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HIGHLANDER PLAZA LIQUORS INC - ESTABLISHMENTS �,1y��unJtr P�a.�, G.��0cs, inc �! �ab�rr vJuy RNIVERSAL® UNV-12110 MADE IN USA SUSTAINABLE MN.REC a FORESTRY FOR1INJIEST!VE CDNfBtf1, CYmfied Fiber Seurver; rosTcaNSlne+ .1fiproprem erg ?Ibl!A, 1 I j Commonwealth of Massachusetts City of Salem Kimberley Driscoll Board of Health Mayor 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/11/2010 ESTABLISHMENT NAME: Highlander Plaza Liquors, Inc File Number:BHF-2004-000030 21 Traders Way Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0234 Jan 4,2010 Dec 31,2010 $70.00 / WATER SOURCE:CITY WATER SEWER DISP:CITY WATER , TOBACCO VENDOR BHP-2010-0235 Jan 4,2010 Dec 31,2010 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2010 Board of Health J 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 + o BOARD OF HEALTH - 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT I-►L� rk«I*Y (kf� c, �-�Cyi'vr% TEL# Gl`Igv �Ju4/J) A.DD.�.Ec—z'—z OF EO—TARL,10—.uh,Ar-'�IT O ( t/e;L .f5 W 4 .K[.�2 w� FAY.N. �� 0 t� / (e MAILING ADDRESS(if different) EMAIL-Business': QQ Website: OWNER'S NAME I TEL# ?U SCF / ADDRESS ?d P.0CAAP-1.4 t� ( 0-4p S-1 j 0U A V1__ 0d019G STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON ��1I PZl 1 SG HOME TEL# CO 2 1� �<_ ©AYSF"QF'OPEIZATION,, Monday Tuesda .J Wednesday;; ;Thursday," 'ASaturday� �Suntlsy' n HOURS OF OPERATION i /G Please write in time of day. For example11am-11pm I %h l 3°UW _ / /' TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$7 1000-10,000sq.ft. 280 more than 10,000sq.ft. =$420 --------------------------Y-------ES---- --------------•--••_------------------------------------ - - ------------------------------- RESTAURANT NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BffbiB-RE-AA --------------------Y-ES------146---------------------------------------------------------------------------------$100------- CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y 1 25 TOBACCO VENDOR E NO ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all stale tax returns and paid all state taxes regwr dunder the.law. .Signature Date ../ Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Datet' 1/ah// / _—$04!20 Commonwealth of Massachusetts c City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 II ESTABLISHMENT NAME: Highlander Plaza Liquors, Inc File Number:BHF-2004-000030 21 Traders Way Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0149 Dec 23,2008 Dec 31,2009 $70.00 / WATER SOURCE:CITY WATER SEWER DISP: CITY WATER TOBACCO VENDOR BHP-2009-0148 Dec 23,2008 Dec 31,2009 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31,2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS ` BOARD OF HEALTH �^ w 120 WASHINGTON STREET,4T"FLOO4,.� ' TEL. (978)741-1800 ` »Y KIMBERLEY DRISCOLL FAx(978) 745-0343 N OV 2 ��'QIt 1DIONNI3 e nS LEM.COM Ml ?oOw 0 JANET DIONNE, Op �tM ACTING HEALTH AGENT �N 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTNL x��.. P�yt�_nt „r TEL#. Q60 ADDRESS OF ESTABLISHMENT_al fcta-w, (,Uruu FAX# C79 419 G-31 MAILING ADDRESS(if different) - EMAIL- Business': cc .yn Website: OWNER'S NAME W�Vk r...,r t (I� kTEL# 7&1 ADDRESS 20 1�&Wkb t 'Wle-, CJS6 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) - EMERGENCY RESPONSE PERSON HOME TEL# DAYS:OFOPERATION . 1':_ Monda .a..rTuesda' Wednesday.' Thursda Friday I Saturday Sunda. HOURS OF OPERATION /�}} Please write in time of day. C 7 7 (For example I1am-11pm) u ' � Sf>( 'R��1�'���i ! ��VYJ-�_f D. ��yvl- jDl��rvt- 1D Gi 1 apH-IoP TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. more than 10,000sq.ft. =$420 --------------------------------- -------------------- ------------------------------_ ....... RESTAURANT YES N less than 25 seats =fi40 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/B-REA-KAST --------------------YE-S--- O ---------------------------------------------------------------- $100 CHILDCARESERVICES ------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $ TOBACCO VENDOR C_Sv NO 135 ALL NON-PROFIT(such as church kitchens) YES NO 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. - Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returnsan pai all state tax s r quired under the law. -Signature Dae Social Security or Federal Identification Number ------------------------------------ — --- -- Revised 424/07 FOODAP2008.adm Check#&Date/iT9T ads�'j/ $ av'3 — AUG-14-2008 01 :55 AM MARKET WINE AND SPIRITS 978 744 6319 P. 01 s MARKET WINE & SPIRITS 21 Traders Way Salem, Ma 01930 (978) 745.8700 76 Fax (978) 744.6319 4 www.marketfinewine.com Michael@Marketfinewine.com FACSIMILE TRANSMITTAL TO: �'Ltz� "AcAu � FROM: Q'I£� Q� C'oUa�- MARKET WINE AND SPIRITS 978 744 6319 P. 02. AUG-14-2008 01 56 AM; INI L SERVICE REXLAR SERVICE DEXTRA SERVICE rN YNIN10T. COMMERCIAL SERVICE AND INSPECTION REPORT Y A------------- 9 1$,Al-A::M ,pIA 01970 OPERATOR NAME&OERTIFICATION NUMBER SUPERVISOR NAME&CERTIFICATION NUMBER I ''inJ'713 Nk Pe+ 1Awa u R.. u Material@ Pali{ u P"w loo'dw. i—, Tws 400 es Pet OWt Bt all U ool. m 0 F� (3 odw 410 P� 0 Va i Post Control Malwilds Used CPA ROD.I m1fic AmmK nft a tdwnbe t3ra^alar Ant Ban(a8wmcttn 61)0.01x% 488.310Meas ins and/or Treated 40D-370 "D 408,407 ...'parva Awa M 5,4% �12( 100 We Dui omit W4.120, t3 aanxM C9 pomeab< mag UD 6w 0003% unmyo 100-I069 210 DAgowd G P01mm"40x% {3P-936 -O keeNnexti Damm -i W 40% 'm eQe420 41 GoMMKftdl Inm% 2124454 So Gsmsfi�Mnl Waw Pelt Olemalonel 0.0026% 7173-218 Nuhlwmlb L 641 (k, JY • rmz Q Ki&kW CC hOmi 0006% J0114 UO2% 4333149 j P.." 3w uquftx 0 Bed pwmwh Sat of Dofi&oml C10914 352 Mof=@FGR.Ch98ltStell l 432-1257 094umwn "„ 961 Mvxfime FG AW HeI18xBllom PlamA@0.01% x31-,269 deal T Sea uaxlmaf*39xeaH19 tNydremahYl,mnl,xi9t 492.42x2 Me W..w sm 4 ar1mMlEee.OK6' E.Gam "twc." S-T� IP. T-ft, A-mmw+ PaItlACeerVBwiatl<.terP QiM Lf Aro eupwwsoes Cwx%HIMtsn 0 Tah ChAi,cle. . . . +,p6;t 41 p164-rldl-1 cus s N u r—AMOUNT PAID :1 UNRESOLVED PROBLEMS? IGN �E fun CALL I-800-TERMINIX(1-S06.837.94$4) CUSTOMER'S COPY ..................... AUG-14-2008 01 ;57 AM MARKET WINE AND SPIRITS 978 744 6319 P. 03 sfviv so'26ot 1 J.Y1,1, 6 . 1, w INITIAL SERVICE C3 REGULARSERVICE 0 EXTRA SERVICE R e cl a I ij r COMMERCIAL SERVICE AND INSPECTION REPORT 4'S� 0 4:1 6/;tA (.)ij J n*,* •30ti4p) W:[Nr,:' ANIQ S4tIP111:1t -31 tHAPI. R,; WAY N1.J,1TI)N ,MA 0246,1� '0Q::41 OPERATOR NAME&CERTiFICATiON NUMBER SUPERVISOR NAME&CERTIFICATION NUMBER JOHN F' Sf1f':JA*W IY62* R , ARTIR-JR ,14 . n Ocu,Wslu "m materials Parts - 0 U a sYrMt`muuwPwn, 450 rn Affi a 61 Q Ir,wt%kM1(41$ TB 640 acme tet61ten2 Peat Control Materials Used RPA Reg.0 TIC VC At t Snap TIM Ha wa i1 sun No Areas Inspected and/or Treated —M Aovvce DUQI Mo+.AM 901(A ,Dctln 01)0 011% $to Awsod Firs!j9113�011 11 Uvw. 200 Avm RD4G1B&161Plione MIA 0.06% IN NvPKo300B Nt Del9etl lBgo.j aa% 499.482 90ft.. fj^w� 7 is 0,015% ,0�.ow U006w IDD-1088 --to—ft9a¢xa22tnel�m00% 166 TODIOW 189429 41 (uMMIECftdMDmMA)o06% 2724.051 T173-219 noo, 5% 7173.236 30 JMcft GmdW 90 P#MaAAfl! .,L,73079-7 42 ftAvECtP"MA,) 0006% o , 5% 1 432.114 --------�,.o P.a.,Aw'. 12455-01 352 10.0arca ro 8n.h son Stoll"(Flowil 005% x32.1257 LA 4Mu 301 M.16,m FC AM RA4 ftl0m.IFIpronl)0,01% -12-12M MI? %UAMm#FC AM ft 50 14 0,001% 432-126A .3 380 maloce FC f.bd Poch B8190—(FIP-1tm%— 472.1250 uww.wk... 095432-vio 00,02% A IC"41whon)0.1%--_ 41470 To PTCY-WO CS %#.* 00075%00025% 000t6 D011% 4B43N 319 P7&01001842 DIMoOM at)0.05% AW4 to, Precautions Pf 565 P84 no"Mm""a)0.5% MM cwM4M.naw. 130 PT T40*MMW P4,10 MMON t8-6 IP,�h11151 0.6% 408.363 ..... 8,1 TMnnU;,,.WP Wn, 432-130.1 Q.0.. 63-Tempa SCkLftloymhri —.432-1m 6o Pa xwnp•rwrwa«xmtMoucem4nr4 01 ULDDP100ULv(PYMmA8)1.0% 4"4591115,10-0 mDffP=t&vM4,;"3,0% 164.1 Y-ww a 0.mm. R.Ywo 8F.6W4 0.io A. tw.w P. fto0.0 SWAM AbAkart Qm Oft supmvism-a Comm aws: 4") , I'ay CkISTO S 11 IGNA r AMOUNT PAID 10 1 ra 11, 1111 Q 90 o0 a DATEf, UNRESOLVED PROBLEMS? MI.11.800-TERMINIX(1.800-837-6464) CUSTOMEFFS CORY J AUG-14-2008 01 :59 AM MARKET WINE AND SPIRITS 978 744 6319 P- 04 �'`� v.C-14 y tyti11.. ' LJ('P ➢ .I.0665.Tlii 1 0 IfYITIAL SERVICE -1$1REGULAR SERVICE 0 EXTRA SERVICE �� RC•5 ul ;,17• I )...I]LA; COMMERCIAL • INSPECTION REPORT ME ihAd /q y....fl y0Q ?;?,- 'I' 4L'i 00 32iIEI.L ( %a YJ 1415 MU I IN�1 1. I 1L) A WLNf.' ANCI Iii/>:CI"4'I"1'!ii 1'Fi:RI`1:J.N:CX J.N'TIS:RNn11.-1.cl•IAI, ;!:L TRADERS WAY 1.^0RUMP'-(1141:)' WAD!, 9t.)T:'1'E: 11:✓ .IAI...cM ,MA 01.970 N;!::W'T'QN ,MA 0'2+I66" i S OPERAMR NAME&CERTIFICATION NUMBER SUPERVISOR NAME&CERT)MOATION NUMBER .101IN F" 131 II:F:I'IAN 1./6'21.."'i I''TSl.,I:.,p , AI'1'I'Id I,IR I-1 . 1.::'i 90 Talget `e1 eNmm ce4wa.anee .',q Rv.mm 4nn a R11 a Daee.brd m.meeN Materiels 4u«d sur Pests u nmmwn coee,veenN V MP^! O.q•- 6 roae ' L1'eegnPNeuerreeN" ygp-IhaNe9 970 WIND-VP TflN'6' - I U rnromq C4angeanP. i] fee mM ❑ eu.ennn U Dm.,- No lmeol Mdnita. NO TIN CATs 1), U DInM tlwMN,4M, U qM1 MN 0 PNe U Dme, 410 Phe10m @ Tee 8 690 Pet Ball Btnlone ae0-Qkw MO M-o Bell BlMlane ! Pest Control Materiels Used � BPA nee.B vc Etc Amalml F7 ; Ba, I 03 FawMe DMnuw nM 3A(AbemnMln 01)0011% .Br-970 Arose Inspected and/or%aced ' s, adwm4 Dual CnN[eant e4lr(gbemwlln 81)0011%, 491499 Rii CMnvlwN,he uevel,rcAbeMOr ooam hom OvrerlvA ' "A's Awend Flee Am eah(Abem em Bl)00/1% AN-370 9e7aw mwe � 141 Aeel Roach Ball Blelkne(Al.045% 409.407 0 mm,A 781 Aceirmse,MOB Am 001 Ben W)54% 4ee-262 OUHkea ICI ewe Deal(Dnn is Sea 00% 0444120 18 0wwd C9Lemaa,thalmnrin ]0.016%�00 n•0u 004691.. tOd10e8_ . . OPue%mou 710 Della0eld 010weme,Na90,05% 432.939 LL'"Ok t%reeem, 1 IM M &d O!a a Ow1(B31tt 00190H P BNMe 1.0% 491`429 3'91aNey 4NM �1 41 OeM1f1EC ne 009% 272,-3 '_ }14mmr/w;1enP4em Tr. 1w Owvellan we Bla07e BEI pfelhgbne 00025% 7173.219 %ege✓WeryMe uaep.#v �. New Grenuly Bed lOnho li 4ll 00% ,. . . . J•� '.� 70 Mba[ :.}.'.. * .'"`w';y'..y. ..�t:,ll M Kbear EC(Pymehln.) 130.05% ":301% UO2% 1 431-1145 U PNImI >nm1 NO LIOUITox Il Bell Mlwdlum Ben of 010hwIwM10.100% 12455x91 U4aeaw ON mwme FC Flown Bell slift""wl90.05% 92.1257 dei M ons fmmm)0.01% 432.12M . Ua4ww 147 C MB %(lrag0.001% 432124.fcOeol 119 Me4lelce FC a%wl Mown Bml Gel(Flprml00..01% 432-1259 091w1tt ParMgN 919 Mwlmce FO/newt Bell(HydremethylnoN 1.0% 19321282 ULeMscepware 49 NyIq EC(P}MproaAa,9 U0,015% 130.02% 17715.307-57010 U LnaapOHHNOampw, 111 MVy.KIck A%wo1( Orn)0.1% 489470 ❑r1mK 70 M Mick Cs Inhrr000075%00025% 000M%00.1% 499-304 Precautions 712 V7 WenG Bell(Abwaelln 81)0.05% e"4M Keeputionaldiknnmdvme. ! N pTfi Phq xL04aNSM ryyMNiei)D.6% 400.290 914 PTT AArowl(NIk,ANo0eM.01(Pyralhdne 0. /9B- Ngc11ne lye,nnr.evMl.mgw M1NNg4. ' 393 /WOIn tlNlNp bwam mlNe,014141•.NarmfW Ha1WINWM. i .11 T#M=Udte WP(CYOWrOO 00.02575 00.09% 00.1% 172-1]01 Dpippm yvwee to ecMme. ., N TemNGc IlbA"jlhm)13002919 00.05% U0.1% 132.1383 De nNNmptt wnn Nelnuabe meewmt4. 01 ULD OP w0 ULV 1PyNI41nn)70% IB1492/11910-0 M wmlurn to l.h.r rlW.m Do em lawn wewanNa umxory. O9 ULD tM 300 UW P[YiNhrMe)7.0% 499190/11940-1 FeIW 1.1Nmgnq,niMti eltwnled eaablanawwmelaurnwgnwnilary, s=sa,nCWe 8101' C_tlrN:aeGC Va Vpld a_eenma: 6=90an ..N-Bek 'DO.DMclsatmmcl e.!'eane aP.spoor'-I IN-M an b� 'oetle Nol'. N•C4mp,WBwew T•Tep 6e�614 aialbn Nen NlM Owla •cAxglp een9dl' M-Pav Vwmm, F•uLV 1 Pol/ele',e,N01 a110e;; U Me O No supervisor's Comments: F'Y•:ioI, Ila Lslrtl:e. l 4 , 00 Bask ce Amt:. . . . , . . 't• RPS . nO AMOUNT PAID Ff) La:I. Ia ll hl. . 270 , 00 e De all s AlURE, L a UNRESOLVED PROBLEMS? CALL 4-800•TERMIND(0-IM-837.8464) _J; i CUSTOMER'S COPY 6t;�"e INFORMAT10AIC4\04 W,1 NE A N 11-,S I-11 R I TS ITRADERS WAY A 11J_11 ,M"� D'�I,V rffAffMr- Service Arealf-ActIvity and Conditions Observed This IPM MP 1.art clattaft whom pouts witure found Its and around the facility.The report also lists those steps you can take to help limit or milmlaille,peat Invasions.For each of the suras aided below,numbers rapreganit.thaltype of past&found la the area,and IsNersropreaaat- any cmntations pleasant that May 08 contributing to a CUR"t or P"S"a future.Pont Wdfttatibm. Interior Areas- Poll"- C.VRpft,m-' FoodAroas Posts Conditions Q Offices U Dining Area — 0 Lobby/Pubic Areas It Ll Stove/Oven Lars., — — Lb Erarrywaye U Food Storeroom- — — Rest/Locker Rooms U Olshwashing Area — — Janitor chrearts U Dell/Bakery — — L) Laundry 0 Proriasolng Area — 0. 0.Bollor/Furnace Room U Packaging Arm 48torage Utility L) Produce At" 0 Warehouse L) ful"V89alfood Shop Extedar Areas J Patient Rooms 13 Exterior Walls-North U icu C) Exterior Walla-South J Linan Storage Rooms -- .. U Exterior Walls-East Q Kitcharra"esZ) Exterior Wails-Wast Nurses Stations 3 Loading Dock LJ Guest Rooms L) Dumpstor O Ber"Quet/mosting Rhomms ExteMpr Stdragis plights, 4 U11 splay Ai$1400-:4, �Y-4r- U nooi 'or U Other U Other Aon Q Other t 0 Other rifinc 00 to ac h a% 6.Pharaoh Ants 11, Occuslonal Invades 7,Pavemovil Ants hunting Spiders 17 mice N, 12 �`Vlwlqnt Akockmaches, 9.Fire Ants 13, Web-Building Spiders 18. StoodProduct Paste L Outdoor Cockroaches 9.Ahientles,Ants 14, Brown Recluse 3p)(Ifirs, 19, Other 5 "adioh 4 10 —Ants, 15, xk&_Aw _�IVkrdovv SPAOFit _7 Ir Ih A Ofilm GNxtgeatDiny 1. Papm/Licier Q Poor storage Practices X Move DumpsuarAway From Bide. B. Food Debris Under Table J. Water leak R. Roger Water Damages Wood Z. Dumposer Area Needs Cleared C.Food Debris On Shelf K Maps Improperly settled S.Seat Exlelo,cmicks/House AA, Mercury Vapor Light"Ovilards 0. Food Debra,Under Appliance L. 'Trash 6malneve Nasal Clothing T Trim Back Ties/Shnib Branches 68,Keep DOOM DOW E�_,,Wia Organic Matter In Cracm M.Heavy Dust/DIM Deposit, U Remove Pilots Of Debris CC,Repair Doorisorturn scaFloo' N. Numerous Cobasba present V CIA Toil Giasafteeds 00,Replace Dooniveolhosturipping H.t=revore=69its,on Equipment O.Repair Floo,411"Nall/Claing A.Improve outside Drainage EE Poor Outdoor 9lonage practices Dishes Lott Over Night F. S"HoulkslCriahts in Were X. Imagan Gravel Foundation Barner FF. Other Comment$ tf Service Professional's Signature Date CUSTOMER'S COPY CU � N 11.1SA WfN � I, IR ITG ,21 TPAIDERS' WAY E.MMA AWWAMW I Service Ares"clilvity and Conditions Observed, i This IPM report detaft where posts wore found in and ground the facility.The report also lists those al take to help limit or d minimize post invasions.For soon of the am"finad below,numbers mpmftnt the type of peals found�n0t*hn'ua*.n9ntenors represent j any candidates present that MW be stornribulato to a current,or possibly a future,peat ternabstion. Interior Areas Pester Condition# frooctilbrogro Poo* - condma" J offices 0 Dining Area ,.a Lobby/Public Areas 3 $hsvo/Ovon Line 0 Entryways 0 Food Storeroom LJ est/Lockv Rooms U Dahwoothfing Area Janitor Closets U DWSakery Q Laundry 0 Processing Area 3 Soller/Fumace Room U Packaging Area "3118torago utility ZY Pooduci Area U Warehouse 0 Meat Sealood Shop — 0 Basement Exterior Areas 0 Patient Rooms U Womor Wall$-North — LI ICU U Exterior W&IL*-South — U Unan Storage Rooms U Exterior Walls-Eael U Mchonettas LI Exterior Walle-Waxt D Nurses Stations U Loading Dock 0 Guest Rooms ;JI Ournpolor 4 U BarquevIvIeeting Rooms Ll Exterior Storage Rooms .7. Ll Displ y Al I S 0 Roof — 2 A,,_. Q Other— — a Other ca Oftrl— — I raflaan Cockroaches 6.Pherson Ants 11. Occasional invaders 16 note 2, American Cockroaches 7.Pavernart Ann 12 Hunting 51,164's 17. Mice 3 Oriental Cockroaches 0.Fire Ants 13 W80-9.ricingstaftim; t8. 3towao Product Pews 4. Ouldom Cockroaches S.Argerift Ante 14,•Soava Rutift-SpIAWS Is, Other 5. snvirssn 10 —AMM I& Black Widow Spidars 20 Other A.-Oraih C r. Paperotter O. PbofftiageProcticea, Y Move Oump8hkAv4FrM B. Food Cootie Under Table J. water lank A, Repair Water Damaged Wwd Z. Ouffloste,Arm Nestle Ginned C:._Fwd F.W Doors On Snail X S. Sea]E.Iarior Cracks/Holes As,Mercury Vapor Lights Outside D. Food Dabna under Appliance L. Trash Containers Need Cteantnq T Trim Back Too/Shrub Branch" B"eap Doors Cloud E Wet OrgenIcMaher inCracks M.Heavy DuaVDIM Deposits U.Aamoyo Plies of Debris CC Repair Doot/Scrun I F green Dep"Aa on Floor N NwreroaaCobwebe-Pl"amt \L Cut Tali Cr sM ods Do Popleco,DoonMeathstanipping G.Grease Deposits on Equipment 0.Repair FloorMlao/WalliCelling W Improve Outside Drainage E15. POO'outdoor Storage Practices H.Back!Dishes Left Ove,Night P Sui HolesiCrack,m Vftk X ftwiGravel FOWI"tlonawtw FF. Other comments Cu erne St $$rvIce Professional's Slonatt4d Date -T (11 fcTnMF:Rlq Mpy L ,pl}' CU$�OMER 106nmAt m ithtr' WA Tit7�lN/NIJ�. . i �Titrant ire, lent i~: i..,Itt�4i;W,Pt) r7:i�r>ix � �.r��;� t vl.i��. �, r Service Areas-Activity and Conditions Observed I This IPM report details where posts wen found in and around the facility.The report also Mato those slope you can take to help limit or minimlzo past invasions.For each of the areas listed below,numbers represent the type of paws foiaad M the area,and lettere npreand- I any conditions present that may be eonkibuting to a cla mli,or possibly a Mur,peat infes IOM Interior Areae PealeFood'Arssor peals Conditions .LT-ptiicea ' '.. �.. U Dining Area U Lobby/Public Areae --. U Stove/Ovan Line --_- U Entrywaye --- U Food Storeroom --Cr-liast/Locker Rooms ->r2.' =: U Dishwashing Area � . U Janitor Closets -- U Delv$skary U laundry __ U Processing Ara ' U Boiler/Furnace Room —.-.. U Packaging Arse — `a Storage Utility «' 0 Produce Ares -- d Warehouse a r i'4 'a Me rtSeateod Shop U Basement Extedor Areas U Patient Rooms U Exterior Walla-North _ U ICU - U Exterior WallsSouth — L l Linen Storage Rooms U Exterior Wada-East ____ U Kitchenettes - Q Exisdorwase-West — U Nurses Stations — U Loading Dock — U Guest Rooms U Dumpeter ❑ "Liathvosting Roome i.—t - , . .O. Exnrior Staiego Rllioms.. .•. 8"Dispiay,Aisles k_,_,,. ,` Vii'. ,/G—�—.. . U Roof ' U Other U Other _`S'::5.'�•.... 0 Other U Otho 1. German Cockrom;hea Ph~AMe it OCCeaotlailnv8dlro 18'ZRate 2. American Ceckrosches �3svemant Ante- 12. Hunting$pdere— 17'"ig'1 '8877. 3. Orionte Cockroaches Vita,Ante 13 Web-Building t of" led,QNdoct Pests I d. Outdoor Cockmaohes 9,A,gentine AMB til. Brown ReCNO spidam 19. Othof Nether i0. Ante. its_a84akif ,gas Smdue 26:x'0 A. Drain Clogge"irty 1. PaporrUnaz, O-PoorBrpregaPrecicie Y. Mow Durtpatar Rway From Bide. S. Food Dabla Under fable J. Water leak A. Repel,Water Damaged Wood 2. Dumpeter Ares Nsede Cleaned C Food Dabds On$half K. Mope Impropeny SIUBd S. Seal Eeledor Cracks/Nolte AA. Mercury Vapor Lights OuIeWR D.Food Debria Under Appliance L. ltaen Contamere Need Cleaning T Rim SeCk Tree/ShMb Bmnoh9a 88,Keep Doors closed E. Wet ChosMc Matter In Cracks M.Heavy Duettist Depoette U. Ramove Filen of Debits CC,Repay Dom7SCreen F. Gnsee 9eposae on Mawr Y 1 N. NruneroW Cobwebs Present V. cut'rest Gra nifteeds. OD.Rapiers Door Wesidwintipping 0. Greea9'Depoaee on Equiprri'oht O.Raper Floorlrgee/WawCelling w.Improve outside Oratnage EE. Poor Outdoor Storage Practices H.Soiled Dlahe9 Leff Over Night P. Sae HolaarCreCks in Walle X. Install Gravel Foundation Butler FF. Othe, Comments ' I I I I � w ' C oma sSlgdature ` . Service Profaaiorsai`e.Sign giute,.r -�y:- f'r %.,.._....-, Data CUSTpMEA'SCOPY L—_ r My VistaPrint Electronic Business Card Page 1 of 1 Elizabeth Salandrea From: Michael Gillen [michael@marketfinewine.com] Sent: Monday, August 11, 2008 3:37 PM To: Elizabeth Salandrea Subject: Health Inspection Dear Liz, Took care of missing hand soap, proper trash receptacle in men's room & having fridges cleaned presently - will take a few days to get copies of Terminex receipts to you. Yours truly, Michael Gillen http://-www.mai-ketfinewine.com ;_a s ��tEt 6tj�&' tClf Uori�eivousleuirr� ,.�- N�a�liaal G taltlen� � .` +� �hiefVinotherapist �=- � 21'bTradersWay Sale rt Mk.01930 8:745.8700* Ly 978744 6319 MichaelapMarkeifineme com " j vkwM arketfinevyinexcrn 8/15/2008 21 Traders Way Market Wine & Spirits City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency ;Telephone: PROTECTION FROM CONTAMINATION i 745-8700 - Handwash Facilities FAIL Critical ❑d RED Owner: Comment: Men's room missing hand soap. Provide handsoap in wall hung dispenser at all times. William A. Busa Men's room also missing proper trash recepticle;trash being disposed of in a plastic bin.Provide proper trash recepticle. PIC: Mike Gillen There were two knives,a bottle of dish soap,and a cleaning implement in the men's room at the sink.Restroom sinks are to be -Inspector used for handwashing only. Elizabeth Salandrea Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Date Inspected:Correct By: 8/'1'1/2008 Comment:2 club sodas,2 mountain dews,4 Schweppes ginger ales and 3 Schweppes 6-packs removed,outdated.Owner to closely monitor all expiration dates. Risk Level: Equipment and Utensils FAIL Non-Crifical BLUE -- Comment: Pepsi fridge and wine fridge next to the Pepsi fridge need general cleaning in the door tracks. Permit Number: Physical Facility FAIL Non-Critical BLUE BHP-2008-0056 Comment:There are a few stained ceiling tiles in the middle of the store.Investigate for leaks and replace stained tiles. Status: j SIGNED OFF l #of Critical Violations: 2 Time IN: Time OUT: Urgency Description(s): BLUE: Please notify Board of Health within one week that violations noted have been corrected. Violations Related to Good Retail Practices (Critical Please also fax last 3 months' extermination receipts to Board of Health within one week. violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 15,2008 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require 'immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 15,2008 ) Page 2 oft r - am W. �y .,,R •. #. K ._,.+ �, .n. va '*+P'.� art s ��'�e�'x„� ��� 4n.���ab Y�.•. Commonwealth of Massachusetts City of Sslem Board of Health = IGmberley_Driscoll 120 Washington Street,4th Floor _ Mayor- - - SALEM,MA -01970 Food/Retail Establishment Permit - - DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME- Market Wine & Spirits File Number.BHF-2004-000030 21 Traders Way - Salem MA 01970 LOCATED AT: SALEM, MA 01970 . Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0056 Jan 3,2008 Dec 31,2008 $70.00 7 WATER SOURCE:CITY - ... " WATER SEWER DISP: CITY WATER Total Fees: $70.00 PERMIT EXPIRES December 31,2008 Board of Health �f This Permit is not transferable and must be reissued upon change of ownership or location.-The permirmust:be posted in ' a prominent location in the Establishment In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 9 of 46 QTY OF SALEM, MASSACHUSEM BOARD OF HEALTH ' 120 WASHINGTON STREET,4'm FLOOR TEL.(978)741-1800 KIMBERLEYDRISCOLL FAX 978 745-0343 �+ MAYOR IscOTraa sALEM.COM R E C E N E D JOANNE SCOTT, DEC 6- 2001 HEALTHAGENT CITY C - _EIVi BOARD OF l- AL FH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT HIO�IC �Cuu v��,tnrc. TEL# 00%_ 1115 SWO ADDRESS OF ESTABLISHMENT Q L _Tra4A-13 L-L,c.- / FAX# MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'SNAME CeJi,LIte 'i)+. c, TEL# `/FSI kGI fk(G , ADDRESS V33 VV65S Ct L 266 lam VA61 d)L Y- � STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYS OF OPERATION 1 Monday i Tuesday Wednesday i Thursday Friday i Saturday E Sunda HOURS OF OPERATION Please write in time of day. For example Ilam-11 m TYPE OF ESTABLISHMENTFEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------YES NO $---------------... --------------------------------------------100 - ------ BED/BREAKFAST/ CHILDCARESERVICES ----------------*---------------- ------------...._. ----- ------------------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains andpenalties of perjury that I,to my best knowledge and belief,have fled all state tax- returns and paiidd pll state taxe required under the law. ignature Date Social Security or Federal Identification Number ____–_--______._.__-__—----------__----------__--___–__.__.._ _------ -_– ---- _----- _ _---- __-------- Revised 4/24/07 FOODAP2008.adm Check#&Date 21 Traders Way Market Wine & Spirits City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 745-8700 PIC Assigned/Knowledgeable/Duties PASS RED Owner: Noncompliance with: William A. Busa Anti-Choking PASS PIC: Mike Gillen Tobacco PASS Inspector: John Gehan I EMPLOYEE HEALTH Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 611112007 Personnel with Infections Restricted/Excluded PASS RED Risk Level FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS RED BHP-2007-0100 Receiving/Condition PASS RED Status: SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED 0 ' Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 11,2007 ) Page 1 of r Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS 0 RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED immediate corrective action) Proper Adequate Handwashing PASS 0 RED Good Hygienic Practices PASS 0 RED Prevention of Contamination from Hands PASS RED Handwash Facilities PASS 0 RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS RED Toxic Chemicals PASS RED TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS 0 RED Cooling PASS 0 RED Hot and Cold Holding PASS 0 RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS 0 RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 11,2007 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: There are no violations at this time. L� IL City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 11,2007 ) Page 3 of £� n7,ri ri�.r'`°-wpb �x " yS:SCOm°^mOhWCalth 0f„TM4+SSSaOhUyS�tt9'�W Nox ,� , � f•,f Ye* h.�MTr`#r. ' Salem��;� "'1� ; T • ix }. • �.nr�r,Dy'�-A�t���,3�^�}"v�{BO dof Healfh i+'1b� -�� v""t f 'k 'j� q��y:� S�rt"��S'.My+xU`t^,ks n:�i�`t' IGmbetie s .11 120 Washington Street,4th Floor, y r } . . . •MayorD1ls- 7 SALEM,MA T01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: Market Wine & Spirits File Number:BHF-2004-000030 21 Traders Way Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0100 Dec 19,2006 Dec 31,2007 $50.00 / WATER SOURCE:CITY WATER SEWER DISP:CITY WATER TOBACCO VENDOR BHP-2007-0102 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 olf Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 2 _30-2006 02 :53 AM MARKET WINE AND SPIRITS 976 744 6319 P. 02 4 CITY OF $ALEMf MASSACHUSETTS BOARD OF HFAI,TH 120 WASHINGTON STREET, 41H FLooa SALEM, MA 01970 TEL.976-741-1800 FAX 976.745.0343 Kimberley Driscoll WWW.SALEM.COM }►�����y Eit 1 Mayor JOANNE SCOTT, MPH, RS,CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT't./ �y, NAME OF ESTABLISHMENT Y 't Y`--'"rY� UJtL i + � (V� TEL# 9 4�- s- o � i� ADDRESS OF ESTABLISHMENT_?.( t �� 6 FAX ff %8 _ L(` ^ ITP 1( MAILING ADDRESS(if different� t)}-� EMAIL-Business':� Vk![ t Vg S . Owner's: QYVNER'SNAME TEL# '72� �`(y ��d� ADDRESS_ {rjxt (0 A- 1 YYIa G1 q,)a STREET I CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# 6AYS@F@PERATI@R MsadeF TeesdtiY Wednesday ihufsday Frida Sadlrtiav Snntllnt ROURS6F@PERATI@R 3d R 1S 5 Pc 7v $ 3 J t _—. - eleesewriteta"remuar `d ° 8 3 q r" S30 $3a trot eeemule tiaot-name TO $0 _ TYPE OF OSTABLI� `' FEE check ( �� RETAIL STARE YE=S NO less than 100gsq.ft. 110DO 1000.10,000s .ft. j7 more than I0,000sci t. =$250 ........................................................................ _....... RESTAURANT YES NO Tess than 25 seats $100 25.99 seats =$150 more than 99 seats =$200 -F-A, ...... - --- ------ .... _ _ ........... ...----_ ........_.................................... ... _ ... ..... --............. BED/BREAKFA-. ST YES NQ $tpp ADDITIONAL PERMITS MAKE not just serve) ICE CREAM, YOGURT, SOFT SERVE $5 NO $50 ALL NON-PROFIT(such as church kitchens) YES QD $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MSL Chapter 62C, Section 49A, I certify under the pains and peoeid"of perjury that I, to my best knowledge and belief, h8v�p,fil. I alalll Mate lax felt�nsa�nd paid all ata taxes required under the law..L�_ `� Signature "�dt� Abe or Fed ra�Tr — 9 ate Social Security or Federal Identification Number ............... - • ----••----------------- ---------------------- ------------------------ Revised 11/13im I-0007AP2007 adm 'Ctleekd s Dale $ /00` tTU 21 Traders Way Highlander Plaza Liquor City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: - FOOD PROTECTION MANAGEMENT '746-8700 PIC Assigned/Knowledgeable/Duties PASS ❑d RED Owner: Non-compliance with: r William A. Busa Anti-Choking PASS PIC: '. Bill Busa Tobacco PASS Inspector: 'John Gehan EMPLOYEE HEALTH Date Correct,By: Reporting of Diseases by Food Employee and PIC PASS ❑Q RED llymajo& Personnel with Infections Restricted/Excluded PASS RED Risk Level FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS ❑J RED BHP-2006-0111 Receiving/Condition PASS RED Status:1 SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS RED #Of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS ❑d RED 0 ,r Time IN: Time OUT: HN Urgency Description(s): BLUE: Violations Related to Good Retail Practices(Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 27,2006 ) Page I of Item Status Violation Critical Urgency RED r a*`r PROTECTION FROM CONTAMINATION Violations Related t0, �. . Separation/Segregation/Protection PASS ❑d RED Foodborne Illness Interventions and Risk Factors (Require .,,, Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED immediate corrective actlorl) Proper Adequate Handwashing PASS ❑d RED Good Hygienic Practices PASS ❑d RED Prevention of Contamination from Hands PASS ❑J RED Handwash Facilities PASS ❑J RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS RED Toxic Chemicals PASS ❑d RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑d RED Reheating PASS ❑J RED Cooling PASSN❑ RED Hot and Cold Holding PASSd❑ RED Time As a Public Health Control PASS ❑d RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 27,2006 ) Page 2 of Z • Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE - Other-See Notes PASS BLUE GENERAL COMMENTS: 711:Owner to fax over last three months of extermination reports to Board of Health. No health code violations exist at this time. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 27,2006 ) Page 3 of ` v-, r��+ s!7h „Y✓� �'rk'!S£t^� st� .�1i6.�.t+ ' °1 ^ r n sr" tx1'' �� wr 'n, � " � COmmOnWe8lth Ot M8868ChnSettS��'� K''S+n� ''`L rti X� , n ,1�'*d»a.i ✓J �� City of Salem ` Boardo[Health . . �r'z' 120 Washington Street,4th Floor e SALEM,MA 01970 ri- y� Food/Retail Establishment Permit OW DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Highlander Plaza Liquor File Number:BHF-2004-0030 21 Traders Way Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-01 11 Jan 3,2006 Dec 31,2006 $50.00 ESTABLISHMENT TOBACCO VENDOR BHP-2006-0112 Jan 3,2006 Dec 31,2006 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 5 of 9 i CITY OF SALEM, MASSACHUSETTS " BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR � SALEM, MA 01970 1 8 C/ �00nn TEL. 979'741-1800 �q ry0 STANLEY J. USOVICZ, JR. FAX 878-745-0343sq MAYOR WWW.SALEM.COM /�/�fl"I� JOANNE SCOTT, MPH, RS, CHO l jy HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT IL)11 6_..Jr Q,r t _TEL# ADDRESS OF ESTABLISHMENT at MAILING ADDRESS (if different) OWNER'S NAME j&�M l Lc5 U TEL#j (, ADDRESS rw, t2 A CtTY_ a= ��. p� STATE_ CERTIFIED FOOD MANAGI TS NAME{S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# HOURS OF OPERATION: Mon.—Tue.TWed.—Thu. Fri.`Sat.—_Sun. TYPE_OF.ESTABLISHMEN. FEE (check only) RETAIL-STORE] YES NO less than 1000sq.ft. 50, <111- !'' l 1000-10,000sq.ft. =$100 qq +J4 more than 10,000sgA. =$250 RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =S200 .......... ................. ...... --------..............................--..........,.. ....... BED/BREAKFAST YES NO $100 - ... ............. - --- - ------------------ .......... ... .......... . ............................ _.--------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE S NO (TOBACCO VENDOR-1 _0(0 $5 YE NO �p5`0 ALL N61V-Ah6F1T(such as church kitchens) Y NO $25 *Please pay total with one check payable to the City of Salem , This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains.and penalties of perjury that I, to my best knowledgJJe'.Pnd belief, hay, filed all state tax r1attlims and paid all state taxes required under the law. Signature ke Social Security or Federal Identification Number ---------------------------------------------------------------------------------------------------------------------------------- Revised 11/03105 FOODAP2.adm Check#&Date-Z/ o CITY OF SALEM MASSACHUSETTS �. i BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR a �Ao SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO- MAYOR HEALTH AGENT June 17, 2005 7 Market Wine&Spirit 15 Traders Way Salem, MA 01970 Dear Owner: On Wednesday May 25, 2005 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Market Wine& Spirit is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of (ONE Hundred Dollar fine)for the FIRST offense. FOLLOWING THE THIRD(3RD) OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th floor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, r ianne Scott Health Agent JS/mfp CERTIFIED MAIL: 7003 3110 0005 1992 1431 cc: North Shore Tobacco Control Program Christina Harrington, Board of Health Chairman and Members t � � 21 Traders Way Highlander Plaza Liquor City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephone:' "' " Item Status Violation Critical Urgency Nature of problem or correction 745-8700 Non-compliance with: Not Done LOwner: Anti-Choking PASS ❑ William A. BUsa' Tobacco PASS ❑ `-PIC ,-. FOOD PROTECTION MANAGEMENT Not Done James Reich 3 PIC Assigned/Knowledgeable/Duties PASSd❑ RED Inspector: David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected; COffeCt By: Reporting of Diseases by Food Employee and PIC PASS ❑J RED 9/16/2005 Personnel with Infections Restricted/Excluded PASS ❑d RED Risk LeveC " s FOOD FROM APPROVED SOURCE Not Done -Permit Number: - -,. Food and Water from Approved Source PASS J❑ RED BHP-2005-0157 Gm Receiving/Condition PASS ❑d RED Status: Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED SIGNED OFF Conformance with Approved Procedures/HACCP PASS ❑d RED #of Critical Violations: Plans PROTECTION FROM CONTAMINATION Not Done Time IN: Time OUT: Separation/Segregation/Protection N/A d❑ RED Notes T Food Contact Surfaces Cleaning and Sanitizing N/A RED 303: Proper Adequate Handwashing PASS 0 RED Urgency Descrlptlon(s) Good Hygienic Practices PASS RED BLUE: Prevention of Contamination from Hands PASS �/❑ RED Violations Related to Good r, Retail Practices (Critical` Handwash Facilities PASSJ❑ RED violations must be corrected immediately or within 10 days)(Non-critical violations` GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 19,2005 ) Page 1 ora r _ y 21 Traders Way Highlander Plaza Liquor must be corrected immediately PROTECTION FROM CHEMICALS Not Done or.Within 90 days) Approved Food or Color Additives N/A ❑d RED RED', Violations Related to Toxic chemicals N/A ❑J RED Foodborne Illness Interventions TIMEfrEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures N/A Q RED immediate corrective action);. Reheating N/A ❑J RED Cooling N/A RED Hot and Cold Holding N/A ❑d RED Time As a Public Health Control N/A RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP N/A ❑ RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A ❑d RED Violations Related to Good Retail Practices (Blue Not Done _ Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE Establishment sells a limited supply of pre packaged chips and snacks. No heakth code violations cited at this time. GeOTMS(@ 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 19,2005 ) Page 2 of i 21 Traders Way Highlander Plaza Liquor ;,mxn /1a GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 19,2005 ) Page 3 of y a+3.5 —s tiyp aRo # 'S tY',mn 1 .#... -r 1 .n F''..r � xAti� CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 9} 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT . COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Highlander Plaza Liquor/ Market Wine & Spirits Address of Establishment: 21 Traders Way Owner's Name: William A. Busa Restrictions: Application Date: 11/29/2004 Permit for Food Establishment 81-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 63-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT IMPORTANT MESSAGE FOR ,V1� DATE Lj 2� J TIME aq(L(� � M OF Alot 0.0 P) L°PJ4 I PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA COOE NUMBER TIME TO CALL TELEPHONED PLEASE GALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL / J WILL FAX TO YOU MESSAGE )�l�lG.�d /d✓G��i mac. /Jgiors/ SIGNED FOR 4009 MP U.S.A. NOTES -- 3i Lr' rsa33n+.ers'M"°"t" .Yr::.w�.• _ a .rev ` CITY OF SALEMP MASSACHUSETTS 4..� BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR - SALEM, MA 01970 TEL. 978-741-1800 G%VM FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Highlander Plaza Liquor Address of Establishment: 21 Traders Way Owner's Name: William A. Busa Restrictions: Application Date: 11/29/2004 Permit for Food Establishment 81-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT �mei 7v Rlt} ,dnwu +4v, cj,44 ,4d -14 2 / 7P�� CITY OF SALEMr MASSACHUSETTS r 1o �L BOARD OF HEALTH ;"-0 sit 120 WASHINGTON STREET, 4TH FLOOR as SALEM, MA 01970 TEL. 978-74 1-1800 Fax 978-7478-745-0343 JOANNE SCOTT, MPH, RS, CHO STANLEYMAYOR MAYOR JR. HEALTH AGENT e�� � //�������/~^ 2005 APPLICATIONS IFOR PERMIT TO OPERATE A FOOD ESTABLISHMEF NAME OF ESTABLISHMENT t}ly�Ir kF�_L_( _�, �IFG TEL# q!lK 7"4S <�;?fit) ADDRESS OF ESTABLISHMENT MAILING ADDRESS S (if different) r OWNER'S NAME \ / ,i Cwv TEL#? I tt l I kO G ADDRESS J YvCA.SS CJ r.. _ CITY STATEl ZIP CERTIFIED FOOD MAN GER'S NAME(S) _CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON &t R 6 t5rti HOME TEL# ! t b i ct�Cc`}' HOURS OF OPERATION: Monq:Lu Tue,y'lo Wed.jj o Thu. -10-Fri. -,Io Sat.r p-_,Sun.l)(, TYPE OF ESTABLISHME FEE check only RETAIL STORE YESNO less than 1000sq.ft. _$50 1000-10,000sq.ft. =$100 6b more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROrll(such as church kitchens) YES NO Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. Inaccordance 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 b Lt t k a e ge a�ef, ave filed ail sta to returns and paid all stat •taxes required u yi@r the law. Signature Urate Social Security or Federal Identification Number ----------------------------------------- ------------------------------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adrn Check#&Dale _, =�L�"--t— _. CITY OF SALEM MASSACHUSETTS - a BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR c SALEM, MA 01970 TEL- 978-741-1800 FAX 978-745-0343 STANLEY J. 1JSOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT - COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter Ili, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Highlander Plaza Liquor Address of Establishment: 21 Traders Way Owner's Name: William A. Busa Restrictions: Application Date: 12/1/2003 Permit for Food Establishment 60-04 Frozen Desserts/ice Cream Permit for the Sale of Tobacco Products 14-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT u 'CITY OF SALEM, MASSACHUSETTS �- BOARD OF HEALTH � NOV 120 WASHINGTON STREET, 4TH FLOOR N 212003 • SALEM, MA 01970 TEL. 978-741-1800 4l I Y '✓i- bFLI_M FAX 978-745-0343 BOARD OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ��i�G/� /z / / �Cc�U TEL# Z�' 7 t/S 5F700 ADDRESS OF ESTABLISHMENT 2/ 1�4 MAILING ADDRESS (if different) OWNER'S NAME ,/il�j/�icwde 4� /t�/S c TEL# ADDRESS {—� iw ✓� / CITY STATE::j ZIP L � ` d CERTIFIED FOONA ERWAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun. TYPE OF ESTABLISHVfIffi, FEE check only RETAIL STOREES NO /�� less than 1000sq.ft. _$ 50 1000-10,OOOsq.ft. =$100 more than 10,OOOsq.ft. = 250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS �' ) MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES X18' $5 TOBACCO VENDOR r-TW NO $50 ALL NON-PROFIT(such as church kitchens) TES. r7O $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my be knwl d e and el' , have filed all state ax turns and paid all state taxes required under the law. iw.c. . r6ly //�y 9� C y3 s 1 S O '� 5 o e- Signature Date Social Security or Federal Identification Number ------------------------------------------------------------------ -------- -------- ----�-1- -d---------- --------- - -------- Revised 11/03/03 FOODAP2.adm Check#&Date /i /--/- /�,�0�::� , 05/24/00, 13:49 DROPKiN 8 PERLMAN i 978 740 9705 NO.658 P001/002 DROPKIN, PERLMAN, LEAVITT & RUBIN A1101neys and Counsellors at Law 910 Bedford Street Samuel i.Perlman Lexinglon.MA 02920 Michael E.Rubin W.FL 181 860.9500 Machell E.Wei:man Fax 181 861.0096 'Alsa,(,bm qed Tatem. \I.Hornung Ann%t do Colasanti Sidney Gurovila Peter),Aalko Dm id Simone Dor id 0,Stein Jenni(ar L.Walker FACSIMILE COVER SHEET John John I edeas/ / y DATE: p� I, '� ( "' •',laoricc).Leavitt �1 U ••\lac Borten.M,D..J.D, FROM: RE: &SIrr Plr~3.� L r 4u `rS� ltie TELECOPIER NO.: NUMBER OF PAGES INCLUDING COVER SHEET: AutMESSAGE: �cg5'I .-e� � oxr- 12;�1,(,a,•,�cr�s�� /1�9lresAw►- ! Wrr.B � unl<e�P (oc. � 0 �� n c/I���. dn ({J�,�►caaP� . T Wks a�oTICEo c Nd F ENnnuTY drA.0!A•t.q, 5 This transmission is Intended only for the addressees) listed above and may eentatn certain informadon that is confidential and privileged. If you are not addressee(s), any use, disclosure, copying or communication of the contents of this transmission Is prohibited. If this massage Is received in error,please telephone us immediately(collect If necessary). Thank you for your attention to this conrem: f l r lM u l S oM �ryxro Tt�e 4&S It 5 4"e!"Id %S �- t`7�t 11� gnu � U �+rQ q& s{a-t (A--O-At– 'r Aare 464.5 Sumciville._MAa02145 Danvers.MA 01923 Frominglipen'.MA 01701 `/ Braintree(./(%I X 0011_84 jl .r jt7,-,C. w1N Q (2AW1 a(9 dLlm_ Oslty Aa *&, GAffit ^o —44 �r ta>L.�o„cPu.. alt r t 8 6��3�iAWJ- c- 05/24/00,13:49 DROPKIN & PERLMRN 4 978 740 9705 NO.658 P002/002 HAY-22-2000 03:22 Pit BUSA ENTERPRISE 7818818122 P. 01 rewPye►� EI*Wo Ems 16 FW*ptMa eftr&v U*WWMn 0 i a"■a dam. 16 TItdM Way,eadm.VA *l.'��O ur.av 'SAgPdweM1: 4'0' caro AM 4Q t.CanataoM asap to dMeft eyw Medy ieyart MMg. ® 0 0 2.Ar�Ssigsleanlobsh�iowMans.(8aoon, VIA T11e leoaonaaiyJ fpm IOdMNombtkadekepnork wsdswss. Ptmob?de 1 ® 4.howd.ew WOW Ser66a1Ra..,lYeelesr.proarwyirsaowbdIM j aw ftm ®Tub a.W*14SM dbew Ho abepke as ti kugk bdbc.eM. NRddbna�dsgeWw ..bow OM vwff*aakbghfnaado"whhdwAin atm d Arrw.y nod a beer dkael a All Reload=Oft 0bedarUAW, I tAk!bwdk*400 WIMN web if a saaskneaft mer ®�-,� dberdbewaws ro.ft a baa.OMW kwwAkssd dam"door,bwbd vrM elle bumpy bkd se addax web.(Lad WON*It MM) tt.EIsa44a breRa,mne aan�epieew katlkal6(Power plw►.redempon I 1 11, , It*M wag shove brd4d b Mo"Askdd diaL Fe1Yk eppiwSgn bradlawta b MBiro MrodlnO owlet �CddWlkWrdelPenal. 18.PAN 111 walheeM Mill;sae►.pW.buryumy woad a%0411e0014 TVN oswp�t'Os DtAylsTbp OnndsT4s Uq aoalr,c t#lso aFWaG krrr!000ad dWakAtW aMlalow Few"CdnORtC Sealed a7 P Q tb Beer Chest 17'0'W x 42'0"L z V 4"H s°� Outa*de FW" ra So" Cuta"Pwmtm wan 14Y kyr� s.e 41. 9uaAvtWls a ePlluTs-SV EM,bu loot• wkr Mr FIMdWd ® SeaNtl �� J—� a.r.ry SGA1.E: 1'■170' Remove Block.IHP1eb Overhead Dow )t ad!d=*In Whew) DROPKIN, PERLMAN, LEAVITT & RUBIN r "Somerville/Framingham/Danvers/Braintree!Boston John J. Boni Attorney at Law 430 Bedford Street Lexington, MA 02420 781 860.9500 FAX 781 863.0046 Email:jbonazzi@dpirlaw.com CITY OF SALEM, MASSACHUSETTS . ; LICENSING BOARD 95 MARGIN STREET P.O.BOX 1042 TEL 744-0171 EXT.30 Chairman,Harold F.Blake,Jr. CLERK James M.Fleming JUDY DAVENPORT John H.Casey HEALTH DEPARTMENT NOTIFICATION FORM IF YOUR APPLICATION INCLUDES THE SERVING OF FOOD YOU MUST HAVE THIS FORM SIGNED BY THE HEALTH DEPARTMENT PRIOR TO SUBMITTING YOUR APPLICATION TO THE LICENSING BOARD. (this form MUST be signed by the Heath Deptartment and returned with your application) . NAME OF CONCERN: Highlander Plaza Liquors , Inc. LOCATION: 274 Highland Avenue, Salem, MA 01970 TELE. # TYPE OF LICENSE: Liquor APPLICANTS NAME: William A. Busa D' y; RESIDENCE: 8 Farm Road CITY: Lexington STATE: MA ZIP: 01970 TELE#: ( 781) 861-9567 HEALTH AGENT/INSPECTORS COMMENTS:/ l �VC� A±± 44' LTH AGE T CITY OF SALEM, MASSACHUSETTS : LICENSING BOARD 95 MARGIN STREET P.O.BOX 1042 TEL 744-0171 EXT.30 Chairman,Harold F. Blake,Jr. CLERK James M. Fleming JUDY DAVENPORT John H'.Casey ROUTING SLIP The Salem Licensing Board requires that each applicant have the appropriate Departments sign this Routing Slip and return it to the Licensing Department before licenses will be issued. BUSINESS NAME: Highlander Plaza Liquors, Inc. LOCATION: 274 Highland Avenue, Salem, MA 01970 TYPE OF LICENSE: Liquor APPLICANTS NAME: William A. Busa Residence: 8 Farm Road City: Lexington State: MA Zip: 02420 Telephone: ( 781) 861-9567 TO ALL DEPARTMENTS : your signature on this form is notifying Licensing that all requirements of your department have been met, at which time the Licensing Board will issue a license. Salem Historic Commission One Salem Green/Planning Dept. Sign Review/Planning Dept. One Salem Green Salem Health Department 9 North St. Fire Prevention 29 Fort Ave. / Building Inspector / Occupancy One Salem Green Department of Public Services Water Dept. (for billing purposes ) One Salem Green I PORTANT MESSAGE FOR GATE TI M E P2 P. M OF PHONE AREA COBE NUMBER EXTENSION ❑ FAX • MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSA E �j_�t SIGNED Mlbps. FORM 4009 ///YYY ���111 MADE IN U.S.A. ��� NOTES - -- :- Massa6husetts Department of Public Health Salem Board of Health 120 Washington Street,4'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHI IV7eINSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 NameMahlandeaftx_r / / ' U 0 D,te v Tvoe of Ooeration(El T e of Inspection D: LlFood Service outine Address jn' Risl VRetail ❑ Re-inspection Telephone oL Level El Residential Kitchen Previous Inspection 8 .S - OD ❑ Mobile Date: Owner /, 'l l h a m Iq f3 us a- HACCP Y/N 0 Caterer Temporary ❑ Pre-operation UlJ El Suspect Illness Person in Charge(PIC) / Time ❑ Bed&Breakfast E] General Complaint Icha Lal GBL In: ❑ HACCP Inspector O e /. Out: Permit No. ❑Other Each violation checked r quires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT : ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El 13. Handwash Facilities EMPLOYEE HEALTH ❑ 2. Reporting of Diseases b Food°Employee PROTECTION FROM CHEMICALS p g y and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE � _ _ ' E] 15.Toxic Chemicals . ._ ❑ 4. Food and Water from Approved Source TIME/rEMPERATURECONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE.POPULATIONS(HSP)_ F-1 10. Proper Adequate Handwashing F-121. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices L,CONSUMER ADVISORY.., ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related / Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below P 9 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 5901nspecfFomb14 d. �n eSig Lure: Print: PI r, s Signature: Print:/Y' ( 6_;` LIL Page._0f_Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT I Cross-contamination F 590.003(A) Assiiprmenl of'Responsibility* 3-302.11(A)(1) Raw Animal Fcxxls Separated from 590.003(B) Dentonshation of Knowledge` Crooked and RTE Foods* 2-103.t 1 Person in charge-duties � Contamination from Raw tngredionts (A)(2)-Raw- 3-302.11 Aninul Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employeesand 3-302.1 I(A) Foal Protection* a iticturts* 3-302.15 Washing Fruits and Ve*etables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* C'haree* Contamination from the Consumer 590.003(0) Re iardn b Person in Chuee* 3-306.14(A)(B) Returned Food and Rescn ice of FWd" 3 590.003([)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(5) Removal of Exclusions and Restrictions Food 3-701.11 Discarding(e Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources. 9 Food Contact Surfaces 590.004(A-B) Ccnnptiance with Food Law'K 4-501..111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* Sanrttzation'pem eratuzes* 3-201.13 Fluid Milk and Milknoducts* 4-501.112 Mechanical Warewashing-HotWater 3-202.13 Shell Eg s* Sanitization Tem eratures* 3-202.1.4 E«=s and Milk Products.Pasteorized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and harzlness. '" 5-101.11 Drinking Water from an Approved System 4-601_11(A) Equipment Food Contact Sutfaces and Utensils Clean* - SkXf.006(A) BottledDrinkin Water'" 4-602,It Cleaning Frequency oofF ui mentFoal- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surf es and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan - Food Contact Surfaces of Eaui stent* Sheilfisft" 4-703.1.1 Methods of Sanitization-Hot Water and 3-201.'15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Re MatoAut Game and Wild Mushrooms Approved by 2-301.1 1. Clean Condition-Hands and Arens" hori 3-202.111 Shellstock.Identification Present:k 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash' 3-201.19 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11 Eatin ,Drinking or l7sin=Tobawo"` 3-202.11. PHFs Received at Proper in eratures* 2-401.12 Discharges From the Eyes,Nose and 3202.15 Package Integrity, Mouth` 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventine Contamination When Tasting* 6 Tags/Records:Shellstock 1.2 Prevention of Contamination from Hands 3-202.19 Shellstock Identification* 590.004(F) Preventing Contamination from 3-203.12 Shellstock Identification Maintained'° Etn ilo•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* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205,11 Accessibility.O aeration and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 S.ectializedProcessin Methods* Devices 3-50212 Reduced os en acka ring.criteria'" 6-301.11. Handwashh Cleanser,Availabilit 5-103.12 Conformance with A. roved Procedures" 6-301.12 Hand Dryin r Provision '"I)enot critiad item in the Federal 1999 Ford Code or 101 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: h ) C Q _ Zl Date: 3 �7-6� Pager of Item Code C—Critical Ite DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item "" Verified 6� ..PLEASE PRINT CLEARLY - GU SIP 1tf -W, a / .0 u h �- d II II __ / E N:/ a i /ter e Ae 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 ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Emersion P ❑ Re-inspection Scheduled ❑ Emergency Suspension rpomply with all mandates of the Mass/Federal Food Code I undeyttand that . noncompliance may result in daily fines of twenty-f' d r uspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According;to Law Coaled to Factors(Items 1-22) (Cont.) 41."F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs Food or Color Additives 19 PHF Hot and Cold Holding 14 3-501.16(B) Cold PIiFs Maintained at or below 3-202.72 Additives* 590.004(F) 410/45°E 3-302.14 Protection tront Una) roved Additives* 3-501..16(A) HotPHFs Maintained at or abase lj Poisonous or Toxic Substances 140`F * 7-101.11 Identit}4ng Information-Original 3-501.16(A) Roasts Held at of above '13WT. Containers* 20 Time as a Public Health Control 7-102.11 Common Name-Working Containers* 3-501,19 Time as a Public Health Control* 7-201.11 Restriction e (ration-Ston tet* 590.004(H) VarianceRe uirement 7-202.]1 Restriction-Preunce and Use'K 7-202.12 Conditions of Use" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-20'3.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers.Criteria Chemicals* 7-204.12 Chemicals fol Washin,Prod cc,Critexi it* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beveraps with W amino t,bels" 7-204.14 Drying Agents.Criteria* 3 801.11.(B) Use of Pasteurized EaOs* 7-205.I.1 Incidental Food Contact,Lubricants` 3-801.1.1(D) Raw or Partially(eked 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 Packa re Noe Re-served." 7-206.13 Tracking Powders, Pest Control and Monitorin=` CONSUMER ADVISORY TIMEtTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or Id Proper Cooking Temperatures for _ Not Otherwise Processed to Eliminate PHFs Pakhog�us r ""' "D0' 3-401.1IA(1)(2) Eggs 155"F 15 Sec. E--s-Immediate Service 145'F I.5sect 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell -3--401,1 1(A)(2) Camuinuted Fish.Meats&Game Animals-155"F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Per 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,Bnjected Meats- 1550F 15 catering, moble food, temporary and sec. * 3-401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-i 65'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 Anunal Fonds Caked in a practices should be debited under#29- Microwave 165'F:l Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145"F'15 sec. * t7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.1 I(A)&(D) PHFs 1650E 15 sec. " (Items 23-30) 4-403.1.1(B) Microwave-165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness iwernenribns rind risk factors listed above, can be 3403.11(C) Cotumercially Processed RTE Food- found in the following sections crj'lite Food Code and 105 CMR 1400F* 590.000. 3-403.11(8) Remaining Unsliced Polu"s--of Beef Item 1 Good Retail Practices FC 590.000 Roasts* 23. Management and Personnel _ FC-2 .003 iR Proper Cooling of PHFs 24 Fox and Fog Protection _FC. 3 .004 - 25 Equipment and Utensils _F_C_ 4 .0.05_ 3-501.14(A) Cooling Cooked PHF�s from 140'F to Cooling '. 26. Water.Plumbing and Waste i FC-5 .006 ' 70`F Within 2 Hours grid From 70`F 27. Ph sical Facility .F 6 .007 to 410F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient _ _SLnecal�uiremenis_ _ .009 Temperature Ingredients to 4t0F/45"F L30. Other Within 4 Hours* *Denote critical iteru in the federal 1999 Foot Code or 103 Ch4R 590.000. ap i coxwr CITY OF SALEM, MASSACHUSETTS Alww yF% �fn BOARD OF HEALTH �QL q rs 120 WASHINGTON STREET. 41Fi FLOOR ari j SALEM. MA 01970 TEL 978-741-1800 ➢RCG rtNe Fax 978-745-0343 STANLEY USOVIC7. JR. JOANNE SCOTT. MPH. RS. CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to : Owner ' s Name : William A. Busa Name of Establishment : Market Wine & Spirits Address of Establishment : 21 Trader ' s Way Type of Establishment : RETAIL FOOD Application Date : 01/02/2003 Restrictions : Permit for Food Establishment 211-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 47-03 These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT I� CITY OF SALEM, MASSACHUSETTS j <,t BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01 970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT EL# CIJMS . TLK 8*)D ADDRESS OF ESTABLISHMENT Z t d2 &1� S SfA L"VNA MAILING ADDRESS (if different) OWNER'S NAME Q kA-t- ADDRESS CITY LW{ tom. — STATE Met _ ZIP—a7�t2 CERTIFIED FOOD MA G�E(S} CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# 30 HOURS OF OPERATION: Mon.7-Tue, -10Wedr(-(O Thu. -(L) Fri.�Sat. _Sun, lZ-Cp TYPE OF ESTABLISHM FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO �P less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR <:=> NO 4v-63 $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Purs t to L C pter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best n wt g an lie h filed al stat tax returns and paid all state taxes required under the law. 9 to 1361uz_ o G13 S-( 9 C� S Signature Date Social Security or Federal Identification Number Revised 11/25/02 FOODAP2.0m�'Check#&Date J'sew-+r^..�:.,:,,r"--+�,.�r9a.nsy'Y*yrv+89<-:va+waw,n.,w r.-�W#--wTTw.,*+w,..vs/+...,n,.w„«,.+w.-.n..�.�w�.�....^true•-r+��nt:r-cr..--�s+.an:r��+&.ra+,.�.+.�,r"..�^. THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name {y/ // / / Date Ty�oeration(s) Tvoe of Inspection /����iGG> Gbi,�e J ".i!-i T� G/o'4' ❑ Food Service I�Routine Address Risk [d-'Retail ❑ Re-inspection a/ � � Level ❑ Residential Kitchen Previous Inspection Telephone yf_ 8, 00 El Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation /f I/ Lf0 ❑ Caterer ❑ Suspect Illness Person In Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: //;iA- El HACCP Inspector ^ �f Out: Permit No. 03 111 Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 4. Food and Water from Approved Source [116. Cooking Temperatures El 5. Receiving/Condition El 17. Reheating ❑ 6. Tags/ Records/Accuracy of Ingredient Statements El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling ❑ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board andRisk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: //' � Print: T. �� PIC's Signature: Print: Page / of ,) Pages FORM 734A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 1 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 11 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowled e* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment �Z' 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require repotting by Food Employees and 1w, * 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE ;;,g;" Food Contact Surfaces Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-70111 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10` Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301,11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* '' 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating, Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* '111 > Prevention of Contamination from Hands 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destmction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(1) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 71 Conformance with Approved Procedures /HACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: /Vl t 47- /y%.c Date: 611,' 3 Page: of � Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY AZ17 o 9 J - ->c c ..C7cc� T i l lvC�c �G9 C L!.-7r �J 2i l�,a �S � !../,�! [+Te tee•. '(S A•u u i. 4c c ,.. 1...'.,e TH — Te ,7 S ..:v12,.� OTs .. e,- .�, I ec h - r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, nd to Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I u rst.Ind that noncompliance may result in daily fines of twenty-fiv Ilar us entic}n/ evocation of ❑ Embargo ❑ Emergency Closure your food permit. (/ 0 Voluntary Disposal ❑ Other: 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 4I'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-50t.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives' 3-50L16(B) Cold PHFs Maintained at or below 590.004(17) 41°/45°F" 3-302.14 Protection from Unat roved Additives* Ig Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140°F. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1.30°F. * Containers* 7-102.11. Cotmmon Name- or in Containers* 20Time as a Public Health Control 7-201.I I Separation-SUA aee* 3-501.19 Time as a Public Health Control' 7-202.11 Restriction-Presence and Use* 590M04(H) Variance Requirement 7-202.12 Conditions of Use, 7-203.11 'Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Saoitizers. Criteria-Chemicals* POPULATIONS(HSP) _ 7-204.12 Chemicals for Washtn¢Produce,Crrferia* 21 3-801.I I(A) Unpasteurized Pre-packaged Juices and 7-204.14Drvm�Agents. Criteria' Beverages with Warning Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized hags* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Conked Animal Food and lit Raw Seed S routs Not Served. 7-206.1313 Tracking 7-206.12 Halt StaEionsStations* 3-801.11(C) Llno uened Food Packs>e NotRe,-served. Powders,Pest Control and Monitorin�* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.71A(()(2) Eggs- lis°F 15 Sec. Pathogens. . Ee-s-Immediate Service 14501715sec+ 3-302.13 Pastern ized Figs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eats* Animals- 1550F 15 sec. * 3-401.11(B)(1)(2) PatkandBeefRoast- 130°F t21 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Mcats- 155'F 15 590.009(A){D) Violations of Section 590.009(A)-(D)7in vee catering mobile food, temporary and 3-401.11(A)('3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should 5tumngcontamingFisu Meat, u.a,wa .;ndei the - r rr_i..t Poaltn'or R itites-165'F 15 sec. * above if related to foodborne illness 3401.11(Ch3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 14511F is 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.I1(A)(1)(b) A(1 Other PHFs-145'F 15 sea I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. a (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 Time* f todhorne illness interventions and risk factors listed above, can be 3-403.11(C) Conunercially Pnxessed RTE Food- found in the following sections of the Food Code and IDS C.MX 140-171 590.000. 3-403.'I I(E) Remaining Unsliced Portions of,Beef Item Good Retail Practices FC 590.000 Roasts* _23._ Management and Personnel FC-2 .003 1$ Proper Cooling of PHFs 24. Food and Food Protection __FC-3 .004 25. Equipment and Utensils _ _ -C 4 .005 3-501.14(A) Cooling Cooked Pl Fs from 140°F to 26. Water Plumbin and Waste FC 5 006 70°F Within 2 Hours and Froin 70°F 27. Physical Facility FC-6 .007 to 41'F/45'F Within 4 Hours.* 2I 8. Poisonous or Toxic Materials IFC-7 .00S -- 3-501.14(B) Cooling PHFs Made Froin Ambient -29- _SLecial Requirements_ 009 Temperature Ingredients to 41'F/45'F 30, Other Within 4 HoursA s llb4r Denote.,critical item in the federal 1999 Fuod Cxle w 1015 ONIR 390.0011. Cr r f Massachusetts Department of Public Health 'a Salem Board of Health 120 Washington Street,4'"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name \ Date T of 0 eration(s) Dgpe of Inspection Food Service Routine Address l Risk Retail Re-inspection Level Residential Kitchen Previous Inspection Telephone C/ O ❑ Mobile Date: Owner HACCP Y/N El Temporary ElPre-operation h ^ „� y.. ❑ Caterer ❑Suspect Illness Person In Charge(PIC) Time ❑ Bed 8 Breakfast ❑General Complaint Inspector OPermit No. ElOt BCP U : Each violation,checked requires an explanfliown the narrative page(s) and a citation of specific provision(s)violated. I Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) 13---590.909(F)-n action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT- ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties E]_ 13. Handwash Facilities EMPL_OYEE HEALTH, - PROTECTION FROM CHEMICALS ..n. ❑ 2. Reporting of Diseases by Food Employee and PIC " r El14.Approved Food or Color Additives El 3. Personnel with Infections Restricted/Excluded _ _____� -- E] 15.Toxic Chemicals FOOD FROM APPROVED SOURCE El 4, Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition [11.6. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Pians ❑ 18.Cooling PROTECTION FROM CONTAMINATION _ _ , x , 1-i [119. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ­ ­ El 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATI--T ONS_(HSP)' El21. Food and Food Preparation for HSP [:110. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices [CONSUMER ADVISORY' - _ ` ❑22 Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-4)(9590.90.0 0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water,.Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing PH28. Poisonous or Toxic Materials (FC-7)(510.008) 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: I r S.5901nspstFgmB-14.a N n Inspector's Signature: Print: �. . 1 PIC's Signature: Print: G r ` Page of ages -D & i��t�tQ �i �o � CA, Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION $ Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(1,) Raw Animal Foods Separated from 1 590.003(A) Assisttment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3302A I(A)(2) Raw Animal Foods Separated from Each Other' EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables a liamts* 3-3(4.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Fooll Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3306.14(A)(B) Returned Food and Reservice of Food* 590.003(G)___ Re orcin b Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.1.1 Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources FOE Food Contact Surfaces 590.004(A-B) Compliance with Food law* 4-501..1.11 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* _ 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-HotWater 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH; 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101.1.1 Drinking Water from an Approved System 4-601.11(A) - Equipment Food Contact Surfaces and- 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food- Shelffish and Fish Fron an Approved Source Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and - 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chernical* Sources* _ 10 Proper,Adequate Handwashing Game and Mushrooms Approved by Ra MatoAuthord 2-301.11 Clean Condition-Hands and Arms* Aut 3-202.1.8 Shellst(vk Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms" 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2.401.12 Discharges From the Eyes, Nose and 3-202.15 PackageInte,,it * Mouth' - :3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shelistoch 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 ShellstoekIdentification Maintained* Em to ees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3402.12 Records.Creation and Retention* 5-203.11 . Numbers and Capacities* 590.004(J) Labeling of ingredients* 5-204.11 Location and Placement* q 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 packaIring,criteria* 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures* 6-301..1.2 Hand Drying Provision *Denotes critical item in the federal 1999 Foot Code or 105 CNIR 590.000. CITY OF SALEM ' BOARD OF HEALTH Establishment Name: tSc c 4 �rt�QOrtC1J Y��,� AV,, ate: Page: - �f Item Code C-Critical ee16/ LJ DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date. No. Reference R-Red Item �-t- �r_y verified _ PLEASE PRINT CLEARLY 0"4 tX A 4.Pm i(.+Z2/ LLD P)e'1S`Li. n p �. )Aigz -C�P >nL. o�_iir ., Q D" + i /_) t' .\;I,? "ti - Sly Discussion With Person in Charge: Corrective Action Required: ❑ No / X I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee! est is ion/ violations before the next inspection, to observe all condition as escribed, and to Exclusion p � ❑ Re-inspection Scheduled ❑ Emergency Suspension r comply with all mandates of the Mass/Federal Food Code. I and rst nd that noncompliance may result in daily fines of twen�/doll rs or us` ension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. / G ❑ Voluntary Disposal ❑ Other: � r 3-50I.14(C) PHFs Received at Temperatures Walatlons Related to Foodbarne Illness Inrervenflons and Risk According to Law Cooled to Factors(Gems 1-22) (Cont.) 41'F45`17 Within 4 Hours. PROTECTION FROM CHEMICALS 9 CHF Hot and Gard Holding 3-501..15 Coolie Methods for PRFs 14 Food or Color Additives 1 3-501-16(B) Cold PSiFs Maintained at or below 3-202.12 Additives*, 590.0W(F) 410/450 F* 3-302.14 Protection from Unapgroved_Additives" 3-501,16(A)ifi(A) Hot PHFs Maintaineded at or above 15 Poisonous or Toxic Substances 140`17 7-101.11 Identifying Information-Original 3.501.f 6(A) Roasts Geld of or above 1300F, Containers* 7-102.11. Catmnon Name-WorkingContainers* 20 Time as a Public Health Control 3-501:19 Time as a Public Health 6 Centra 7-201.11 Separation-Storage* 7-202.11 .Restriction-Presence and Use* 5W,004(H) VarianceR nirement 7-202.12 Conditions of Use* 7-203.11 'Toxic Containers-Prohibitions* REQUIREMENTS 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONSS(HSP) FOR HIGHLY SUSCEPTIBLE 7-204.12 Chemicals frrr 4Vashi Produce,Criteria* 21 3801.11(X} Ungastsmized Pre-packaged Juices and Drying1-204.14Agents.Criteria* Beverages w th W'antin*Labels* 3-801A I(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact, Criteria* te3-801.1 l(D) Raw or Partially Cooked Animal Food and 7-206.71 Restricted Use Pesticides,CriRaw Seed Sprouts Not Served * ,-206.12 -1 Rodent Bait Stations* 3-801.iI C Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY T[MEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for PHFs - Not Otherwise�Procvssed to Eliminate Patbogens.* 3-401.11A(1)(2) Eggs- 155F 15 Sec. fMa *,nronr E os-immediate.Ser icc 145'F15sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E * .Animals-155'F 15 sec. 3-401.I1(B)(I) 2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-461.11(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section .590.(1(19(A)-(D)in sec.* catering, mobile food,temporary and 3-401.1.1(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec, * above if related to foodborne illness 3-401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F" 590.019 violations relating to good retail 3-401.12 Raw Animal Foexls Cooked in a practices should be debited under#29- Microwave 165°F' Special Requirements. 3-40LII(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES t.. 3-403.11(X)&(D) PHFs 165'T 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time" foodborne illness interventions and risk,factors listed above, con:be 3403.11(C) Commercially Processed RTE Food- found in the following sections.of the Food Code and JOS CMR 1400F* 590.000. 3403.11(E) Remaining Unsiiced Portions of Beef nem 1 Good Retail Practices 1 ,17C 590.000 Roasts" 23.-- ; Management and Personnel -'; FC-2 .003 1g Proper Cooling of PHFs 1 24. Food and Food Protection FC-3 .004 25. 1 Equipment and Utensils IFC-4 .005 1 3-501.14(A) Cooling Cooked PHFs from 140`F to 26, Water.PlurrlbiM and waste FC-5 .006 700F Within 2 Hours and From 70'P 27. 1 Physical FaciNty 007 to 41`F/45'F Within 4 Haws. * ! 28. ' Posonous or Toxic Materials FC-7 ooll 3-501.14Ct1) Cooling PI{Fs Made From Ambient i 29. Special R uiremenis - .009 1 Temperature Ingredients to 41017/45° 30 I Other _T-i- L_ Within 4 Hours* .;D nvtrx;critical stain in the L-deral 1999 Food Code or 10 CMR 590.000. 1 r Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'b Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Nam Date T e of Operation(s) Type of Inspection 91 Food Service 4/1 Routine Address 1-1Retail ] Re-inspection ^ Level Residential Kitchen Previous Inspection Telephone h c1 ❑ Mobile Date: Owner / 6 HACCP YM El TempoCatera ary ElPre-operation El Suspect Illness Person in Charge PIC El Bad&Breakfast g (PIC) ! - e _ D Time (}V� [I General Complaint In: El Inspector l'- . Out' Y Permit No. ElO herr- Each violation checked requires i xplanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking , Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.609(E),p 590.00eip-6 action as determined by the Board of Health. [FOOD PROTECTION MANAGEMENT - El12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH.® PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ____-. �__ ❑ 15.Toxic Chemicals 4FOOD FROM.APPROVED SOURCE TIMElTEMPERATURE CONTROLS P ❑ 4. Food and Water from Approved Source (Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing [REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO PULATIONS_(HSP)' E] 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices .CONSUMER.ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C iv by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-z) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-4)(5590.090.0 054))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION:�_ *m 2 S.590MA Y 0r 44.x Inspector's Signature: Print: OI_ Y� 1.C 0 AOA PIC's Signature: /- Print: Page of�-ages U r 1 Violations Related to Foodborne Illness interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION S Cross-contamination _ FOOD PROTECTION MANAGEMENT 3-302.11(A)(1,) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge` Contamination from Raw Ingredients 2-103.11 Person in charge -duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH• Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Fond Protection* require reporting by food employees and 3-302,15 Washing Fruits and Vegetables , applicants* 3-304.1.1. Food Contact with Equipment and 590.003(F) Responsibility Of A Fool Employee Or An. Utensils* Applicant To Report To The Person In Contamination from the Consumer Chat 590903(G) Reporting b Disposition of Adulterated or C Person in Charge* 3-306.14(A)(Ft) ,Returned Food and aced or C of Food* 3 590.003(0) Exclusions and Restrictions* Contaminated 590.003(E) Removal of Exclusions and Restrictions 3-701..11 Discarding or Reconditioning Unsafe Fes* FOOD FROM APPROVED SOURCE 4 Food and Water From Regulated Sources <) Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Fo0ti in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-HotWater 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Ergs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water* concentration and hardness. * 5-101.1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food Shellfish and Fish From an Approved Source Contact Surfaces and Utensils" 4-702.11 Frequency of Sanitization of Utensils and 3-201.,14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and uMushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arens* 3-202.18 ShellstockIdentification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* nimal 3-201.17 GameAs* It Good Hygienic Practices g ReceivinglCondition 2-401.1 t Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges.From the Eyes,Nose and 3-202.15 Package integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records;Shellstock L12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 59004(,E) ,Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Em to ees* TagstRecords:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling ofIngredients* 5-204.11 Location and Placement* g Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 S eciaii,. d Processin Methods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with A. roved Procedures* 6-301..1.2 Hand Drying Provision 'Denotes critical item in the federal 1999 food Ca$or 101 CMR 590.0(10. CITY OF SALEM BOARD OF HEALTH /, Establishment Name: of Date: 16-LO-10 Page:_ of nem Code C-Critical Item U U DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date-- No. Reference R-Red Item Verified PLEASE PRINT CLEARLY _o p-� � V A ' tom- W,p'n AA rG ( n u,L v V n (n') �i (� Mr - �5�I f1U , 1 a� t�U , �'t fs? �n � D V Srg9 2 n 0 UO. 1` cV.d \ 0 N A.P n.a A&IAAe C 1 1 ( V 0I4 IN R/I.tI'Ap rio �C3./L ,,fJOAA ,, 0A `Cln njtjn 1 C_-VP 0- /_ n t 1 IQn P A , k /, "n d . I Discussion With Person n Charge: U Corrective Action Required: JA No 1 1, Yes A 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 descrExclusion ))tsed, a d to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I ut derstaW that noncompliance may result in daily fines of twen�W'five dollar for susKension Fev dation of o Embargo ❑ Emergency Closure your food permit. / � /'' � ❑ Voluntary Disposal ❑ Other: i 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items I-V) (Cont) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Not and Cold Holding 3-501.16(B) Cold PHF;Maintained at or below 3,202.12 Additives*" 590.004(F) 41°/45°F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at 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 s Public Health Control 7-201.11 Se aration-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Present a and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTSS(HSP) HIGHLY SUSCEPTIBLE POPUONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* LATI 7-204.12 Chemicals for Washin Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Bevem es with Warning Labels* 7-204.14 'n encs.Criteria* 3-801.11(13Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801..11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* y 7Raw Seed Sprouts Not Served.* -206.12 Rodent Bait Stations* g Powders Pest Control and 3-801.11(C) Unopened Food Packs Not Re-served. 7-206.13 Tracking Monitoring* 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 3401.11A(i)(2) Eggs- 155°F 15 Sec. Patho ens.*eHedi"t Eggs-immediate Service 145°Fl5sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3.441.11(A)(2) Comminuted Fish.Meats&Game E Animals-155'F 15 sec. 3401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS _ 3.401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food, temporary and 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 3.40Lll('C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited tinder#29- Microwave t65'F* Special Requirements. 3401;11(A)(1)(b) All Other PHFs-145°F 15 sec. 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3-403,11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3403.11(B) Microwave-965'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and riskfactors listed above,carr be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Nem Good Retail Practices .FC 590.000 Roasts* 123. ! Management and Personnel FC-2 .003 "I r24. Food and Food Protection FC-3 .004 i 11; Proper Cooling of PHFs ---r-� 25. Equipment and Utensils � FC-4 .006 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water.Plumbing and Waste FC-5 .006 70'F Within 2 Hours and From 70'F _ 27. Physical Facility_ FC-6 007 to 41°F/45'F Within 4 Hours.* 26. Poisonous or Toxic Materials 's FC=7 8 3-501.14(B) Cooling PRFs Made From.Ambient 29. -Special Requirements .003 Temperature Ingredients to 41'F/45'F 30. I Other Within 4 H<wrs* s:svox„m...N zm:. *Denotes critical item in the federal 1999 Foal Cale or 105 CMR 590.000. ` 21 Traders Way Highlander Plaza Liquors, Inc s City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-8700 Handwash Facilities FAIL Critical RED Owner: Comment:Men's room missing soap. Provide soap at all handwash sinks at all times. William A. BUSa Violations Related to Good Retail Practices (Blue Items) PIC: Food and Food Protection FAIL Critical BLUE Mike Gillen Comment: Dish soap observed in women's room and knives observed in men's room.Glasses were also observed on a rack Inspector: between the restrooms.No cutting of any food is currently permitted at this establishment,and all wine tastings must use single serve cups only. Elizabeth Salandrea Equipment and Utensils FAIL Non-Critical BLUE Date Inspected:Correct By: 9/15/2009 Comment: Pepsi fridge needs thorough cleaning sand sanitizing in door tracks. Risk Level: Same unit also requires a visible,accurate internal thermometer. Physical Facility FAIL Non-Critical BLUE Permit Number: Comment:Sinks in restrooms are not draining properly. Please fax work invoice for repairs to the Board of Health; PIC states they BHP-2009-0149 are to be fixed today. Status: SIGNED OFF #of Critical Violations: 2 JTime IN: ` Time OUT: Urgency Description(s): BLUE: Please fax work invoice for restroom sink repairs and July and August extermination receipts to the Board of Violations Related to Good Health within one week. Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately ' or within 90 days) r City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 ,GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 15,2009 ) Page! of2 r„ s Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) i City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 "GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 15,2009 ) Page 2 oft 1 * CITY OF SALEM z BOARD OF HEALTH / Establishment Name: jN\a,f et K 4W c. ind Date: '�Rfi Page: of Date Item Code( C-Critical Item , �W 'x `- s y DESCRIPTION OF,VIOLATION/ PLAN OF CORRECTION ,# �, Verified " No.,,, -Reference. R-Redltemrq. - r u '^�'' Y" '!c',. .*: `a"d` ��7i •^" �i'," ='s;.'!`f' r A - "" PLEASE PRINT CLEARLY =-• _ `" -00( Inc, C- j rov-+iRQ in-510ecton Ck+ (i5bMVn-t k11v�f c rk1 I� 1 'K"kerA ohserue�l (YlcaAt (� fh50eC�x lAffS � olcl by tn�ccvDctrl Udi rte( (�i/ per tczy ;. a )Ivij9_ -I-C4S+r)" < CAOCI so -tiYr05 .Servec I wrt�q Wi �q�In aS �r V Ch ee.Se f)JYC WCe`P trnY�l ��1Gu� c Ct U 4iLd with it Viivvs 0641,4 in v , , t��'Si- roles i F�ctblishr>1�,�� (lues tm� ��-ve -tt�e -�-ce�� IFIeS e�t�;.avrtp.��f- -15 :t�r;�� ry clvo r Ca rl ,Ccin'4;?,e ciL-)600 o(- � r+�vtSi l< Inca do�� i^si� I1& 0? rx Cerci= 'It;c/ O -1p-A r`e ow clfi, � nr �� r11 tCP rn Q nv hr �rnCcY he_ c-�rv-Ilue�nnc� cel` -P �a h'Ii.�h f • � wln�, �S �� vwc6 . l� � U5-I �2 �vtl�t S�. vYc{ �h SInc, e -u,�P Cu c . � CXnY 'tYDP. � C >°Pr�52 O wig lescyd e , ,- - L Le � (�r\� ;� I� Si n cl p —c1,g P t 7'f"�P 1151 S �`, �E eetalell��v��vrrt wr. (1e5 I r . -kD i ex. A-o z (1a,) 4&--s] 1r)r��e) ke.rviC2_ V)V( �o QQ{ (t�1 TTSt Iih rieeNt �''1 iSCteS tlQ.n-, Ond C.�lclrle.e. v Sanl 'arra I Discussion With Person in Charge: Corrective Action Required: L) No ❑ Yes r I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance Cl Employee Restriction/ 1 Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension i comply with all mandates of the Mass/Federal Food Code. I understand that F .noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �� LiVoluntary Disposal 0 other. F Violations Related to Foodborne illness Interventions and Risk Xxxlrdiq,to Law Cooled to Factors(Items 1-22) (Cont) __ 4 1 IF14Y F Within.}Hour.;. ' t_35(TI, PROTECTION FROM CHEMICALS L _C_2�ljjw,�,Meffiods for PHPs 14 i Food or Color Additives !9 PHF Hot and Cold Holding Cohl PHI Maintained at or below 3-202,12 A(Icbtjvoa* 590,0(14(F) I I*/45"F- 3-302,14 Protection firrituLLI'li)kro,'!�d MdiuyL 3-501 INA) Hot PHI s%frablabled at or above I5 Poisonous— Poisonous or Toxic Substances 14(0),F, 101.11 Identifying Information - Ori.mal Roasts Held at of above 130-F. Cornainera� as a Public Health Control 1 Common Ninne - Workint,Containers* 20 _ Tune 3_30i'19 Tiaw,as a Public iieZh Control, 7.201.11 S�Parauon li90'004(11) Vari 7-20111 Re"tricurin -Prest-ncr and Usew arlcc_Raulrclrl�fjt _ 7-2()2.12 coaditrom of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 9203.11 Toxic Contahaw- POPULATIONS(HSP 7-204.11 Sanitizers'Trlteria-ch­e"l*llicnls' 7-20412 chenlicAls 21 7204= 14 _Dryi!!aAvevts rata rW 1-801 I I(B) Uz of,pa,tew iz(zcd E 205.3 i Inci&naal Forsil Contact,Lube scants' 1-1-06.11 l2cstrictcd L'Se fle'ticides�criteaul, 3-801,11(t)) Raw or Pailililly 0,oke([Aaunal Food and Raw St M Sirrouis Not Scrved, L106 2 Rt stein B41 11'In 3,80 1 ",XXI PaLkagr Not Re-served. _711 _0 I L 'k T, 7 2fl 3 Tracking P,(�..Ilier,, �'(ruthul ,d NJ Monitorin., CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3 A 'oro Mar 1 (IN isoi v flostd tor C(litnimption of Anirnl,l Paw, Undercookcl u, a roper Cooking Temperatures for Not 0dierwise Pnw.e�ised to Fliunnare PHFs 3-40 Ll I A(l)(2) Eggs- 15,5'F 15 S,,c. jrrunadiaw Servicc 145'F)5sec' Li Paiteori%,dl ggl;Subsutur,l for Raw Shell 1-4()LIJW(2) Cumalinuiled Fish, Meats& Gzane Annuals 1_55"F15 sec 3-40Ll1U3)(I)(2) T(alk ;7dlloef Roast 1301� 121 nell-17 SPECIAL REQUIREMENTS ... ....------------------ in 3-X10]-]iRaiitce, Inicoed MeaP, - 1 5 F 15 oatorinmobilcr ftx.xitemporary and residfm iial kitchen opLwations should be i_4()I.IllAr(3) Poultry, WiliFiallie. Slufred PIqFs' Stuffill dI, gConlailling Fish, Meat, 'hiled under the appropriate qectrojis --louln orRathes-i65"T'.IS sec� above if related to Oodhorne Illness 3-40LWC)(3) Whole-musde. Intact Bccf Steaks intei ventions trod ds'k factom Other 145"F* 590.009 violations relating to good rela!I 3-401.12 Raw Animal Footk Cooked to a piactices should be debited under#29 - — Microwavil! 165'F Spec ual Requirements. M Other PHI, 145'F 15 sec, LILL_ Reheating for Hot Holding ry VIO"TIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1 HAT&(D) P14F.i I85)F 15 sec, (Items 23-30) �-403AYB) Microwave- 165'V2 Morino Staildin.,, it, found ix tlwfol[I�mcg so lit)m Me Food Code and 10-5 CrIlt �3- 3.11(C) Cornmercia .'Processed IiTFT1Xj 590.000, � f-eno oaseni ac� 3-40311(E) Rerrainin,C"I"jd PortionsPortionsof I, ,,1 rcn ' N1 na nt.�nd Personnel FC -2 003 ees FC �59n OW _an qjjrae_ ---1--- 1-24, fij,,N)d and Fixxi-pnDiectio'n FC_3 til Ig Proper Cooling of PHFs —�T_ HP -1 501,14(A) Cooling C(7XoRrA PHFs froni 140F t 1 4, 2 If 17 in our"l�j( roba 71atei FC , ' -1 H_ 70�17 Within 2 liour�'and From 701 F -71- 7 P -6 -PlInf w4l"F/45ll Within 4 26 1 Porsollous or Toxic 5 k9 �W9 '008 aisint Rcqu r501 141 Cooling PHFs Made Front Ambient Temperature Ingredients to 41'F/45 IF o' Other-------- -------- _.Wjthin4Hour0 Dmlles aitical Item is Th, f"Clent! N99 Foml Cl)&ar 105 C k%5911000, MAssachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 - Namate Tvoa of Ooeration(s) T e ,Ins ection r - 5 LJF Service outns Address `. Risk etail ElHe-inspection Level El Residential Kitchen Previous Inspection Telephone q'n I C 5 ❑ Mobile Date: Owner HACCP Y/N 0 Cate erTemporary ElPre-operation ❑Suspect Illness Person in Charge(PIC ( r Time ElBed&Breakfast El General Complaint Inspector 0 0 , Permit No. ElO herr Each violation checked requires an explaa ion on the narrative page(s) and a citation of specific provisfon(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) 590.009(F) ET 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 LEMPLOYEEHEALTH� .- ,�.___ -- PROTECTIONFROM CHEMICALS"""' " ° N- ** ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded r,_, -__- __ ❑ 15.Toxic Chemicals FOOD FROM.APPROVED SOURCE ' 1 _ 7 uti, ❑ 4. Food and Water from Approved Source 7111iE/rEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans 18.Cooling 'PROTECTION FROM CONTAMINATION- ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing LRE RIUOLRE EMEN7S FOR HIGHLY SUSCEPTIBLE POPULATIONS_(HSP)! 21. Food and Food Preparation for HSP E] 10. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices CONSUMER El 22. of Consumer 22 Posting of sumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below C x by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2)(e90.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3)(990.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: -,/ 2,o-- kc s:sw�nspec�o„s-�a.ex Inspector's Signature: Print: PIC's Signature: Print: G a? Pagel of,2ages f N Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-3021.1(A)(1) Raw Animal Foals Separated from '1 590.003(A) Asia meat onl es onsibilit 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* Contamination from Raw Ingredients' 2-1.03.11 Person in charge-duties 330211(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(0Responsibility of the person in charge to 3-302.11(A Fiord Protection* require reporting by fad employees and 3-302.15 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(1) Responsibility Of A Foal Employee Or An * Applicant To Report To The Person In Utensils Contamination from the Consumer Charge* 3-306.14(A)(,B) Returned Fad and Reservice of Food* 590.003 G Reporting b Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701,11 Discarding or Reconditioning Iinsafe 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 Warewasbing-Hot Water 3-201.1.2 Foal in a Hermetically Seated Container* Sanitization Tem ratures* 3-201.13 Fluid Milk and Milk Products* 4501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eg2s 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 DrinkingWater from an Approved System* tem* 4-001.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- -Shellfish and Fish From an Approved Source Contact Surfaces and Utensils`" 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP lasted Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Ri5gulatory Authortt 2.301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Clearin Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices g Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.1.5 Package Integrity* Mouth* 3-101.11, Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tastin " 6 Tags/Records:Sheiistoc4 12 Prevention of Contamination from Hands 3-202.18 Shellshxk Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* - Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Record;-Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(1) Labeling of Ingredients' 5-20411 I-eication and Placement* q Conformance with Approved Procedures 5-205.17. Accessibilit ,Operation and Maintenance 7HACCP Pians Supplied with Soap and Hand Drying 3-502.11 Specialized processing Methods* Devices 3-502.12 Reduced oxygen acka hg.criteria* 6-301.11. Handwailaing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision °Denote critical item in the federal 1999 Food Code or 105 CMR 590.000. ,4 CITY OF SALEM BOARD OF HEALTH el Establishment Nam11n.a 1_, 4 ) '; I 1t ,CJ. Date: rV J� — l .�, Page:_ of Item Code C—Critical itbrh U DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date. No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 'P/�nn r� —.nrz 45�,AAN�c.�- , 111-1, �- l- yZy [ �o� a u-allk 04 )C-4jrA e\ 00, 1 G 441AM: �"' V C int n nn 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 Z7voluntary Compliance El Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twe y-five do7�s or uspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. VdAk- ` 5 17i ❑ Voluntary Disposal ❑ Other: r 1 3-507.14(C) FHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'R45°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHF5 14 Food or Color Additives 19 PHF Not and Cotd Holding 3-20212 Additives* 3-501.16(B) Cold PRFs Maintained at or below 3-302.14 Protection from Unapproved Additives* 540'0()4(17 41 145 F 15 Poisonous or Toxic Substances 3-50L 16(A) Hot PHFs Maintained at or above 7-101,11 Identifying Information-Original ;- 140`ts 501.76(A) Roasts Held ae or above 130"F. * Containers* 7-102.11. Common Name--WorkingContainers* 20 Time as a PuHealth Control 7-201.L 1 Separation-Storage* 3-501;19 Time as a Public c Health Control* 7-202.11 .Restriction-Presenceand Use* 590.004(H) VarianceRc Require 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS FISP 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged luices and 7-204.14 Dry=Awns.Criteria° :Beverages with Warping Labels* 7-205.11 Incidental Foal Contact,Lubricants* 3-801.11(6) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-801-II(D) Raw or Partially Cooked Animal Food and ?06.12 Rodent Bait Stations* Raw Seed Sprouts Not ServetL* n 3-801.11(C) Unopened rood package Not Re-served. 7-206.13 Tracking Powders,Pest Control and ^` Monitoring* CONSUMER ADVISORY TIMETTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Faxls That are Raw.Undercooked or PropHFs Not Otherwise Processed to Eliminate Patbo yens.*2ra,cnc anaxrr `3-401.IIA(1)(2) Eggs- 155F 15 Sec. Eggs-Immediate Service 1450F15sec* 3-302.13 1 Pasteurid 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) Pork and Beef Roast- 130'F 121 min* 3-401A I(A}(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering, mobile food,temporary and 3-401.1 i(A)(3) Poultry,Wild Game,Staffed 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 Fo h;Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-40LII(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(AA)&(D) PHFs 165'F 15 see. *_ (Items 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing Critical.and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3.403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3403.11(E) Remaining Un,liced Portions of Beef Rem {_Goad Rstaif Practices J .FC 1 590.000 Roasts" i 23_ i Maaapamant and Personnel ! FC-2 .0031 1g Proper Cooling of PHFs i 24. _ I Food and Food Protection FC-3 .044 1 25. 1 Equipment and Utensils IFC-4 .005 i 3-501.14(A) Cooling Cooked PHFs from 140'F to ` 26. r1. Water.Plumbing and Waste 1 FC-5 006 1 70'F Within 2 Hours and From 70'F 27. Physical Facility FC-6 to to 4I'F/45'F Within 4 Hours. * I_28` t.Poisonous or Toxic Materials FC-_7 .008 i 3-501.14(B) Cooling PRFs Made From Ambient 1 29. (, Special Requirements i - ,009 Temperature Ingredients to 410F/451 30, Other Within 4 Hours" 'Denotes exincal ivnt in the fedenil 1499 FoW Cafe ar105 CMR 590.000. s } . Commonwealth of Massachusetts City of Salem s e Board of Health 120 Washington Street,4th Floor Kimberley Driscoll SALEM,MA 01970 Mayor Food/Retail Establishment Permit DATE PRINTED: 12/29/2011 ESTABLISHMENT NAME: Highlander Plaza Liquors, Inc File Number:BHF-2004-000030 21 Traders Way Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2012-0156 Jan 1,2012 Dec 31,2012 .$70.00 f WATER SOURCE: CITY WATER SEWER DISP: CITY WATER TOBACCO VENDOR BHP-2012-0171 Jan 1, 2012 Dec 31,2012 $135.00 Total Fees: $205.00 `PERMIT EXPIRES IDecember 31, 2012 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted " in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by,the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS s�•Tt. BOARD OF HnA-LTH 120 WASHINGTON STREET,4" FLOOR TF.L. (978) 741-1800 KINIBERL.EEY DRISCOLL 1-,AX(978) 745-0343 MAYOR h atnchnQsalem.com 1,A]MY RANVIN,WS/ItH IS,CI 10,CP-I*S HiiAlal l A( IFNf 201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT k tc)M& L P ai.4 L+c, u vr, TEL# q7q 74S- 0 p O ADDRESS OF ESTABLISHMENT 611 T(-d„e,.s Loc,.., FAX# �-K ITZ (o31`7 MAILING ADDRESS(if different) EMAIL- Business': pp Website: OWNER'S NAME W t I k-. 6Sc, TEL# 9jj( $G f I W, ADDRESS](I P.2of 4 o( ( tee[ uw l oro4.o STREET - CITY STATE ZIP CERTIFIED,FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYSOFOPERATION. Monda Tuesda WeCriesda Jhursda • Frid Saturday Sunda HOURS OF OPERATION (�3i - /U Please write in time of day. 30 /t] (S 1�5 J (For example 11 am-11 pm) j TYPE OF ESTABLISHMENTFEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -- ------- ------------------------------------------------------a --- --seats-------------- - ------- RESTAURANT YES ;N6t less than 25 =$140 (Outdoor Stationary Fn,-,d Cart$210) v 25-99 se-,!s =$280 more than 99 seats =$420 --- ---- -- - ---- ----------------------------------------------------------------------------------- --------- BED/BREAKFAST/ YES NO $-4-0-0- 100 CHILDCARE SERVICES/NURSING HOME------------------------------------- ------------------------------------------------------------------- --------------- ADDITIONAL PERMITS- MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES 0 $25 TOBACCO VENDOR YE NO $135 1 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section.49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. zc)w , &&tom ra�rl� --gignature Dae Social Security or Federal Identification.Number Updated 523/11 FOODAP201 l adm Check#&Date , 4O` $ U 1 wig Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Highlander Plaza Liquors, Inc File Number:BHF-2004-000030 21 Traders Way Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0064 Jan 1,2011 Dec 31,2011 $70.00 / WATER SOURCE: CITY WATER SEWER DISP: CITY WATER TOBACCO VENDOR BHP-2011-0065 Jan 1,2011 Dec 31,2011 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH ..r . 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KIINIBERLEY DRISCOLL FAZ(978) 745-0343 MAYOR DGREENBAUNI&ALEM.COM DAVID GREENBAum,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT J TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT C, �/&a4 . Pl^e4 TEL#_. ADDRESS OFESTABLISHMENT.Q11 /416 l 1w11L (AJe.-y FAX# 27Y LI-n 63 /9 MAILING ADDRESS(if different) EMAIL- Business': Website: OWNER'S NAME IJc�I �5�1 // TEL# ) YI 'F(-,/ j t0_6 ADDRESS 33 Ivt2YS 4,� to ,O1 L l VYU O)L-t0-e STREET �' CITY r STATE - ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAY,S`OFOPERATION ' . "Monday ...I'r ,'Tuesday;, i.g_Wedaesday,,.;`, ;eThursdayr.r x, Fnd0j62, IV ;,Saturday .:' I.;,- .=Suhday =w ' HOURS OF OPERATION ! r / Please write in time of day For exampleIlam-11 pm ! I s TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE 1'E NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 — ---- --------------------------------------------------------------------------------------------- RESTAURANT YES �l0 less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seals =$280 more than 99 seats =$420 - - - - --------------------------------------------------------------------------------------------- BED/BREAKFAST/ YES O $100 CHILDCARESERVICESINURSING HOME--------------------- -------•--------------------------------------------------------------------------------------------- ADDITIONAL PERMITS ,�;,,� MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YF-S $25 TOBACCO VENDOR E IW 135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and aid II st taxes r re oder the law. '. ZZ /nL/9/�() Gy 3s/ 5-0 7S' Sim3afunj Date Social Security or Federal Identification Number -------------- ------j---/�------ -- ----'---- ------------------- Revised ionli 1 FOODAP201 Lad------m Check#&Date