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HESS EXPRESS 21519 - ESTABLISHMENTS f 90 NORTH STREET u a 0 i i 4 li d n W 1 1. V 0 c r � � 1 I Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name Da Type of Operation(s) Type of Inspection b Food Service ❑ Routine AddressRis tailWe-inspection Telephone Level ❑ Residential Kitchen Previous Inspection Tele p ?) ❑ Mobile Date: OwnerHACCP YIN El[3 [IPre-operation s ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Tim ❑ Bed &Breakfast ❑ General Complaint In: ❑ HACCP Inspector Out. Permit No. ❑.Other cxte Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) - Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590. ❑ q Allergen Awareness 590.0009(F)09(G) ❑ corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities .'EMPLOYEE HEALTH PROTECTIONFROM-CHEMICALS` ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMErrEMPERATURE"CONTROLS.(P.oterdlalty Hazardous Foods) E] 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling PROTECTION FROM CONTAMINATION [119, Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20. Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSUSCEPTIBCE-POPULATIONS(HSP) ❑ 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_(Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22); of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. C N 590.000/federal Food Code.This report,when signed below 23. Management and Personnel (FC-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 5. Equipment and Utensils (FC-4X590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5)(59o.o06) 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-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.099) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S: aa.doc Inspector's Signature: Print:.I' I 0 r.Xk / PICT Signature: Print: l Page_df images Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION $ Gross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(]) Raw Animal Rands Separated from 1 -590,003(A) Assignment otResponscbifit *-� Cooked and RTE Fnods* 590.003(6) DemonstretionofKnowled e"` _ Contamination from Raw Ingredients 2-103.11. Prason in charge-dukes 3-302.11(,4)(2) Raw Anit n l Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.(X)3(,C) Responsibility of the person in charge to '3.302.11(A) Foal Protecnon* require reporting by frmd employees and a ilic3-302,15 WashSn Fruits and Ve*etables ants* 3-304.11 Food Contact with Equipment and 590,003(F) Responsibility Of A Foal Employee Or An Utensils* Applicant To Report'ro'llie Person In Contamination from the Consumer Char e* 590.0113(G) Reporting by Person in Charge* 3-306,14(A)(B) Returned Foal and Reservice of Food* 3 59,0.003(D) Exclusinns and Restrictions* Disposition of Adulterated or Contaminated Food 590.003 E> Removal of Exclusions and Restrictions 3-701.,1.'1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A.B) Compliance with Food Law* 4-501_I I I Manual Warewashing-Hot Water 3-201.12 Pcxxl in a Hermetically Scaled Container* Samtizationlenreratures*_ �_ 3-201.13 Fluid Milk and Milk Products* 4-501.112 MechnicalWarewashing-HotWater 3-202.13 Shell Eggs* _ Sanitization Tem eratures* 3-202.14 $ sand Milk Prudncts,Pasteurizz�d* 4-501.114 Chemical Sanitizatiml-temp.,pH, concentration and hardness. * 3-202.16 lee Made From Potable Drinking Water"' Equ 5-101.11 DrinkingWater from an Approved System* `f-601..11(A) Utensils Foci Contact Surfaces and A) Bottled DrinkingWater* -T-6021 Cleaning Clean* 590D)6(F1) Water Meets Standards in 310 CMR 22.04' 4 6D2.11 C".leaning Fregaency of Equipment Food- )6(1) Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recicationally Caught Molluscan Foai Contact Surfaces of Equipment Shall6sh* 4-703.11 Methods of Sanitization-Hot Water and. 3-201.15 Mollllseam Shellfish from iNSSP Listed Chemical* Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Anns" Re ulator Authorlt 3-202.18 Shellstock 1dentiticatton Present* 3-301.l'2 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 21 Good Hygienic Practices 5 Receiving(Condifton 2401A I Eating,Drinking or Using Tobacco" 3-202„11 PHFs Received at Pro ei Tem ,ranges* 2.401,12 Discharges From the Eyes,Nose and 3-202.15 Package hrtegrit * Mouth* _ 3-101.11 Food Safe mid Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6TagrdRecords:Shellstock 12, Prevention of Contamination from Hands 3-202.18 Shellstock Identification° 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintimed* En pla ees* TagslRecords: Fish Products - 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11. Numbers and Ca aaines* 590.0040) Labeling of Ingres tents' 5-204.1.1 Location and Placement* Conformance with Approved Procedures 5-205.ll. Accessibilitt ,O reration and Maintenance IHACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11 Specialized Processing Methods* 3-502.12 Reduced oxygen aoka n*,criteria* 6301.]7 Handwaghin Cleanser,Availabi1i 5-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Dr n Provision * i I federal 1999 Pard Code.or 105 CMR 590.00). Denoras critical i[em n the ed CITY OF SALEM , pp BOARD OF HEALTH Establishment Name: �j jFV(IAo6S a9) 65^by� Date: tr Page:_ of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, No. Reference R-Red Item � Verifled PLEASE E PHIIN/T CLEARLY F AJ 3�� ► — — oraj 9� Discussion With Person in Charge: Corrective Action Required: ❑ No es 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 Ll Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ``�--1 ❑ Voluntary Disposal ❑ Other. i 3-501.14(0 PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41°F145'F Within 4 Hours. PROTEC71ON FROM CHEMICALS 3-501.I5 CoolingMethods for PHFs 14 - Food or Color Additives 19 PHF Hot and Cold Holding --•- 3-501.16(B) Cold PliFs Maintained at or below 3-202.12 Additives* 'r 3-302.14 Protection from Unapproved Additives* 590.004(F) 410145°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above MOR 7-101.11 Identifying Information-Original 3.501.16(A) Roasts Held at or above 130°F. ' Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* - 3-50L 19 Time as a Public Health Control* 1 7-202.11 .Restriction-PresenceandUse* 590.004(H) Variance Requirement -- 7-202.12 Conditions of Use* t REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-ZK I 1 Sanitizars.Criteria-Chemicals* Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing `l 7-204.14 ig encs.Criteria* ,Bevern s with Warning labels' ` 7-205.11 Incidental Food Contact Lubricants* 3-801AI(B -Use of Pasteurized Eggs* ! 3-801.11(17) 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* i - 3-801.11(C) Unopened Food Pae ,e Not Re-served. F 7-206.13 Tracking Powders,Pest Control and 4R Monitnrin * CONSUMER ADVISORY f TIMEfiEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Conking Temperatures for Animal.Foods That are Raw,Undercooked or PHFs - Not OtherwiseProcessedto Eliminate Patbo*ens.*Eft""' 3-401.I1A(i)(2) Eggs- 155°F 15 Sec. E -immediate Service 145'F15sec• 3-302.13. Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) � � Comminuted Fish.Meats&Game E n ' Animals-155'F 15 sec. 3.40L11(B)(ix2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 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 F(txls Cooked in a practices should be debited under#29- 'i Microwave165°F* Special Requirements. 3.401.11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-,W3,1 l(A)&(D) PHFs 165F 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 listen above, can be 3-403A I(C) Commercial ly Processed RTE Food- found in the following sectionsofthe Food Code and 105 CMR 140°F* 590.000. 3403AI(E) Remaining Unsliced Portions of Beef Item 1 Good Retail Practices FC 530.000 Roasts" `L23. i Management and Personnel ! FC-2 .003 18 Proper Cooling of PHFs 1 24. ,'Food and Food Protection 1 FC-3 .004 1 25. Equipment and Utensils i FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140`F to 1 26, Water.Plumbingand Waste i FC-5 .006 70'F Within 2 Hours and From 70'F 27. Physical Facility l FC-6 .007 to 41`F/45°F Within 4 Hours. * 1.2_6. Poisonous or Towc Materials FC 7 .008 3-501.14(.B) Cooling PHFs Made From Ambient 29. I�.ecial Requirements 009 Temperature Ingredients to 41°F/456F 30 1 Omer - within 4 Hours" 'Denotes critical ivm in the f doral 1999 Food Cade or 105 CMR 590.0()0. Massachusetts Department of Public Health Salem Board of Health Division of Food end Drugs 120 Washington Street,4'" Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTAB ISHMENT INSPECTION REPORT Tel. NameD Type of Operation(s) T pe of Inspection El Food Service Routine Address Risk Retail Re-inspection 9 � Level Residential Kitchen Previouglnspe ion Telephone El Mobile Date: 30 r� Owner HACCP YIN 11 Temporary ElPre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time ❑ Bed &Breakfast ❑General Complaint In: ( � ❑ HACCP Inspector Out. I Permit No. El,Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provisions)violated. Noncompliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items Anti-Choking 590.009(E) E] 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 ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION TROWCHE.MICALS, ❑ 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 TIMEREMPERATURtCONTROLS.(PotentlaltyHazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling 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 HIGHLYSUS.CEP.TIBLE-POPULATtONS;Map) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2xs90.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3X590.004) ) cited in this report may result in suspension or revocation of 5. 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 (r-C-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: S 6-f4.doc I t Inspector's Signature: Print: PICS Signature: D .` Print: Page_102:i Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION Gross-rontaminabon FOOD PROTECTION MANAGEMENT 3-302.11(A)()) Raw Animal Foods Separated from 1 590.003(A) I Assignment of Res on,tt}litq* Cooked and RTE Poods* 590.003(B) Demonstration of Knowledge"- Y Contamination from Raw ingredients 2-103.11 Pei son in charge--duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.1.1(A) Food Protection* require reporting by food employees and 3-302-15 Washing Fruits and Vegetables a xlicmtts* 3-304.11. Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Comaminatlon from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(0) Reportin�Person in Charge* 3 590.003(D) Exchtsionsand Resnictions" FFoodstlonafAdulteratedorContaminated 590.003(F) Removal of Exclusions and Restrictions 3-701.1.1 Discarding or Reconditioning Unsafe. FOOD FROM APPROVED SOURCE Food" _ �'- L4 Food and Water From Regulated Sources 9 Food Contact Surfaces___ 590.004(A-B) Compliance with Food law'r 4-50t.I 11, Manmd Waiewashing-Hot Water 3-201.12 Food in.a Hermetically Sealed Container* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-13ot Water 3-202.13 Shell Eggs* ___ Sanitization Temperahtres* 3-202.14 E gs and Milk Pmducts.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 Drinkin Water* Utensils Clean* 4-602.1 t Cleaning Frequency of Equipment Fwd- 590-006(B) Water Meets Standards in 310 CMR 22.0"' Shellfish and Fish From an Approved Source Contact Surfaces and Utensils'" 4-70111 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Cant 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* 1p proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory AuthorH 2_30} 11 Clean Condition-Hands and Anes* 3-202.1.8 Sheilstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Attitnals* I] Good Hygienic Practices 5 Receiving/Condition 240411 Fatin ,Drinkin or Usin Tohacco* 3-202.11 PHFs Received at Properr Temperatures* 2401A2 Discharges From the Eyes,Nose and 3-202.15 Package lutegrit * Mouth* 3-101.11. Food Safe and Unadulterated * 3-301.12 Preventing Contamination When Tasdn * Tags/Records:Shelistock La_., Prevention of Contamination from Hands 3-202.18 Shelistock Identification * 590.004(F) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* - plo Lm ees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction*_ _ 4 Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11. Numbers and Capacities* 590.004(5) Labeling 61 IngredlemV 5-204.11 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance lHACCP Pians Supplied with Soap and Hand Drying 3-502.11. Specialized ProcessingMethods* Devices 3-502.12 Reduced ox ' en acka nn,criteria* fi-301.11. Handwashin Cleanser,Availability 8-10-1 12 Conformance with Approved Procedures* 6-30).12 Hand Drying Provision *Denotes critical hem in the federal 1990 Pant Code or 105 CM12 590.0001 CITY OF SALEM BOARD OF HEALTH Establishment Name: Ag Zr& Date: __ Page: of Rem Code C-Cdticel Item 'DESCRIPTION OF VIOLATION/PLAN OF CORRECTION No. Reference R-Red Item - Verified PLEASEPRINT CLEARLY (21 � L C70-0 - I O N $'�--Y-To(. w04 ru cl fit. ild- — �a �• — r 2 : Q c ^ I o Q1l �✓t c5 W l Sa le f CPA — Q6 1�3 � t �0_ C A —I n/ c zz ' Discussion With Person in Charge: Sha_l� �C.u'te_ � 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 spection 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. �`^ /y, ❑ Voluntary Disposal ❑ Other: 3-501.t4(C) PHFs Received at Temperatures Vdotadons Reinted to Foodborne i8ness,interventions and Risk According to law Cooled to Fi ctors(items 1-22) (Cant. 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Coolia Methods for PHFs 14 Food or Color Additives ig PHF Hot and Cold Holding 3-501.16(B) - Cold PHFs Maintained at or below 3,202.I2 Additives* 590.004(F) 41°/450 F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) ab 16(A) Hot PRFs Maintained a4 or ove 15 Poisonous or Toxic Substances 14U°F. * 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* Time as a Public Health Control 7-102.11. Common Name-Working Containers* 20 3-501.19 Time as s Public Health Control* -� AI Separation e* 7 _01 - 590.004(kI) Variance Requirement ' 7-202.11 .Restriction-PresenceandUse* 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.1' S Chemics.als Criteria i Chemists' * 21 3-801.11(A) Unpasteurized Pre-packaged luicee and 7-204.1_ Chenncals fw Washing Produce,Criteria Beverages with Warning Labels* 7-204.14 in encs.Criteria' 3-801.11(B Use of Pasteurized E -s* - 7-205.11 Incidental Food Conine Zxrbricants* 3-801,11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides;Criteria' Raw Seed Sprouts Not Served. * [L-.2t,212 Rodent Bait Stations* 3-801A I(C) Unopened Food Package Not Re-served. 7-206.13 Tacking Powders,Pest Control and Mom.tonng* CONSUMER ADVISORY . TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PRFs Not Otherwise Processed to Eliminate 3 401.ISA(i)(2) Eggs- I55`F 15 Sec. PathO ens.*FJkrono 1,"' 3-302.t3. Pasteurized Eggs Substitute for Raw Shell Eggs-Immediate Service 145'F15sec* 3-401.11(A)(2) -Comminuted Fish.Meats&GameAnimals-155°F 15 sec.* SPECIAL REQUIREMENTS 3401.11(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 sec.* 3-40LI UA)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3401-1.1(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F' 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited tinder#29- Microwave 165°F* Special Requirements. 3-40111(A)(1)(b) All Other PM-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403,11(A)&(D) "PHFs 165°F 15 sec. (Items 23-30) 3-003.11(0) Microwave-'165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time' foodborne illness inwtventions and risk factors listed above, can he 3-403A I(C) Commercially Processed RTE Food- found in the following sectionsofthe Food Code and 10.5 CMR 1400P 590.000. - 3-403.11(E) Remaining Unsliced Porticros of Beef tier i Good Retail Practices FC 590.0w Roasts* ( 23. 1 Management and Personnel I-FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25. -I{ Equipment and Utensils FC=4 .005 3-501.14(A) Cooling Cooked PRFs from 140'r to , Water,Plumbing and Waste I FC-5 .006 70012 Within 2 Hours and Front 70`F p7, Physical Facility :: FG 6 .007 to 41°17/45'F Wit thin 4 Hours. * 28. Poisonous or Toxic Materials ! FC-7 W3 3-501.14(B) Cooling PHFs Made From Ambient 29. S dial R uirements Temperature logrediena to 4PF/45'F 30' 1 Other .Within 4 Hours* *ihnotes critical item in the federal 1999 Fend Cade or 103 CMR 5901MHi. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"'Floor Division of Food and Drugs Salem 01970-3523 Tel. 1978 741-18 Fax (978) 745-0343 City/Town of . Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name Dater Type of Operations) Tye of Inspection W;L'a- ElFood Service JARoutine Address S zr V16k Retail ❑ Re-inspection Telephone Level residential Kitchen Previou_Vnspgction p 3 ❑ Mobile Date" Owner S HACCP YIN ❑ Temporary ❑ Pre- peratidn ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) TI El ElBed &Breakfast ❑General Complaint In:�! ❑ HACCP Inspector 0uC Q Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)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) ❑ pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ Violations marked may P q Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT - ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities 'EMPLOYEE HEALTH .PROTECTIONS{ROM'CHEMIOACS ❑ 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'FRod and ater SOURCE TIMEITEMPERATURE CONTROLS(PotentlaiiyHazardous F..00 i.1 ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition [:116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION - ❑19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20. Time as a Public Health Control 'W9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR.HIGHLY4USCEPTI6LE=POPULATtohs(HSB) ❑21. Food and Food Preparation for HSP [I 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMERADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22).- of -22);of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2)(990.003) 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 aright to a hearing. Your request must be in writing 8. Poisonous or Toxic Materials (Fc-7Hsso.00e) 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:' i Inspector's Signature: - Pri PICsSignature: Print: - Page�otPages _ w Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION $ Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 59(1.Op3(A) Aswg tment of Responstbilitq* Cooked and RTE Focxls* 590.003(B) Demanstrataon of Knowledge°` Contamination from Raw ingredients 2.103.11 Pcnon in eba[ga -dubes 3-302A l(A)(2) Raw Annital Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590M03(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require i sporting by food employees and 3-302.15 Washing Fruits and Ve Eetables applicants" 3-304.11. Food Contact with Equipment and 590.003(F) Responsibility Of AFood Employee Or An Utensils* Applicant To Report To The Person ht Contamination from the Consumer Chatty* 3-306.14(A)(B) Returned Food and Resetvice of Food* 590.003(G) Revortina by Person in Char e* 3 59,0.003(1) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(B) Removtd ol'Exclusionsand Restrictions 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 Scaled Container* Sanitization Tem ep ratures* 3-201.13 Fluid Milkand Milk.Products* 4-501.112 Mechanical Warewashing-H,ot Water 3-202.73 Shell Eggs* __ Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized" 4-501,11.4 Chemical Sanniration-temp.,pH, 3-202.16 lee Made From Potable Drinking Water* - concentration and hardness. * - 5-101.11 DrinkingWater from an A roved 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* 4-602.1 t Cleaning Frequency of Equipment Foud- Sheflfrsh and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of 5aniti72tion of Utensils and 3-201.14 Fish and Recicationally Cau dit Molluscan Food Contact Surfaces of Equipment*_ Shellfish* 4-7033.11 Methods of Sanitization-[lot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Aegutatory Authorit2-301.11. Clean Condition-Hands and Arms*y 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1.7 Game Animals* It Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PRFs 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 Tastin * Tags/Rectruft Shellstock 12 _ Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Ent In ees* 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* 590.0040) Labeling of Ingredients* 5-204.11 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaL6mt,criteria* 6-301.11. Handwashing Cleanser,Availability 5-103.12 Conformance with Approved Procedures* 6-301.12 Hatrd 1r 'n*Provision ''Denotes critical item in the federal 1991)Food Cods:or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: '3h 6-- Page:_ of Rem Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, No. Reference R-Red Item Verified PLEASE PRINT CLEARLY of -r�kVt(#eL 'j t Tb lf,15, _LJj ksor Ic Cu el c� g n1 'i gill — Q 14 hysao f 11^^ 1 C CY1. } C,-nM u A/ Discussion With Person in Charge: Corrective Action Required: ❑ No s I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion 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. ` Q (� CA �l ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PRFs Received at Temperatures Wolations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors Stems I-M (COW.) 41.°F/45°F Within 4 Hours.' PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PRFs Maintained at or below 3-202.12 Additives* 590.004(F) 41°/45°F* 3-302.14 Protection from unapproved Addidves* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 110,E 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Heid at or above 130°F. Containers* . 20 Time as a Public Health Control 7-102.11. Common Name-Working Con amers* * - 3-501.19 Time as a Public Health Contrat* 7-201.12 Separation-Stora 590.004(H) Variance 7-202.11 .Restriction-Presenceand Use* eR Requirement 7-202.12 Conditions of Ilse* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP) 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washin Produce,Criteria• 21 3-801.11(.4} Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels* 3 Et01.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Foal Contact Lubricants* 3-801.11tD) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Spixims Not Served 7-206.12 Rodent Bait Stations* 3-801.1)(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and . Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFS Not Otherwiseocesssed to Eliminate 3-401.11A(1)(2) Eggs- 1551 15 Sec. Path Em.-Imriiediate Service 145°F15sec" 3-302.1.3. Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec.* SPECIAL REQUIREMENTS 3.40LII(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) Rallies,Injected Meats-155°F 15 sec.* catering, mobile food,temporary and 3401A I(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 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under##29- Microwave 165°FSpecial Requirements. 3401;l l(A)(l)(b) All Other PHFs-145°F 15 sec._ 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403A 1(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) 3.403.1.1(B) Microwave 165°F 2 Minute Standing Critical,mid non-critical violations,which do not relate to the Time* foodborne illness inw.veniions and risk factors listed above, can be 3403A I(C) Commercially Processed RTE Food- found in the folloxing sectionsofthe Food Code w,d 105 CMR 140°gam 59(.000. 3-403.11(E) Remaining Unsliced Porticros of Beef >ient 1 Good Retalf Practices T,FC 590.000 Russia* 23. Mane ement and Personnel FG-2 .003 1g Proper Cooling of PRFs 24. Food and Food Protection FC-3 .004_ 3-501.14(A) CoolingCooked PHFs from 140°F to 25. ! WateEquipr,Plumbing and Utensils FC-4 006 28. I Water,Pldmbi and Waste � FC-5 � 008 1 70°F Within Hours and From 70°F 27. Physical Facility FG-6 ,007 to 410FAFF Within 4 Hours. * 2B. Poisonws or Toxic Materials '; FC_7 .008 3-501.14(B} Cooling MIR Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. ( Other _ .Within 4 Hours* F motes critical item in the federal 1999 Fuad Cale or 103 CAIR;90.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: 3a Page:_ Of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date' No. Reference R-Red Rem - Verlfled ' PLEASE PRINT CLEARLY `t t ( D _T� a V 2.Fc &V' I Y(- - rel � Gil Ol- IR f �J G�G ko. _ o m tr— Jr k,�p 74 /1� s 4 CA,A6 Discussion With Person in Charge: Corrective Action Required: ❑ No - Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to 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-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.t4(C) PHFs Received at Temperatures Violations Related to Foodborne Illness.tntementians and Risk According to law Cooled to Factors(Items 1-22) (Cont.) 41"F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 CoolingMethods for PHFs 14 - Food or Color Additives 19 PHF Not and Cold Holding 3-50L16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41°/45°F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. * 7-101.11 Identifying Information-Original 3-501.16(.4) Roasts Held at or above 13WR Containers* Time as a Public Health Control 7-102.11. Common Name-Working Containers* 21 * 3-501.19 Time as a Public Health Control* 7-201.11 Separation-Storage 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance R uiretnent 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS NSP 7-204.11 SanChemicalszers.Criteria i Chemicals, 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Preface,Criteria* Beverages with Wamin°Labels* 7-204.14 n Agents.Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Foal Contact,latbricants* 3-801.11(D) Raw or Partially Cooked Animal Food and - 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served t 7-206.12 Rode nBait Stations* 3-801.t I(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of TIMEITEMPERATURE C 16 Animal Foods That are Raw,Undercooked or Proper C ONTR Temperatures for PHFs - Not Otherwise Processed to Eliminate Pathogens. `"°""' '&w1 3-401.I1A(t)(2) Eggs- 155°F 15 Sec. -- . Eggs-Immediate Service 145°FISsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell E 3-401.11(0)(2) Comminuted Fish.Meats&fame ' .Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3.401.1 I(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 540 009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats- 1.55°F 15 catering,mobile food,temporary and sec.* 3-401.11(A)(3) Poultry,Wild Game,Stuffed PIFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 1.5 sec. " above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited trader#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403,11(A)&(D) 'PHFs 165°F 15 sec.* (Items 23-30) 3-403.1.1(B) Microwave 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Tithe* foodborne illness intervennow and risk factors listed above, can be 3-103A I(C) - Commercially Processed RTE Ford- found in the following sections of the Food Code acrd 105 CMR ' 140°F* - 590.000. 3403.11(E) Remaining Unsliced Porticos of Beef Ifem 1 Good Retail Practices LFC 590.� Roasts* 23, 1 Mane ernent and Personnel - I FC-2 I .003 I 1g Proper Cooling of PHFs 24. Food and Fwd Prosect on FC-3 .0__; �- Equipment and Utensils FC-4 .005 3-501.14(A) Cowling Cooked PHFs from 140°F to 26, Water,Plumbs and W aste FC-5 .006 70°F Within 2 Hours and Front 70°F 27. Physical Facility FC-6 .007 to 410F/45'F Within 4 Hours. * 28. Poisonous or Tabic Materials { FC-7 .008 j 3-501.14(B) Cooling PHFs Made From Ambient 29. special Requirements .009 Temperature Ingredients to 41°F/45°F 30' 1 Other -•------ .Within 4 Hours* *Denotes critical imui in the federal 1999 poral Code or 105 CMR 390.000. AC 1, ♦ r • • • • • • - • Item �_`� ■iii 1 i.` - « / �l 1 _/ 1!•. 0 �IN�IWO CIO � .•.l •G/• ��t�=/✓f ` ta� It ��s-- �T�� S ' 3-501,14(C) PHFs Received at Temperatures - Violations Related to Foodborne Illness Infement/ons and Risk According to La.w Cooled to Factors(lfertta 1-22) (Cant.) 417145'17 Within 4 Haus. r� ROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs P ` ]¢ Food or CHEMICALS Additives19 - PHF Hot and Cold Holding ' Co_ 3-501.16(B) Cold PIIFs Maintained at or below 3-202.12 Food r 590.00 3-302.14 Protection from Un 3-50d.16(roved Additives* 1PEFs Maintained of or above t5 Poisonous or Toxic Substances 6( 41Aj 'Hott F* PFI 140°F. 7-101.11 identifying Information=Original ;__501.ib130T) Roasts Held at or above l30 " Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-301.11 Separation-Storage* 3-501:19 Time as a Public$Iealth Control* 7-202.11 ;Restriction-Presence and Use° 590,004(H) Variance Regurtrement 7-202.12 Conditions of Usc* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE r 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP ` 7-204.11. Sanitizers.Criteria-Chemicals* t 21 3-801.11(A) Unpasteurized wit Pre-packaged els* and i 7-204.12 Chemicals for Washing Protons,Criteria* Severages with Warning Labels' 7-204.14 Drying Agents.Criteria* ", 801.11(6) Use of Pasteurized Eggs* _ 7-205.11 Incidental Food Contact,Lubricants* 3-801-I1(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 - C Monitorin * CONSUMER ADVISORY t TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of ]6 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs - Not Otherwise-Processed to Eliminate 340i.IIA(l)(2) Eggs- 155'F 15 Sec. Pathogens' Eggs-immediate Service 145'Fl5sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155'F 15 sec. * SPECIAL REQUIREMENTS 3401.11(6)(1)(2) Pak and Beef Roast-130'F 121 miu* 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in see * catering, mobile food,temporary and 3-401.1.1(A)(3) Poultry-,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3--101:.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other % 1450F v 590.009 violations relating to good retail 3 4Di.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for trot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403AI(A)&(D) PHFs 165'1715 sec.* (Items 23-30) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* - foodborne illness interventions and risk factors listed above, can be 3403.1l(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code mrd 105 CMR 1400F* 590.000. 34113-11(E) Remaining Unsliced Portions of Beef hent ! GoodRetall'Practices FC 590.1770 Roasts* M i Management and Personnel i FC-2 .0033 24.. Food and Food Protection f FC -3 .004 I ]g Proper Cooling of PHFs 1 25. Equipment and Utensils _ FG-4 .005 3-501.14(A) Coaling Cooked PHFs from 140`17 to f26, Water.Plumbing and Waste IFC-5 .006 7( F Within 2!lours and From 70*P ' 27. Physical Facility i FC-6 007 to 4I'F/45'F Within 4 Hours. 28- ' Poisonous or Toxic Materials FG-7 .008 3-501.14(.6) Cooling PHFs Made From Ambient 29. S cola!Requirements .009 1 Temperature Ingredients to 41'F/45°F F3-- I Other . Within 4 Hours* 'Mmtas critical iwin in the federal 1999 Food Cale or 105 C IR 590.000. f ( CIS OF SALEM, DEC 02 2014 MASSACHUSETTS � \V., Public Health BOARD orHEAt:rii 120 WASHINGTON S1REE"r,4TF1 F7.00li KIMBERLEY DRISCOLL Ti-u-(978)741-1800 FAx(978)745-0343 8( 1 I" LARRY R NIDIN,RS/RJAIS,CI 10,CP-FS MAYOR Iramdin@satem.com HiNAL I I A(;U NP Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: dI �►ess —xpfeS3 15 [01 2) Establishment Address: !k NOC'T' 1 SA 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: 7 gq-lq/ I Hess plaza/7 Flaherty 5) Applicant Name&Title: Woodbridge,NJ 07095 B) Applicant Address: JFLAH=62S3 EE) 7) Applicant A Telephone No: 24 Hour Emer ncy No: � Email: P 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address vA corporation An individual A partnership Other legal entity ^redrew E Bernstein, Asst Secretary 12 Person Directly Res onstble For Dail O erations Owner, Person in Charge,Supervisor,Manager,etc. Name&Title: Address: Telephone No: �- I g r t J Fax: Email: Emergency Telephone No: a-- 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: 1</ Check# --4 Dater Amount: l y Food Establishment Information U) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) Ct n 4 16) Days and Hours of Operation: 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( `g00 Sq. Ft) 13 Caterer Mermanent 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 (check one) RETAIL STORE RESTAURANT .......B.re.akfa.st-.E.stabi-I.s.hmen.t.s...................... Annual �Less than 1000sq.ft $70 ❑ Less than 25 seats $140 Seasonal/Dates: 1000-10,000sq.ft. $280/ 0 Residential Kitchens $140 O More than 10,000sq.ft. $420 0 25-99 seats $280 ❑More than 99 seats $420 Temporary/Dates/Time: - - - --WW " ---'--- -- ----- - ------------- ------------------------------------------------------------------------ ❑ Bed 8 BreaastlCdcare Services(Nursing Home $100 --------------------------------------.............................. ------------------ --------------------- --------- ADDITIONAL PERMITS MAKE ICE CREAM,YOGURTISOFT SERVE $25r 0 PASTURIZATION $25 ❑ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare&private club 23) Food Operations: Definitions: PHF—potentially hazardous food(time/tempersture controls required) Non-PHFs—non-potentially hazardous food(no time temperature controls required) (check all that apply): RTE—ready-to-eat foods(Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held V 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 comoleted by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: 305 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. /1 24) Signature of Applicant: I/ 7- 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: r Hess Retail Operations, LLC 1 i II ( III NOPOSTAGE 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 o 1 HESS PLAZA WOODBRIDGE NJ 07095-0961 i k i 2602450253 (800)926-7784 Hess Retail Operations LLC •?Atln:Accounts Payable Dept DATE: December 4,2014 One Hess Plaza CHECK NUMBER:0201656680 Woodbridge,NJ 07095 VENDOR NO:0000540402 00023 CKS 6A 14338 - 0201656680 NNNNNNNNNNNN 3365100006004 %660131 C CITY OF SALEM BOARD OF HEALTH 120 WASHINGTON ST., 4TH FLOOR SALEM MA 01970 Invoice Date Invoice Number Purchase Order Div l Loc Gross Amount Discount Net Amount 12/04/14 120214305 0590 $305.00 $0.00 $305.00 FOOD/FROZ 21519 TOTALS $305.00 $0.00 $305.00 PLEASE DETACH BEFORE DEPOSITING CHECK R195432 ? 2 , w DEC 02 .10A4- IV 4 CITY OF SALEM, "S( MiNSETTS BOARD OF I IEALT�^��-�, j) ,UI 120 WASHINGTON STREET,4`'FLoOR`v Prrvanl,hamme.rraietl. .,, TEL.(978)741 1800 FAx(978) 745-0343 jQ� KIMBERLEY DRISCOLL katndul `salem.com 0 MAYOR H1r.,xvri I AGF?NT 201 APPLICATION FOR PERMIT FOR SALES OF TOBACCO & NICOTINE DELIVERY PRODUCT PERMIT FEE $135 NAME OF ESTABLISHMENT 6 �5 n ` x�f'S S OS 4S I "1 TEL# -1t-{'t`L9 j q iV ADDRESS OF ESTABLISHMENT &P Or-W1 S,+ FAX# DEPARTMENT OF REVENUE APPLICATION NUMBER: MAILING ADDRESS(if different) I IC EMAIL-Business': Websit i Hess Plaza/J Flaherty Woodb edge 111) 732-750.6350 OWNER'S NAME T'JFLA 2-662!S49 JPLAHERTY@�=4- ADDRESS STREET f CITY STATE ZIP EMERGENCY RESPONSE PERSON r Q40,0 ' HOME TEL# /6I�✓S 17I55 Type of Products Sold: Cigarettes Cigars Chewing Tobacco `� Pipe/Cigarette Tobacco T Nicotine Deli Devices Other Tobacco Product(list on additional Sheet) DAYS OF OPERATION Mondayi Tuesday Wednesday - Thursday Friday I Saturday Sunday HOURS OF OPERATION Please write in time"a, E (For example 1lam-llpm) 1711 "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. '�- tia la } 22-2462225 Signature z Date Social Security or Federal Identification Number Updated 723/12 706ACCp.doc Checkli&Date �'"1.�„' $ aZlu�� II ( ( II NOPOSTAG NEECEESSARYE 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 o 1 HESS PLAZA WOODBRIDGE NJ 07095-0961 2602450252 (800)$26-7754 Hess Retail Operations LLC DATE: December 4,2014 -/Attn:Accounts Payable Dept ' One Hess Plaza CHECK NUMBER:0201656679 Woodbridge,NJ 07095 VENDOR NO:0000540402 00022 CKS 6A 14338 - 0201656679 NNNNNNNNNNNN 3365100006004 %86001 C �o CITY OF SALEM R19543271 t City of Salem, Massachusetts � X-A) W Board of Health q 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PabliCHealth PrE Iramdin@salem.com Prevent. Promote. Protect. Kimberley Driscoll Larry Ramdin RSIREHS, CHO, CP-FS Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM-15-145 Permit Type: Retail Food 1000-10000 sqft Goods&Services: Retail Food: 1,000- 10,000 sq ft Name of License Holder: Hess Corp. Name of Food Establishment Hess Express 21519 Address of Food Establishment 86 North 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 ® t. r Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 PPrevent..P[omo,e.ubPI—t-alth P[ l[[,. Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin RS/REHS, CHO, CP-FS Mayor Iramdin@salem.com Health Agent TOBACCO SALES PERMIT Permit# TO-15-12 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: 86 NORTH STREET Permit Fee $135.00 Restrictions: Late Fee $0.00 Notes: 1 Hess Plaza/ J. Flaherty This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 1213112015 , unless sooner revoked or suspended. 442�,Health Agent SUITE 2700 RC GRAYR O B I N S 0 N 401 E.JACKSON STREET(33602) Red RATON P.O.BOX 3324 FORT LAUDERDALE ATTORNEYS AT LAW TAMPA, FLORIDA 33601-3324 JACKSONr1LLE TEL 813-273-5000 KEY WEST FAx 813-273-5145 / LAKELAND 7 � MELBOURNE I 40141q �® MIAMI 813-273.5161 SOA,D pFSAC M NAPLES ANGELA.ROTELLA-GARZONRGRAY-ROBINSON.COM NFACTy ORLANDO TALLAHASSEE July 14, 2014 TAMPA Health Department City of Salem Attn: David Greenbaum 120 Washington Street 4`I' Floor Salem, MA 01970 Re: Hess 21519—Located at 390 North Street, Salem, MA License 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 21519, will be changing to a new entity, Hess Retail Operation,s,,LLC ("HRO") d/b/a Hess 21519, 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 GRAYROBINSON PROFESSIONAL ASSOCIATION July 14, 2014 Page 2 If you have any additional questions, please do not hesitate to contact our office. Thank you. ry tr urs, Angela a- arzon, FRP Licensing Specialist ARG/pmb V10A2192-k 5210739 v I 3 Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,0 Floor 9 Salem, MA 01970-3523 Tel. (978)741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTABLISHMEW INSPECTION REPORT Tel. Name Type of Operation(s) Type oUaspectfon ❑ Fo Service ine Address Le etall Re-inspection Level Residential Kitchen Previous Inspection Telephone -1 'J ❑ Mobile Date: Owner 1 I HACCP YIN ❑ Temporary ElPre-operation ❑ Caterer ❑Suspect Illness Person-in harge(PIC), Timp ❑ Bed&B akf t ❑ General Complaint Inc 1 ° [1HACCP Inspector - Out- , Permit No. 15b, ❑.Other Each viola£ checked requires an exp anation on the narrative age(s)and a citation of specific provisions)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors-(Red Items) Tob Anti-Choking 590.009(E) ❑ pose an imminent health hazard and require immediate Abxco 590.009(F) Violations marked may ❑ Y PAllergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. 0000 PROTECTION MANAGEMENT _ _ _ . . ..� : ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties Ld'f3. Handwash Facilities i EMPLOYEE HEALTH ,PROTECTIONFROM'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:FROMAPPROVED SOURCE-_-- ._ .e - - .....�- - ----- -- ,-. . TIMEREMPERATURE.CONTROLS(PotentlaltyMaaardous Foods);-_3 ❑ 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 CONTAMINATION ,_,i E] 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control _ �- , ,.w L.. .� _ � , F-19. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FORHIGHLYSUSCEPTiBLE=POPULATIONS' El 21.Food and Food Preparation for HSP ii P):, ❑10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY�Y ❑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 detennined 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-3X590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (Fcs)(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-7X590.0(,6) and submitted to the Board of Health at the above address 29. Special Req ' am is (590.009) within 10 days of receipt of this order.) liq 30. Other DATE OF RE-INSPECT I 3`// Inspector's Signa " Print: PICS Signature: Ad Print: Y1 I,� A Pagelofages .�.-.--.-r.-..^.rte. w-��... . ,.,-.-.-.�.. ,..-�._-..,,-.. . . �- --^�...' ..-- • •w `-..w .. .. ' � _ . •f Violations Related to Foodbome Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION S Cross-contamination FOOD PROTECTION MANAGEMENT - 3-302.1.1(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* I Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* - Contamination from Raw Ingredients 2-1.03.11. Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.t 1(A) Food Protection* require reporting by food employees and 3-302.t5 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from sm Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting b Person in Charge* 3 590.003(D) Ezclusiowsand Restrictions* DisposdionofAdutteratedorCanlaminated Food 990.003(E) Removal of Exclusions and Restrictions 3-701,11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ Food* 4 Food and Water From Regulated Sources F9 Food Contact Surfaces - 590.0041A-B) Compliance with Food Law* 4-501.1_!I Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled 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* 3-202.1.4 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* 4-001.11(A) Equipment Food Contact Surfaces and 590.006(.4) Bottled Drinkin 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* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and RecreaGionaOy Caught Moliuscut Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-'Hot Water and 3-201.15 Molluscan Shellfish from NSSP lasted Chemical* Sources* Wild Proper,Adequate Handwashing Game and Wild Mushrooms.4pproved by Regulatory Authority 2-301.11 Clean Clean Condition-Hands and As* 3-202.13 Shellstock Identification Present* 2-301..12 Cleaning.Procedure* 590.004(0 Wild Mushrooms* 2-301.14 When to Wash* 3-201.11 Game Animals* 11 Good Hygienic Practices S Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper TernEerantres* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package line-rity* Mouth* 3-101.11 _ Food Safe and Unadulterated* 3-301.12 Preventin Contaz1 oration When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 -Shellstock Identification* 590.004(E) Preventing Contamination.from 3-203.1.2 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention"` - 5-203.1 I . Numbers and Capacities* 590.004(:) Labeling of Ingredients' S-204.11 Location and Placement* 9 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* - 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures* 6-30t.t2 Hand Plying Provision Denotes critical item in the f.,denil 1999 fool Code or 105 CMR 590.000. CITY OF SALEM OARD OF HEALTH 01Z Establishment Name: r—nS Date: �� C/� Pager of-� Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTIONonto No. Reference R—Red Item - verified PLEASE PRICLEARLY I i Discussion With Person in Charge: Corrective Action Required: ❑ No �ilrek have read this report, have had the opportunity to ask questions and agree to correct all oluntary 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. 1. �2� 2 f 2 c, J ) L f I ❑ Voluntary Disposal ❑ Other: c 3-501,14(C) PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to - Factors(0ems 1-22) (Cant.) 41°Ft45°F Within 4 Homs. 1 S PROTECTION FROM CHEMICALS 3-501.I5 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Not and Cold Herding 3-202.12 Additives* 3-501.16(B) Cold PI3Fs Maintamed at or below 590.004(F) 410145'F* 3-302.14 Protection from Una roved.4dditives'e Ig Poisonous or Toxic Substances 3-501.16(A)- Hot PHFs Maintained of or above 140'F. 7-101,11 Identifying Information-Original 3.501.16(A) Roasts Held at or above 130'F. * Containers 7-102.11. Common Name-WorkingContainers* 20 Time as a Public Health Control 7-201.11 Se anon-Stn * 3-SOP:19 Tirtte 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 j 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitize",Criteria-Chemicals* i 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-gOl.1l(A) Unpasteurized Warning Lare-packaged Juices and f Beverages;with Warning Labels* 7-204.14 Drying Agents.Criteria* 3-801.1l(B) Use of Pasteuriaect E s 7-205.11 Incidental Food Contact,Lubricants* 3-$01.11(0) 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 3-801.11(C) Unopened Food Package Not Re-ser ed. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 7IMEfi EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures far Animal Foods That are Raw,Undercooked or F6 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.IIA(1)(2) Eggns. Eggs- 155"F 15 Sec. Patho tee *ehcax a ^Mn Eggs-immediate Service 145°F 15sec* 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(8)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS' 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.004(A)-(D) Violations of Section 590,009(A)-(D)in sec,* catering, mobile focal,temporary and 3401.1I(A)(3) Poultry,WHd 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((2){3} Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165 F* Special Requirements. 3-401A I(A)(1)(b) All Other PHFs- 145-F 15 sec. I 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-003.11(A)&(D) j PHFs 165-F 15 sec. * (Itentss 23-30) 3403.11(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 3403.t 1(C) Commercially Processed RTE Food- found in she following sections-qf the Food Code and 705 CMR r 140°F* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef item 1 Good Retail Practices , .FC 590.000 r Roasts* 23_ i Man@2ment and Personnel FC-2 M Ig Proper Cooling of PHFs 24. i Food and Food Protection FC-3 004 i 25. Equipment and Utensils I FC-4 .005 I 3-501.14(A) Cooling Cooked PHFs from 140°F to i 26. Water.Plumbinq and Waste i FC-5 .0 70'F Within 2 Hours and From 70'F 27. i Physical Facie FC-& .007 to 41`F/45°F Within 4 Hours.* i 2_8. 1 Poisonous or Toxic Materials ' FC=7 .008 3-501.14(B) Cooling PHFs Made From Ambient X29. -Special Requirements .009 Temperature Ingredients to 41 017/45°F 30 I Other Within 4 Hour's* s7�obma�.c[a.m, *Denotes rA icat ism in the tederai 1!)99 Foci Cale a'105 CMR 590.0(10. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, No. Reference R—Red hem - PLEASE PRINT INT CLEARLY verified 51i 1 PIJA I Discussion With Person in Charge: Corrective Action Required: No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all voluntary Compliance a Employee Restriction 1 violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that ° Re-inspection scheduled o Emergency suspension noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of o Embargo o Emergency Closure your food permit. t 13 Voluntary Disposal U Other: r- "j 3-301.14(C) PHFs Reocived at Temperatures I Violations Related to Food borne illness Interventions and Risk According to Law Cooled to Factors(Hems 1.22) (Cont.) 41°F145°F Within 4 Ream PROTECTION FROM CHEMICALS 3-501..15 Coolia Methods for PHFs 1 19 PHF Hot and Cold Wiling 14 Food or Color Additives 3 501,16(B) Cold P13Ps Maintained at or below 3-202.12 Additives*' 590.004(F) 410/450 F* 3-302.14 Protection.from Una roved.Additives' 15 Poisonous or Toxic Substances 3-50 1.16{A} Hot PHFs Maintained otos above � 140`2. 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'2. Containers" . 7-102.11. Common Name-WorkingContainers* 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 4 7-202.12 Conditions of Use* REQUIREMENTSFOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) HSP 4 7-204.11 Sanirizers.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged 3uiees and 7-204.12 Chemicals Rw Washing Produce,Criteria* 7-204.14 Drying Agents.Criteria° Bevera es with Warning Labels* 3-801.1 I(B) Use of Pasteurized E&2* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.71 -Restricted Use Pesticides,'Criteria* Raw Seed Sinners Not Served. * 7-206.I2 Rodent Bait Stations* 3-801.11(C) Unopened Food Parka Not Re-served. 7-206.73 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY - CONTROLS 22 3-603.11 Consumer Advisory Posted far Consumption of T1MEIfEMPERATURE C_ Proper Cooking ONTR Temperatures far Animal Foods That are Raw.Undercooked or I6 PropHFs Not Otherwise Processed to Eliminate Pathogens.I '6 9n' 1 3-401.11A(1)(2) Eggs- 155`F 15 Sec. Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteuri�d Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Came E Animals-155°F 15 sec. " t 3 401.11(B)(1)(2) Port and Beef Roast- 130°F t21 nun* SPECIAL REQUIREMENTS t 3-401.11(11)(2) Ratite injected Meats-155`2 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in * catering,mobile food,temporary and sec. 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections F, Poultry or Ratites-165°F 1.5 sec. * above if related to foodborne illness 3-401.11(0)0) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F r 590.009 violations relating to good retail 3401.12 Raw Animal Foals Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. ! 31401:1 I(A)(1)(b) All Other PHFs-- 145°F 15 see. 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES t 3403AI(A)&(D) PHFs I6S'F 15 sec. (Items 23-30) i 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 3-403.11(C) Commercialiy Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 140°F* 590.000. 1 3403.11(E) Remaining Unsliced Portions of Beef I Item I Good Retail Practices QFC 590.000 r Roasts* 1 23. 1 Management and Personnel :, FG-2 .003 .I IS - Proper Cooling of PRFs 124. 1 Food and Foots Protection FC-3 .004_ 1 25, 1 Equipment and Utensils _i FC-4 .005 I 3-501.14(A) Cooling Cooked PRFs from 140`F to em, I Water,Plumbing and Waste FC-5 .006 70`F Within 2 Hours and From 70°F 27. j Physical Facility Fr--6 007 " I to 41°F/450F Within 4 Hours. * i 28. ' Poisonous w Toxic Materials ! FC-7 .008 ` 3-501.14(,6) Cooling PHFs Made From Ambient 29. S mind R uirerneMs .009 ?� Temperature Ingredients to 41'17/45°F 30Other _i Within 4 Hours* t 'Demw critical hcm in the federal 1999 Fcvci Cade or 105 QvIR 590.000, r ' } Mr P �*uWW',4. W� y 01 bal d' , s r$�Cigty�-.OStfr Salem },� =.%X'r»." !W' �� n-20 rd of Health �� as m vz e n �r '� '� 1 130 Wsshmgto3n Street;4th Floor.rt x 5z Mayor , i -M a FIT �� - g Foocl/Retalt Estabhstiment Permit a� � F 3 DATE PRINTED ` 12/I8/2013 WC ' or � M'"#s ¢ ....eta. x:7us ,&ro n 'r ` .y„"' P •g . � ti r X n ,� �.;ys � W� "q� �d- gs'�- 48 ", a- `vs•' ? t , % 08 t-=r � z� �' " wa ESTABLISHMENT NAME' aHess Express 21519 � � ,3 IA 4 fir&may F`gv bndg`s .`^t Woode s � ,,�• x3 . ``3 '� 'i me` ' *_a § T'` f ,1., �#`.5- - i a ,gyp " LOCATED AT 0086 NORTH STREET z , 3- y -� -$'w5 y cs rA + &sYv�n.a 55: es xr %'�. ssv-'�. V ,T^- a > m SALEM, MA 01970 , x '41" d , N7, i e Pernut Type Pernut lqo rt$ Permit Issued�Permit Expirest +b Fee Restrictions/Notes RETAIL FOODS BHp2014 0150 h Jan 1,2014{ Dec 31;2014 $280 00 ; �.M _- yx 4; Total Fees ;y 280M �* s a�y. `»^g4& 6. e,�r#.-. tt eWr:. rx �' r� t v .2ft F b +. s Y t: �"p d �.-' v,Y ,yam a ,;'. r �x s s'f`' % "5� # ;AV ,., f kM tx 4 M'", ,.. Y i 4 5 ^'•" d s a rw s# " u `s 3 "" z$„ .,x roi M ^y�TVSez,. z a� ` h g 1". �. d ✓ a �s�b.»�� y ✓� H w 7' V ., ad$>y .- ', �`�' v �— ,33. `y ,. x s s rte r'R ' 3c+ F t a r.., > Fwi, k A x� ,a z. x Y,,T es' '�'� � Q4`'..,�a . �M -z, , , m a ,� + hi ter'-';n- -, s .h r d -- 2' . PERMIT EXPIRES' eceinber 312014 x f g l . � Zm x gr, jR gi- g, � .,., + � �.9A.. `'aSw 3" 1y- i y .� s A q Y :This Permit is not transferable and must be re�ssaed upon change ofownersWp�or locahonThpernut must be:posted `'"`3 ". � p in a prominent location in the Estebhshmen g in,a eordanei with the State Sanitary Code;beofre any revonations,improvements,or-quipment cfianges are made, � �� f ;i a plans for such must be submitted to aad approved by the Salem Board of Heaulth p^ � � r .r..y a � «.x`.�. � ,. b, �, ..^§ tr � e a_`sdE 2 ,{ � �� •� _ e'' r i.`-'fir�" ps �. a` CITY OF SALEM, �� J 09 i �°�' MASSACHUSETTS Ip�n O"J BOARD OI'++HHAun-I Y ECEIV Y 120 WASKINGTON SITZ 1? T,411,FLOOR •, KIMBERLEY DRISCOU 'D:t,.(978)741-1800 FAx(978)745-0343 [)M MAYOR Lamjdjg@salem.co O`Gj R I�1N,RS jRHt,,,NI IS,C}[O,CP-1 S C}TY OF E ALc7vS�113 AGt N'1 BOARD OF HEALTH Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) uJ 1) Establishment Name: SS 1,E?CP�('es-s a0'101 2) Establishment Address: S$(Q 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: 1 Ness Plaza/J. Flaherty WOUft-ritige. NJ 07095 5) Applicant Name&Title: 7Sa780a1t35a7 6) Applicant Address: 7) Applicant Telephone No: Hour Emergency No: Email: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. !fin association Name Title Home Address A corporation An individual A partnership Other legal entity R.1. Lawlor VP 1637Thistiewood Dr Washington Crossing, PA 18977 12 Person Directly Res onslble For Daily Operations Owner, Person in Charge, Supervisor,Manacier,etc. Name&Title: iris Old Address: Telephone No: `J x155 Fax: Email: Emergency Telephone No: - - 13) District or Regional Supervisor(if applicable) Name&Title: Address: - + Telephone No: Fax: Email: Check M-14 y-xv j Date: Joh-' Amount: dC�TJ Food Establishment Information 14) Water Source: 15) Sewage Disposal: +� DEP Public Water Supply No: ( if applicable) CA J C.t 411 16) Days and Hours of Operation: -M 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) WRetail( 1900 Sq. Ft) ❑ Caterer y ermanent 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 Esta_b_lishments (check one) RETAIL STORE RESTAURANT ✓Annual ❑Less than 1000sq.ft. $7013 Less than 25 seats $140 Seasonal/Dates: 1000-10,OOOsq.ft. - $280% - ❑ Residential.Kitchens -$140 _. - ❑ 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 - - - ------------------------------------------------------------------------------- ----- - WTWAD ITIONAL PERMITS RAL ICE CREAM, YOGURT/SOFT SERVE $25✓ ❑�A STURIZATION $25 TOBACCO VENDOR $135✓ ❑ALL NON-PROFIT $25 Including, church kitchens, state funded childcare&private clubs 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs-non-potentially hazardous food(no timr✓temperature controls required) check all that apply): RTE-ready-to-eat foods(Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service ✓ 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 ,iCustomer 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 Date or Reconditioned Food Total Permit Fee: 7 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 howto 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 K,to my best knowledge and belief, • Have filed all state tax returns and paid state taxes required under law. 25) rnr� 25) Social Security Number or Federal ID: 13-7, d/00, /� 26) Signature of Individual or Corporate Name: /'Mess Cor/ w a ^wrw•ww--...+ _T -.n,-..=a��e,e,,.�rx:w�w .wn.�w,uwymw� . �rw.,. 3.�w° iaw,.�,wxn.as 'sw:+r v ,.�es�trv..rve.+ •-. -w`rxw,n+w'+ae.m.,ev'+vm.ruyr+w.r " S ,T Ir 4 # "lot, y i'. r v U !q !> x a@ 11. l x yY f s > H.., d f, - § :, d r 2 rPtI 4 ✓ r lr N.: r,t'ufi ry ^r v r� C/l S1 r F§x 3 >S 75 ° k•" ,+ xn 'eb'" tom! r .4 s 'R n'vy.R "S er r }Y ..�,i} -),q SvR � � A �� " .�$ � � zt.' .! `ff '^ )1 ➢`.5 s> +it' Y H( �' r�A,A } ✓b' C. ] w ✓,> Itr 'rr'r' Y� C.: In } ,,., it $vta 1'J t 'h"drr> 5,k +b z r,r; i, s,R�,S` , ¢ ar-. q' mx<'S +-� $A > i•. r St. pw'`xe•rd + Pt �,. : 5 n; KI R :.. re, „$ r g ^, +S'r ` 4 x r «.c t: .. rXt �' ' *.. 1 a r ri k*1 0� 7 t ,y y rl r ti 2. 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'..q-,.�, :p �.rir's' x � 4}I > ', '¢: a '#mv ,.i+ `aA tt'r« P' a• aik 1x'ap Yq� ' "h {4. a t`g"L£",`}r.a '£N"S*i ex a aq m¢- , �" ,1y' f'}.•,* r X.c{,� s4 t'a' e, a x } ,, r n,), *m= '>x ^ } e .�,�"�rn w'Jr� ry � tiv, ,,�'• �' r,: r • t", .,Aew " " r rt ..i'a x-,tw '} •a� rs"�"z ,`k�,� x .:..'b +� �y Y' J„n ,� ,y ,7:,:. �y.. § e^"w' .�.�.+�' h �,;: a 's��r�',4�..s' -`.• 4 ;:a ,q `r N .,;,xy'n,. .F.''i TA e�?'."t,y It rot.,.f. f f t`'j;'; ` +niul.; �,i;•, '$ , .v.'sq` l4.A'Fv 2pt s + . 1 +., J ,r i+k."• F' 4 F 3SC.t.A 1 ,;","�, k___ � .c_-._Ss_ •' _,_.:.,. e� r.,_ .�. ..>�..''tS°.vr-s,-::. �.. w,�tas'tu...? #_ai...�Jf,.af «.� ,_.�. ,-x+ �" '*s_'^_a. .},Ws_Y4-«'}a:.f .a , ser'a._.''=..� i... .b.,.,5e%f_a:.�;.a..° r CITY OF SALEM, MAssAcxUsrn's BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR 1 CH, th TEL, (978)741-1800 FAx(978)745-0343 KIMBERLEY DRISCOLL Iramdin@satem.com LiULRY Rt\Iv1DIDi,R;i f RFiiTS,C'Hf),(:T-F;i MAYOR I-II.AL:t-f AGENT 201_APPLICATION FOR PERMIT FOR SALES OF TOBACCO & NICOTINE DELIVERY PRODUCT �j PERMIT FEE $135 NAME OF ESTABLISHMENT y`-)IeSS &XP l)e.S$ ab I q TEL# y.q q-Iqu{j ADDRESS OF ESTABLISHMENT go Nor*-' e FAX# DEPARTMENT OF REVENUE APPLICATION NUMBER: � 1 MAILING ADDRESS(if different) EMAIL- Business': HeSS Corporattdn ebsite: OWNER'S NAME Woodbridge, NJ 07095 TEL# ADDRESS 732-7906350 STREET ifl `_ CITY STATE ZIP EMERGENCY RESPONSE PERSON _rbr'4rr'rl Ny -M� HOME TEL# —I�S —105-dl55 Type of Products Sold: Cigarettes Cigars Chewing Tobacco Pipe/Cigarette Tobacco Nicotine Delivery Devices✓ Other Tobacco Product(list on additional Sheet) DAYS OF OPERATION °:Monday Juesday Wednesday, Thursday, Fnday' 'i SatuNay Sunday HOURS OF OPERATION I� Please write in time of da j - 1 (F or example Ilam-71pm) 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 statetaxesrequired under the law. JAMIE FLAHERTY Signature Date Social Security or Federal Identification Number -------------'-'----------------------'----- ------------------------`-- --------- ------------ - - - ------------ -- ------------------ ----------'--- Updated 7/23/12 r��--/W 3112TOBACCO.doc Cheek#&Date _V -ff 4�1*1� $4�_r r Form CT-3T 01129 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 tines. Sales to persons under 18 years of age are prohibited by law. Application Number: 53928 License Number Date of Issue: Federal Identification or Social Security Number: 134-92-1002 01129 09/13/2012 Melling address for license: Retail sale location(if different than mailing address) HESS CORP HESS 21519 1 HESS PLAZA J FLAHERTY 90 NORTH 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. t'�4 .r vry irwrowvewgw+• Commonwealth of Massachusetts S City of Salem " ` Y Board of Health `= Kimberley DnS6011 120 Washington Street,4th Floor Mayor SALEM,MA- 01970 Food/RetaitEstablishmentPermit . DATE PRINTED: 12/05/2012' ESTABLISHMENT NAME: Hess Express 21519 ;�41 Pile Number:BHF-2004-000059 I-Hess Plaza/J. Flaherty - "N 5 p' Woodbridge' NJ 07095 4 LOCATED AT: ' 0086 NORTH-STREET, - t SALEM,MA 01970- Permit 1970 -Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions'/Notes-' RETAIL FOOD BHP 2013-0069 Jan 1,2013 Dec 31,2013- $280.00 TOBACCO VENDOR BHP-2013-0074 Jan 1,2013 Dec 31,'2013 `$135.00. s Total Fees: $415.00 a �. r , e x fi 4 PERMIT EXPIRES jDeeernber 31, 2013 Board of Health g This Permit is not transferable and must be reissued upon change of ownership or.location.The permit must be posted in a prominent location in the Establishment In accordance with the State Sanitary Code,beofre any revonations,improvements,or,equipment change!,are made, - all plans for such must be submitted to and approved by the Salem Board of Health. page 1 " `+ 'z CITY OF SALEM -, r • n , f`' MASSACHUSETTS R� rvu>uxecn BonRlxa HeAI;rll 00 WASHING ION 911tUT,41"FLOOR. KIIIBERLEY DRISCOLl Te:i..(978)741-1800 FAX(978)745-0343 LARRY R )IN,RS/RC I IS,C1 10,CP-FS DEC 0 3 20' MI Iramdin@salem.com MAYOR .i.. IIN.;\1;I'I I AC LN'I' -- - CITY`OF SAL i:i t BOARD OF-HEALTH Food Establishment Permit Application (Application must be submitted at least 30-days-before the planned opening date) 1) Establishment Name: 4ess E?< fes$ 2) Establishment Address: Su No 'c" 3) Establishment Mailing Address(if different): ,1 ION 4) Establishment Telephone No: y-)q 1 Hess Plaza_IJ. Flahert n ge. J 01095 5) Applicant Name&Title: Y32�76p�95Q 6) Applicant Address: 7) Applicant Telephone No: Hour Emergency No: Email: 8) Owner Name&Title(if different from applicant): -- 9) Owner Address(if different from"applicant): f 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. �n association Name Title Home Address ✓A corporation An individual A partnership Other legal entity R.J. Lawlor VP 1637`Thistlewood Dr Washington Crossing, PA 18977 12 Person Directly Res onsible For Daily Operations(Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: C Qd Address: rt Telephone No: -��AIrJ-� Fax: Email: Emergency Telephone No: - 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: �'�� Date: #-/c /d`— Amount: Food Establishment Information 14) Water Source: 15) Sewage Disposal: CIA, 1 DEP Public Water Supply No: ( if applicable) l I C t 4LI 16) Days and Hours of Operation: - 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) JEstablishment Type(check all that apply) � (check one) WRetail( IBM Sq. Ft) 11 Caterer 1/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 Estab_lishments_ ____________________ ------------------------------------------------------------------------------------------------ (check one) RETAIL STORE RESTAURANT 01(nnual ❑ Less than 1000sq.ft. $7013 Less than 25 seats $140 Seasonal/Dates: 2'1'000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑ More than I0,000sq.ft. $420 ❑25-99 seats $280 ❑ More than 99 seats $420 Temporary/DateslTime: ..... .--------`------------------------------------------ - -- ❑ Bed&Breakfast/Childcare Services/Nursing Home $100 -------------I——-- -- ---------------------- -------------------------- ------------------------ -- - RAL PERMITS KE ICE CREAM, YOGURT/SOFT SERVE $25✓ ❑ �STURIZATION I�(TOBACCO VENDOR $135✓ ❑ALL;NON-PROFIT $25 (Including, church kitchens, state funded childcare&private clubs) 23) Food Operations: - Definitions: PHF-potentially hazardous food(tim0emperature controls required) Z Non-PHFs—non-potentially hazardous food(no time/temperature controls required) check all that apply): . RTE—ready-to-eat foods(Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service ✓ 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 iCustomer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hourst contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: AlIko 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: 1J-T/2/210vl a /� 26) Signature of Individual or Corporate Name: /Y�S CU' r/ i Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,0 Floor Salem, MA 01970-3523 Tel. (978)741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT IN PECTION REPORT Tel, Name Da Type of Operations) Type of Inspection Address ❑ F Service ®. Wrinne Ri etail ❑Re inspection Telephone Level ❑ Residential Kitchen Previous inspection ❑ Mobile Date: Owner HACCP 71N ❑ Temporary ❑Pre-operation ❑ Caterer ❑Suspect Illness Person4n-Charge{PIC} r ❑ Bed&Breakfa t ❑General Complaint inspector In: Permit No. P ❑HACCP O t ❑Other Each violation the a squires aK dxplafilitton on the narrative a e(s)and a citati specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors(Red Items) - Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) p Allergen Awareness 590.009(0) ❑ corrective action as determined by the Board of Health. . FOOD PROTEC71ON MANAGEMENTL_ _ _ _ ,-] ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/knowiedgeable/Duties ❑ 13. Handwash Facilities ,EMPtAYEEHEALTH tPROTEC ION F(t0WCHEM(CALS„ El2. Reporting of Diseases by Food Employee and PIC ^ , _ ' ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded . - - _ O. "Fft _ _ __ ___� ❑ 15.Toxic Chemicals FOOD FROM.APPROVED SOURCE _ ❑ 4. Food and Water from Approved Source STIMEftFJJIPERA11tRE.CONTROLS;(Potentially-Hawrdous_F_ooda)" ❑ S. Receiving/Condition 16, Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved ProcedurestHACCP 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 SanitizingREQUIREMENTS FOR HtGHLYS.USCEPTBt E POPULATjgNS(NSP) [110. Praper Adequate Handwashing El21. Food and Food Preparation for NSP ❑ 11.Good Hygienic Practices CONSUMER ADVISORY w. [I22. 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 {may, the items checked indicate violations of 105 CMR of Health.. 590.000/federal Food Code.This report,when signed below 23. Management and Personnel (Fc-2x5go.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (Fc-3x590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC•4x590.o05) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 25.Wates;Plumbing and Waste {FC-5x59o.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6x590.007) have aright 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 Req ,r n (590.009) within 10 days of receipt of this rder. 30. Other �(1}r(//,y11` {i .t{/1� � ��j , DATE�/ OF RE-i PECT N: /tf(J Inspector's Signature: V Print: f , PICsSigmture: �, �, Prink Ya i a Page�of�Pages Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g TCross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) i Raw Animal Foods Separated from 1 590.003(A) Assig ment of Responsibility* Cooked and RTE Foods* 590 003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103 11 Person in charge duties 3-302.1,1(A)(2) Raw Animal Fee&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 a licants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Foal Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Chat *. 3-306.14(A)(,B) Returned Food and Reservice of Food* 590.003 G Reporting by Person in Charge* Disposition of Adulterated or Contaminated 31 590.003(D) Exclusions and Restrictions* Food 590,003(E} Removal of Exctusians and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Foal* FOOD FROM APPROVED SOURCE 4 Food and Water From Regulated Sources t 9 Food Contact Surfaces 590.004(A-B) Com liance with Food Law* 4-501.1.11 Manual Warewashing-Hot Water T 3-201.12 Frnxl in a Hermetically Scaled Container* Sanitization Teicratures* 3-201.13 Fluid Milk and Milk Pr(xiucts* 4-501.112 Mechanical Warewashing-Hot Water Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-to pH, _=s 3-202.14 E mtd mM Products.Pasteurized* concentration and hardness* 3-2^2.16 lee Made From Potable Drinkin Water* 4-601,11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Ap2roved System* - Utensils Clean* 590,006(A) Bottled Drinking Watl 4-602.11 Cleaning Frequency of Equipment Food 590A06(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Sheitlish and Fist 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-?03-1'1 Methods of Sanitization-Hat Water and 3-201.15 Molluscan Shellfish from NSSP Tasted Chemical* Sources* Itt Proper,Adequate Handwashing Game and W#d Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Reoulato Ault orlt 3-202.1.8 Shellstock Identification Present* 2=301.12 henito Wash* Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When t 3-201.17 Game Animals* tt Goal Hygienic Practices g - L-1 Receiving/Condition 2-40111 Eating,Drinking or Using Tobacco* 3-202.11' Pt1Fs Received at Proper Ten eratures* 240112 Discharges.From the Eyes,Nose and 3-202.15 Package flute,it.* Mouth* 3-301.12' PreventingContamination When Tasting* 3-101.1 i Food Safe and Unadulterated TayslRecords:Sheiistock 12 Prevention of Con amination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock.IdentificationMaintained* Employees* TagsiRecords:Flsh Products - t3 Handwash Facilities Convenientfy Located and Accessible 302.11 Parasite D struction' 3-402.12 Records.Creation acidRewrtiun* 5-203.11 . Numbers and Placement* 590. J) Labeling of ingredlents' S-2114.11 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,,O eration and Maintenance Confer Pians Supplied with Soap and Hand Drying IHACC3-502.1) Specialized ProcessingMethods* Devices 3-502:12 Reduced ed gen acka Meting,alter a* 6-301.11 Handwashin Cleanser,.Availabilit 8-103.12 Conformance with Aa roved Procedures" 6-3(}1.12 Hand Dr Provision Dmotat eritie3i item inxbe federal 1999 Faxi Code 5r 105 CMR 590.0N. 1. 4 Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2011 ESTABLISHMENT NAME: Hess Express 21519 File Number.BHF-2004-000059 _ 1 Hess Plaza/J. Flaherty Woodbridge NJ 07095 LOCATED AT: 0086 NORTH STREET SALEM, MA 019.70 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes BHP-2012-0187 RETAIL FOOD Jan 1,2012 ' Dec 3.1,2012 . $280.00 TOBACCO VENDOR BHP-2012-0198 Jan 1,2012 Dec,31,2012 $135.00 Total Fees: $415.00 PERMIT EXPIRES Oecember.31,2012 Board of Health n 6: Q . This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for.such must be submitted to and approved by the Salem Board of Health.. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4T"FLOOR • TEL. (978) 741-1800 HIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DCREENBAUM(Q7SALEM,CONI DAI'ID GREENBAUM,RS ACTING HEALTH AGENT APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1" ss csxP(eSS a6IGI _TEL# ~I9LA_"L�q ) ADDRESS OF ESTABLISHMENT __D_Qr)t�_e_)+__ _ FAX MAILING ADDRESS(if different) HlSi OMT1CN EMAIL-Business':�ima 1519 G)11eSS. COM w boftklgm�SWebsite: OWNER'S NAME HwCOGPOBAT" TEL# ADDRESS W� 'NJ 07086 STREET 739 ?50 6350 CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous/food is prepared) .�/�+ RGENCY RESPONSE PERSON � Ct/1/m QYQ� HOME TEL# IS140DrS-a�� tfflK�Men IQNY `Monday " Tuesday r"I I`Wednisday z-aThursda fr{ Frida ,`` aturday . _STIONdayr / '/m / / TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORENO less than 1000sq.ft. =$70 1000-10,000sq.ft.l $280 more than I0,000sq.ft. = 20 RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 morathan 99 seats =$420 BED/BREAKFAST/ YES 00 $100 CHILDCARE SERVICES/NURSING HOME ---------------------............................. ------..................------.... ------------- ---------------------------------------------- MAKE --- ------ ADDITIONAL PERMITS I MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y NO TOBACCO VENDOR YES $135 ' ALL NON-PROFIT(such as church kitchens) YES N $25 1 g fl) *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. /a��/ii l3- y9aiooa Si ature Date Social Security or Federal Identification Number Revised lonli I FOODAP201 l.adm Check#&Date 1�1�`d �t $