol, Us._ cSPasteuiized `ia_ls* 7-205.1 t Incidental Food Contact.Labneants^ 3.5!71,11(1:! Raw or Partialb,Cooled Animal Focal and 7-206.11 Restricted Use Pesticides, Cntena' - ' Raw Serd Sprouts Not Served. 7-20(.12 Rodent Bait Stations" ',-SOtali(C) UwwricdFood Package Not Re-nerved. .': 7-20(c 13 Tracking Powders,Pest Control and Monitoring" CONSUMER ADVISORY TIMElTEMPERATURE CONTROLS 22 3-603.1 4 Cnnsutttar Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Fucxts Phar are Kaw.Undercooked or PHIes Not Otherwise Processed to Eliminate 1-101.I1A(1)(2) FggYadtogen,. s- 155`FISSrc.. Faces-hnmtediute Service 145'F15sec- - 3-30'.1 3 Pasteunzed F.gcs Substitute for Raw Shell t 3-401.11(A)(2) Comimnuted Fish;Meats.&Game Eggs: Animate- 155'F 15 sec 3-401.11(8)(1)(2) Pork and Beef Roast- 130"F 121 minx SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites; injected 'vicars 155'F 15 590.0fMAr(D) Violafuuts of Section 590.009(A)-(ll) in sec. . catering, mobile ia)d,temporary and 3-401.1 IlA)(3) Poultry,Wild Game,Stuffed PHFs, reauicittial kitchen operations should be Sluftine Containing Fish,Meat, debited miler the appropriate sections Poultry or Ratites-165°17 15 sec. ` above if related to foodhorne illness 3401.11(0(3) W'hoie-muscle,Intact Beef Steaks interventions and r sk factors. Other 145'F;. 590.009 violatwns relating to good retail 3=401.12 Ruw Anivad Foods Cooked in a practices ,could be debited undcr #29- Microwave 165`F SpecialRequii-.ingots. 3-401.; 1(A)(1)(b) All Other PHFs- 145'F15sec 17 I Reheating for Hot Holding ( VIOLATIONS R.:LATEO TO GOOD RETAIL PRACTICES f 3-403.11(-A)S(D) PH Fs IF,5`F 15 sec. ' I (items 23-30) 3-403.11(B) Microwave- 165'F 2 Mmute Standing ('Ktrrai and non-critical ctu,6iions, tvhrch do not rekve to the Time" ! foodbe;rne iltnrss incei-renkuna two risk f:ittors lietrd above, can be 3-403.11(C) Commercially Piocesscd I2TE Food- found hi the jolloi,.ing sections of thr Fund Code and 10.5 Chfk Ido"F> 590.(100. 3-403.11(F) Remainin_' UnslicedPorticnsofBeef I Item Cood Retail Practices FC 590.000 Roasts" 123. Manaoement and Personnel FC--2 .003 tg Proper Cooling of PRFs I ( 24 Food and Food Protection FC-3 .004 25, Equoment and Utensils FC-4 3-501.14(A) Cooling Coked PHFs from 140"P to -& Water,Plumbinq and Waste FC-5 006 7WF Within 2 Hours and From 70"F 27. Physical Factidy FC-6 007 to 41'F/45"F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.11(8) Cooling PRFs Made From Ambient 29, Special Reouiremerts 009 Temperature Ingredients to 41,F/45'F 30. Other Wnhin 4 flours:" *Denot's crmc,d item m the(iteral 1999 Pond Cod,•or 105 CMI:5900011,