ICE SCREAM - ESTABLISHMENTS ICE SCREAM
2 LYNDE STREET
SEASONAL
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p CITY OF SALEM, MASSACHUSETTS
y BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
a SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter I II, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Ice Scream
Address of Establishment: 2 Lynde Street
Owner's Name: Kelly McDermott
Restrictions:
Application Date: 5/28/2004
Permit for Food Establishment 308-04
Frozen Desserts/Ice Cream 23-04
Permit for the Sale of Tobacco Products
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
l oCITY OF SALEM, MASSACHUSETTS
a
BOARD OF HEALTH120 WASHINGTON STREET, 4TH FLOOR MAY 7 — 2004
SALEM, MA 01970
TEL. 978-741-1800 CITY OF SALEM
FAX 978-745-0343 BOARD OF HEALTH
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2004 APPLICATION FOR
PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT C E JC� `E►7I�u 1 TEL#
ADDRESS OF ESTABLISHMENT I L`)N D E � 1 S A LL M MASS, 01V0
MAILING ADDRESS (if different) p
OWNER'S NAME R ELLS M f'bEKHOT TEL#
ADDRESS �03 CORDWALOT
CITY 1 ILMIN(0-10N STATE MASS ZIP 0188
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is pre/pared.)
EMERGENCY RESPONSE PERSON M fi R\) C�"U A H AN HOME TEL# G 176Z6_-713V
HOURS OF OPERATION: Mon. - oTue. 7'10 Wed. `�I I)Thu. q-10 Fri.-/O Sat. ?-/0 Sun. 9110
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. l=$ 50
0 1000-10,000sq.ft. =$100
more than 1 0,000sq.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 YE NO $5
TOBACCO VENDOR YES NO 50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Signature / c Date 7 / Social Security or Federal Identification Number
--------------- j _f-__'L__c2�� ---------------- 0 ---------------
Revised 11/03/03 FO AP2.adm Check#&Date d We
l
I
CITY OF SALEM
BOARD OF HEALTH /
Establishment Name: I e Date: Page: of_L
Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
/J f PLEASE PRINT CLEARLY
4 4J/l e
f
Discussion With Person in Charge: Corrective Action Required: ❑ Nc ❑ Yes
;- I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
3-501-14PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(items 1-22) (Cont) 41'Fi45-F Within 4 Homs.
PROTECTION FROM CHEMICALS 3-501,15 C<wlm-Methods for PHFs
14 Food or Color Additives 14 PHF Hoo and Cold Holding
3-501.16(B) Cold PHFs Maintained at or below
3-202.12 Additwes'r 590,004(F) 41`745°F*
3-302.14 Protection frorn'Una> roved Additives*
i5 Poisonous or Toxic Substances 3-501.1 G(A) Hot PHFs Maintained at or above
1-101.11 Identif3ong information-Original
140°F.
3-501.Lfi(A) Roasts Held at or above 130°F.
Containers*
7-1.0111 Compton Name-Working Containers* 20 Time as a Public Health Control
7-?.01.11
Separation-StCeac&a
3-501.19 Time as a Public Health Control*
.� 590.004(H) Variance Re uiremen[
7-20211 Restriction-Presence and Use*
7-202.12 Conditions of Ilse"
7.203.11 ToxicContainers-Prohibitions"' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11. Samtizers,Criteria-Chemicals*
POPULATIONS(HSP)
7-204.12 Chemicals for W ashine ProdaoC,Criterial21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Drin Agents.Criteria`
Beverages with Warnina lzbels*
E7-2O6.13
11 Incidental Food Contact.Lubricants* 3-801.11(,B) Use of Pasteurized Eggs*
3-801.111) Raw or Par Cooked Ant mal F
t ) t ual and
., Y
1 Resn�icted Use Pesticides.Criteria*
Raw Seed Sprouts Not Served.
12 Rodent Bait dens, P' 3-801.11(C) Uno erred Rood Packa>c NotRe-served- *
'Irackma Powders,Pest Control and
Monitoring*
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods'I'hat are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
Pathogen,.*
3-401.11 A(1)(2) Eggs- 1.55 F 15 Sec.
e,'da a�oi
Eggs-himediate Service 145`Fl5sec* 3--02.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Commutated Fish,Meats&Game Eggs"
Animals- 155°F 15 sec. "
3-401.11(8)(1)(2) Pork and Beet'Roast-130°F 121 min" SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injected Meats-155°F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
see. * 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
Poultr'm Ratites-165'F IS sac. "` above if relatedto foodborne illness
3-40111(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
340112 Raw Animal Foods Conked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3401,11(A)(1)(b) All Other PllFs-- 145°F'15see.
*
i-7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.LI(A)&(D) PHFs 165°F l5 sec. * (items 23-30)
3-103.11(B) Microwave-165°F 2 Minute.Standing Critical and non-crdh'cat violrrtrons, which do not relate to the
Tune* foodbonne illness interventions and risk factors listed above can he
3-40111(C) Commercially Processed RPE Food- found in the following sections of the Food Code and 105 CMR
14WF* 590.000.
3-403.1.1(F) Remaining Unsiiced Portions of Beef Item Good Retail Practices FC 590.000
Roasts* 23. Management and Personnel _-_ FC -2 .003
ig Proper Cooling of PHFs 24. Food and Food Protection _ FC-3 .004
25______.Egui ment and Utensils FC 4 _ .005
3-50t.14(A) Cooling Cooked PHFs from 140°F to 26Water,Plumbin and Waste FC 5 _006
70°F Within 2 Hours and From 70'F 27. Ph sical Facillt�_ FC-6 .007
to 4PFt45°F Within 4 Hours.*. 28. Poisonous or Toxic Materials FC-7 .008
3-501.14('B) Cooling PHFs Made From Ambient 29. _ 5 eoiai R ulrements -T i .009
Temperature firgredients to 41°-/45"F _30, __ Other -
Within 4 Hours;' or ,n„ac-z,a,r
Denote;critical item in the Faic'al 1999 Food Code or 105 CMR 590.060.
CITY OF SALEM
BOARD OF HEALTH
A CC se �- a6 - 0 5l
Establishment Name: Date: Page: � of If
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item - Verified
PLEASE PRINT CLEARLY
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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/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P L3 Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
13 Voluntary Disposal ❑ Other:
� I
3-501,14(C) ,PHFs Received,at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to
Factors(Items 1-22) (Cont.) 41'F/45'F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Coolinly Methods for PHI-1
Food or Color Additives 19 PHF Hot and Cold Holding
1� -T-202 12 Atldttiverk 3-501.16(B) Cold PflF-s Maintained at or belaw-
3-302.14 Protection from Una) roved Additives* 590.004(F))U4(P) 11'145°F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFsMeintainedatorabove
40"F.*
7-101.11 Identifying Information-t)riginal 3-501.16(A) Roasts Held at or above 130'F.
Containers"
7-102-11 Common Name-Working Containers* 2p Time as a Public Health Control
7-201.11 Se.)aration-Storage^'
3-501.19 Time as a Public health ConYrul*
7-202,11 Restriction-Presence and Use* 5-9-0.004(H) Variance Re uiretment
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizes,Criteria-Chentic tls* POPULATIONS(HSP)
7-204-1.2 Chemicals Ynr Washin Protium;Criteria"` 21 3-801.'11(A) Unpastew'iztd Pre-packaged Juices and
7-204.14
Beverages with Warning Labels*
Drigg A eats,Criteria" -
7-205.11 Incidental Food Contact.Lubricants* 3-801..11(B) Use of Pasteurized Ee,gsx
7-206.11 Restricted Use Pesticides.Criteria" 3-801.1 l(D) Raw or Partially CmActl Animal Food and
kaw Seed Sprouts Not Served.
7-206.12 Rodent Bait Stauons* 3-901,11(C) i Unopened Food Packlwe Not Re-served a,
7-206.13 Tracking Powders,Pest Control and
Monitoring*
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
15 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-40'1.11A(1)(2) Eggs- 155'F 1.5 Sec.
Patho ens Elf",'
Eggs-lionnediate Service 145"Fl5sec* .13 Pasteurized Eggs Substitute for Raw Shell
3-401.11.(A)(2) Comminuted Fish,Meats&Game __L311 E gs*
Animals- 155'F 15 sea *
3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS _
3-401.1l(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 wider the appropriate sections
Poultry or Ratites-165'17 15 sea * above if related to foodborne illness
3-4ol.I i(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other
145'F* 590.009 violations relating to good retail
3-401-12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special I2equii entents.
3-401.11(,A)(1)(b) All Other PHFs- 145'F 15 see.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(ll) PHFs 165°F 15.sec. * (Items 23-30)
3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the j'allto ing sections of the Food Code and 105 CMR
14WF* 590.000. _
3-403.11(E) Remaining Unsliced Portions of Beef mem Good Retail Practices FC 58D.(100
Roasts* 23. Management and Personnel FC-2 .003
18 Proper Cooling of FHFs 24. Food and Food Protection __ _F-C-3 .004
25 _ Egpiprnent and Utensils FC-4 .005
3-501.14(A) Cooling Cooked PHFs from 140`F to -"- -- - --- --
26. Water,Plum and Waste FC 5 006
70°F Within 2 Hours and From 70°F 27. Physical Facility FG-6 I .007
to 41'F/45'F Within 4 Hours. ' 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(13) Cooling PHFs Made From Ambient 29_ S euial R uirements _ 1 .009
Temperature Ingredients to 41'F/45'F _30,..- _ Other
Within 4 IIours'k ror ,.n,+wzan�
Denorrs critical item(n tine Federal 1999 Fond Code or 105 CM1R 590.000.
Clti//e� -
IMPORTANT MESSAGE
FOR_
DATE 5 "d� Q� TI MEA.M.
P.M.
i
M
OF G �-Pi/�Iat�J�cy
PHONE 9"7e- 7
AREA CODE NUMBER EXTENSION
U FAX
U MOBILE
AREA CODE NU ER TIME TO CALL
TELEPHONED PLEASE CALL..
CAME TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU RUSH
RETURNED YOUR CALL WILL FAX TO YOU
MESSAGE
c
SIGNED
OpsFORM 009
MARE IN U.S.A.
NOTES
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Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4'"Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name DateT of Operation(s) T e f Inspection C &_ Rid[: Food Service outine
Address ? L Risk El Retail E] Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone
❑ Mobile Date:
Owner ❑ Temporary ❑ Pre-operation
hFLLq 14
`dtrltolo HACCP Y/N ❑ Bed&Breakfast ❑ General Complaint
ct Illness
Person in Charge(PIC) Time ❑ P
Inspector Out: Permit No. El Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
[:FOOD PROTECTION MANAGEMENT. , - , ,, ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
mEMPLOYEE HEALTH- '- - "- <. El 13. Handwash Facilities
' PROTECTION FROM CHEMICALS'
❑ 2. Reporting of Diseases by Food Employee and PIC
El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives
FOOD FROM APPROVED SOURCE ❑ 15.Toxic Chemicals
'- " ' - TIMEITEMPERATURE CONTROLS y "' ` )
❑ 4. Food and Water from Approved Source (Potential) 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 r "`"""` ❑ 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)',
EI21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
El 11. Good Hygienic Practices LCONSUMER ADVISORY❑ ", 'w" w-
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. P 9
23. Management and Personnel (F(3-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (Fc-a)(sso.00s) cited in this report may result in suspension or revocation of
25. Water, Plumbing and Waste (FC-5)(590.008) 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:
5:5901 VWFor -14.do
Inspector's Signature: Print:
PIC's Signature: Print: Page_of Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(Hems 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT S Cross-contamination
1 590.003(A) Assignment of Re onsibility* 3-302.11(A)(]) Raw Annual Fnods Separated from
590.003(B) Demonstration of Know ledge* ; Cooked and RTE Foods' 1
2-103.11. Person in charge--duties Contamination from Raw Ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other`
2 590.003(0) Responsibility of the person in charge to Contamination from the Environment
require reporting by foal employees and 3-302.11(A) Todd Protection- '
a n licants* 3-302.15 Washin Fruits and Vegetables
590-003(F) Responsibility Of A Foch Employee Or An 3-304.71. Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge* Contamination from the Consumer
590.003(0) Re cortin b Person in Charge* 3306.14(A)(B) Returned Food and Resemce of Foo&
3 L590.0(l3(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCEFood*
4 Food and Water From Regulated Sources r 9 Food Contact Surfaces
590.004(A-B) Com chance with Fvud.Law" 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 MechanicalWarewashino HotWater
3-202.13Shell Es s*
Sanitization,Temperatures*
3-202.14 E�=s and Milk Produce.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
concentration and hardness. *
3-202.16 Ice Made From Potable Drinking Water"
5-1.01.11 DrinkingWater from an Approved System,
4-501.1'1(A) Equipment Food Contact Surfaces and
Utensils Clean*
590.006(.4) Bottled DrinkingWater* 4-602.11. Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 21041 Contact Surfaces and Utensils"
Shellfish and Ash From an Approved Source- 4-70111 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of ui ment*
Shellfish* 4703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 �. Proper,Adequate Handwashing
Re MatoAuth
Gama and uMushrooms Approved by 2-301.11 Clean Condition-Hands and Arms*
ori.
3-202.18 Shellstock.Tdentification Present* 2-301.12 Cleanin*Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201..1.7 Came Animals* I it Good Hygienic Practices
g Receiving/Condition 2-401.I1 Eal'in .Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 3401.12 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'1'astina*
6 TagslRecords:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-303.12 Shellstock Identification Maintained" Em to gees*
Tags/Records:Fish Products 13 Handwash Facilities
Conveniently Located and Accessible
3402.11 Parasite Destruction*
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. Onerationand Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Devices
3-502.12 Reduced oxygen packaging criteria* 6-301.11 HandwashinR Cleanser,Availability
8-103.12
vailabilit-
8-103.12 Conformance with A. roved['rocedures` 6-301.12 Hand Drvim,Provision
Denote critical item in the federal 1999 Pond Cale or 105 CMR 590.000.
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street, 4'" Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name Date ion(s) T inspection
6x42 roOae outine
Address 2- L VeQtC sr Risk ❑ Retail ❑ Re-inspection
Telephone Level El Residential Kitchen Previous Inspection
❑ Mobile Date:
Owner �� HACCP YIN [:1 Temporary ElPre-operation
Qx- ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint
Inspector In: ElHACCP
p Out: Permit No. ❑Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE HEALTH - _.a ❑ 13. Handwash Facilities
_ PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC
E] 3. Personnel with Infections Restricted/Excluded E] 14.Approved Food or Color Additives
FOOD FROM APPROVED SOURCE ,,, ' ' ' . " ❑ 15.Toxic Chemicals
J r TIMErrEMPERATURE CONTROLS Potential) Haiardous Foods r
❑ 4. Food and Water from Approved Source (Potentially )
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTIONFROM CONTAMINATION'S _ "'' """"` ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
El 10. Proper Adequate 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
ofOHe Nl ' 590.000/federal Food Code. This report, when signed below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (Fc-a)(sso.005) cited in this report may result in suspension or revocation of
26. Water, Plumbing and Waste (FC-5)(590.005) 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:5MnVp Toren-14 d4
Inspector's Signature: Print:
PIC's Signature: Print: Page_of_Pages
flu. '..xs:. y u-•' ;r
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT S Cross-contamination
1 e90.003(A) Assigutneut of Responsrbilaty* 3-302.1 l(A)(1) Raw Animal Foods Separated from
590.003(B1�Demonstrauon of Knowledge"` Cooked and RTE Foals*
2-103.11 Person in charge-duties Contambevion from Paw-ingredients
3-30211(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other"`
590.003(C) Responsibility of the person is charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) I Food Protection*
a Hearts* 3-302.15 yVashun Fruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge" Contamination from the Consumer
590.003(G) Re porti fig by Person in Charge* 3 106.14(A)(B) Returned Food and Reservice of
Food-
3 590,003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.1.1 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food"
�4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(.A-B) 4-501.111 Manual Watewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization'Pem�erattues*
3-201.13 Fluid Milk and Milk Products'" 4-501.112 Mechanical Warewashing-HotWater
3-202.13 Shell E��s* Sanitization Tern eratures*
3-202.14 F1,p and Milk Products-Pasteurized'" 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Iee Made From potable Drinkinn Water* concentration and hardness.
5-1.0111 Dunkin Y Water from an Approved S stem* 4-601-1'1(A) Equipment Food Contact Surfaces and
[ tensils Clean'
590,006(A) Bottled Drink'irw Water*
590.006(8) Water Meets Standards in 31.0 CMR 22.0* 4-60111 Cleaning Frequency of Equipment Food-
Shellfish
ood-
ShoNBsFish From an Approved Source Contact Surf aces and Utensils*
and
4702.11 Freyneney of Sanitization of Utensils:md
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish's 4-703-11 Methods of Sanitization-.Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical* _
Sources* ToProper,Adequate Handwashing
Game and Wild Mushrooms Approved by &301.1 i Clean Condition-Hands and Arms*
Regulatory Authority ..-_..
3-202.18 Shellstock Identification Present'" 2301.12 Cleaning Procedure*
590.004(0 Wild Mushrooms" 2-301.74 When to Wash- -
3-201.17 Game_Animals" Il Good Hygienic Practices
g ReceivingfCondition 2-401.11 Eatin ,Drinkin or Usin &Tobacco*
3-202.11 PHF's Received at Pru er Tenn eratures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Mouth*
3-101.11 Food Safe and Unadulterated * 3-301.12 Preventing Contamination When Tastilno
(; TagsiRecords:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification * 590.0(F4(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained', Fm nlovees's
Tags/Records: Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Convanienily Located and Accessible
3-402.12 Records.Creation and Retentions` 5-203.11 Numbers and C:a naeit9es*
590.304(.) labeling of Ingredients' 5-204.11 Location and Placement*
Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-5(12.71 Specialized Proeessmglklethods'* Devices
3-502.12 Redaced ex *en nacka rim*.criteria`" 6-301.11. Handwashin Cleanser,Availability
8-103.12 Conformance with A roved Procedures 6-3p].12 Hand Drying Provision
'N Denotes critical item in the federal 1999 Fwd Code or 105 Ci41R 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: ! C!� pjlf.4 roN Date: Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
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/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
�t ti
3-501.14(C) PRFs Received at Temperatures
Violations Related to Foodborne fitness Interventions and Risk According to Law Cooled to
Factors(items 1.22) (Cont.) 4VF145`F Within 4 Homs.
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-501.16(6 Cold PI-IFs Maintained at or below
3-202.12 Atlditives's _ _ )
590.004(F) 41`145°F*
3-302.14 Protection from Una o roved Additives*IS Poisonous or Toxic Substances I lot 3-501.I6(A) Hnt PHFs Maintained at or above 7-101.11 identifying Information-Original F.Containers* 3-501,16(A) Roasts Held at or above 130°F.
7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 _S=Lion-Storage* 3-501.19 Time as a Public Health Control*
7-202.1.( Restriction-Presence and Use*
590.004(H) Variance Requirement
7-202.t2 Conditions of Use"
7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers,Criteria-Chemicals,° POPULATIONS(HSP)
7-204.12 C.`hemtcals for Washnig Produce,Criteria*
3-801A I(A) C'npastew,ized Ike-packaged Juices vtd
7-204.14 Drying guts.Criteria*
Bevet'ages with Y4'arning Labels*
7-205.11 Incidental Food Contact.Lubricants* 3-901_ll(B) Use of Pasteurized Eggs*
7-'06.IT Restricted Use Pesticides,Criteria* 3-801,11(D) Raw or Partially Cooked Animal Food and
Raw Sced S orouts Not Served.
7-206.12 Rodent Bait Stations* :1:-1:11[111(C) Uno oened Fond Packa,c Not Re-served.
7-2-06.13 Tracking Powders,Pest Control and
Monitotim**
CONSUMER ADVISORY
TIMEffEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods'Phat are Raw. Undercooked of
16 Proper Cooking Temperatures for
PHFs Not Otherwise Processed to Eliminate
3401.LIA(1)(2) Eggs- 155°F 15 Sec.
Pathogens.*era><>�o v+:zaoi
E res-hivucdiste Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.1 1(A)(2) Comminuted Fish,Meats&Game
E as*
Animals- t55°F 15 sec. *
3-401.I1(6)(1)(2) Pork and Beef Roast-.130°F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites, Injected Meats-155°F 15 59Q009(A)-(p) Violatous of Section 590.009(A)-(D)in
sec. * catering,mobile food, temporary and
9-401.1.1(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Sonfing 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. Otter
1450.F,. 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165"F* Special Requirements.
3401.11(A)(1)(b) All Other PHFs-145°F 15 see.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(L)) PHFs 165°F 15 sec. * (Iterns 23-30)
3-403.1 I(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, ahtch do not relate to the
Timer, foodborne illness interventions and risk factors listed above, can be
3-403.11(C) Commercially Processed RTF Food- fcmnd in the following sections of the Food Code and 105 CMR
'140"F* 590.000.
_3-403.11(E) Remaining Unsliced Portions of Beef Item Good Befall Practices FC 580.000
Roasts - .003
* 23. Ma
nagement Food
and Personnel FC 2
18 Proper Cooling of PHFs 24 Food and Food Protection _ FC 3 004
25 _ _E m ment and Utensils _FC 4 '. .005
3-501.14(A) Cooling Cooked PHFs from. 14(Y'17 to 26 Water,PWmbino and Waste FC 5 j0005
70"F Within 2 Hours and From 70"F 27. Ph Ical_FaMIt ___ FC-6 A07 --
ao 41°Ft45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(8) Cooling PITFs Made From Ambient 29 5 eciai Re uirements 009
- -- =
Temperature Ingredients to 41°F145"F 30.__ Other _ --------
Within 4 Hours'" no-„.4rs.z.un
"Denotes critical item in the federal 1999 Food Code or 105 C61R 590,000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: leel 4Mr tff wi! Date: Page: of
Item Code C Critical Item DESCRIPTIONOF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
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 Exclusion
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of Cl Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal 0 Other:
3-50I.14(C), PRFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Items 1-22) (Cont.) 41'F/45'F Within 4 Homs.
PROTECTION FROM CHEMICALS 3-501,15 Conine,Methods for PRFs
14
14 Food or Color Additives PHF Hct and Cold Holding
3-202J 2 Additives r 3 5o1.16(B) Cold Pllr-s Maintained at or below
590.004(F) 41°/45'F*
3-302.14 Protection from Unapproved Additives* 3-501,161(A) Not PI-IFs.Maintained at or above
15 Poisonous or Toxic Substances
1401F.
7-101,11 Identifying Information-Original
3-501.16(2) Roasts Held at or above 130'F.
Containers*
7-102.11 Common Name-Workim, Containers* 20 Time as a Public Health Control
7-201.11 Separation-Stora e'` 3-501.19 Time as a Public Health Connot*
7-202.11 Restriction-Presence and Use*
590.0041 H) Varian Re ulrement
7-202.12 Conditions of Use"
POPULLAA
7-203.11 Toxic Containers-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11. Sazers,Criteria-Chemic Chemicals* TIONS(HSP)
ON (HSP) _
7-204.12 Chemicals for W ashinit Produce,Criteria"' 21 3-801.1 l(A) Unpasteurizcni Pre-packaged Juices and
7-204.14 Dr in>Akents,Criteria` Beverages with 11uivuiG labels*
7-205.11 Incidental Food Contact, Lubricants* 3-S01.11(B) _Ise of Pastel tze�
7 206.11 Restricted
Use Pesticides. Criteria*
3-801.1.1(D) Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. "
7-206.12 Rodent Bait Stations* 3-80'1.11(C) Unopened Food PackaEE Not Re-served.
7 206.13 Tracking Powders,Pest Control and
Monitoring*
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16
Annual Foo ds That are Raw, Undercooked or
Proper Cooking Temperatures for
PHFs Not Otherwise Processed to Eliminate
3-401.1.1 A(i)(2) Eggs- 155'F 15 Sec.
Patho ens ne�ry vcoai
1: 2s-Iumedtate Service 145°tl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish,Meats&Game Eggs"
Animals- 155°F 15 sec. *
3-401.11(9)(1)(2) Park and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites, InjectedMeals-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec,* catering, mobile food,temporary and
3-401.11(2)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meal, debited under the appropriate sections
Poultr or Ratites-165°F 15 sec. a, above if related to foodborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and tisk factors. Other
145'F. 590.009 violations relating to good retail.
3401.12 Raw Animal Foods Crooked in a practices should be debited under#P29-
Microwave 165'F* Special Requirements.
3-40LlI(A)(I)(b) All Offer PHFs-- 145°F15sec
.
17 Reheating for Hot Holding ViOLATIOIVS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PH,Fs 165'F 15 sec. " (Items 23-30)
3-403.11(B) Microwave- 165'F 2,Minute Standing Critical and non-critical vaeflaous, which de,not reiate to the
Timc'` finodborne illness interventions and risk factors listed above can be,
3-403.11(C) Commorcially Processed RTF Food- _found in the following sections of the Food Code and 10.5 CMR
'140°F* 590.000.
3-403.1.1(F) Remaining Unsheed Portions of Beef Item Good Retail Practices ( FC 580 000 _)
Roasts" 23. Manaoement and Personnel� .003
ig Proper Cooling of PHFs _24. Food and Food Protection.____ FC--3 .004
25 _Equipment and Utensils Fi 4 205
3-501.14(A) Cooling Cooked PHFs from 140°F to 26
- Water'-ply Plu .0-Within� ours alt From 70'17 27. Physical Facllii -
-----
FC--6 .007
to 4l'F145'F Within 4 Homs.* 28. Poisonous or Tonic Materials _ FC-7 .008
3-501.W(B) Cooling PRFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41`F(45`F 30. ------Other
Within 4 Flours" se..or
Denotes critical irin in the federal 1999 Food Code or 105 CMR 590.000. -