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J & J VARIETY - ESTABLISHMENTS J & J VARIETY - 207 NORTH STREET a 0 �Y q a 0 7 I 1 i a i i d 3 f L e } t t 7 i t t a �OMPLETE THIS SECTION COMP LETE THIS SECTION ON DELIVERY ■ Complete Items 1,2,and 3.Also'complete A. Si nat re Item 4 I Restricted Delivery Is desired. /' 13 Agent ■ Print your name and address on the reverse X - ❑Addressee so that we can return the card to you. B. Received by ,ted Name) C. Date of Delivery I ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: ! If YES,enter delivery address below: ❑No I J & J Variety 207 North Street Salem, MA 01970 3. Service Type ❑Certified Mail 0 Express Mail 13 Registered 0 Return Receipt for Merchandise 0 Insured Mail ❑C.O.D. I. 4. Restricted Delivery?(Exna Fee) ❑Yes 2. Article Number7008 1140 0004: 0940 2080 (Ranter from service Iabso . PS Form 3811,February 2004 Domestic Return Receipt 1o2eesm-M.154o UNITED STATES POSTAL SERVICEZClas`'s'V41— s am j • MA 0 Sender. Please print your name, address,and ZIP44^i4i7box • I I City of Salem Board of Health 120 Washington Street 4th Floor Salem, MA 01970 -�-� III,IIII,IIIFIIIIIIIIII„1Ifil111d11f1111fill III Iff1f11111111 1U.S.,Rostal Servicer„ CERTIFIED MAIL,,, RECEIPT '(Domestic Mail Only;No Insurance Coverage Provided) For delivery information visit our website at www.usps.coms OF ICIAL USE r postage Gertified Fee C3 Postmark Return Racelpt Fee Hem C3 (Endorsement Required) r E3 (End.marmfm R red) Total Postage&Fees $ street, or O s. PS Form 3800.A.gosl 2006 See Reverse for lnslruefions Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders., e Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail, ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested toprovide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Farm 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS,a postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Defivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. - IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 .. t. r e CITY OF SALEM, MASSACHUSETTS BOARD OF H,F,Ai:,TTi 120 WASHINGTON STRFF_'T,4".FLOOR TFL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DClacr,NBAUM r@i SAI,e:,NT.CO.�I DAVID GiuS iI.N NA U M June 29,2009 ACTING Hu'Au I-I AGENT J&J Variety 207 North Street Salem, MA 01970 Dear Owner: On Tuesday June2,2009 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 15 year old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. J&J Variety 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 ($300.00 Hundred Dollar fine)for the fourth 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$300.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4" floor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders,and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 978-741-1800. Sin ely yours, avi em Acting Health Agent CERTIFIED MAIL: 7008 1140 0004 0940 2080 cc: North Shore Tobacco Control Program Paulette Puleo, Board of Health Chairwoman and Members SENDER: 1 •N COMPLETE THIS SECTIONON DELIVERY ■ Complete items 1,2,and 3.Also complete Item 4 if Restricted Delivery is desired. 0 Agent ■ Print your name and address on the reverse X ❑Addressee so that we can return the card to you. R. Received by rated Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. is delivery address different from item 11 0 Yes 1. Article Addressed to: If YES,enter delivery address below: 0 No Owner J & J Variety 207 North Street Salem, MA 01970 ',S. Service Type 0 Certified Mail 0 Express Mail ❑Registered 0 Return Receipt for Merchandise 0 Insured Mail 0 C.O.D. 4. Restricted Delivery?(Extra Fee) 0 Yee z. Article Number 7008 1140 0004 0940 2097 (transfer hom service Iabel) PS Form 3811,February 2004 Domestic Return Receipt 1025e5-02-M-1540 UNITED STATES Pos �p._$.ERV.LC ,,,.� . , <.,. •«�,,.,,,,, r-14 St . e+• :>.d3k,3.@..t -.c. fi:-c.. .{.(:ry" °,•^`q",`,w�+,M, „ 'd(�IgQagRy�y��'�F�yes:J'rSy,�:WPaid Id�IOi� ".:M1'. y�r Li r Ill�l IVU.'�Q�II) :Y4W • Sender: Please print your name, address, and ZIIFP tYiIhis box'' !I City of Salem Board of Her;th 120 Washington Street 4th Floor Salem, MA 01970 - -- -------- --- - .v2v f�'fill l7"'1 it]1111111111111 1'11117111'1111'1iilll IIIIII1I'I.II U:iPottai Service,;, CERTIFIED MAIL,,:, RECEIPT (Domestic Mail Only;No Insurance Coverage Provided) '. For delivery information visit our website at www.usps.come,. w 1 Ir Postage r Certified Fee C3 Return Rwelpt Fee Postmark C3 (Endomement Required) Hem Hesticted Delivery COC3 (Endomement Required) Sent To c3 c. PS Form 3800..August 2006' See Reverse for Instructions Certified Mail Provides: " ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mails or Priority Mails. ■ Certified Mail is notavailable for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece°Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS9 postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement'Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an Inquiry. PS Form 3800,August 2006(ReMM)PSN 7530.02-000.9047 CITY OF SALEM, MASSACHUSETTS BOARD OP HEALTH ' 120 WASHINGTON STME T,4'" FLOOR TEL. (978)741-1800 KIMBL RLEY DRISCOL.L FAx(978) 745-0343 MAYOR DG-111 NB UM SAI MCOINI DAVID GRL:1;NBAU0.Q ACl'ING Hf?Aun-I A(il,Nr June 29, 2009 Owner J & J Variety 207 North Street Salem, MA 01970 Dear Owner: t On June 2, 2009 at approximately 6:27 PM, during a tobacco compliance check, personnel from the North Shore Tobacco Control Program noted the odor of second hand smoke in your establishment. This is a violation Salem Board of Health Regulation #22 concerning the Workplace Smoking Ban including restaurants and bars. Documentation is on file at the Board of Health regarding this violation. You are in violation of Section D(1) and D(2) of Salem Board of Health Regulation #22. According to this section, it is unlawful for any employer or other person having control of the premises upon which smoking is prohibited by this regulation, or the business agent or designee of such person, to permit a violation of this regulation. Section G of this regulation states, "Any employer, or his or her business agent, who violates any provision of this regulation, the violation of which is subject to a specific penalty, may be penalized by the non- criminal method of disposition as provided in Massachusetts General Laws, Chapter 40, Section 21 D or by filing a criminal complaint at the appropriate venue. It shall be the responsibility of the employer, or his or her business agent, to ensure compliance with all sections of this regulation. Violators shall receive a fine of$100 for a first violation, $200 for a second violation, and $300 for each additional fine within 24 months. Therefore, you are ordered to pay a fine of$100 for the violation stated above since this is your first violation within 24 months. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street 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. An attorney may represent you. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 978-741- 1800. ;jinc:Kerely yo s, David Greenba Acting Health Agent Cc: Paulette Puleo, Board of Health Chair and Members Joyce Redford, Director, North Shore Tobacco Control Program CERTIFIED MAIL 7008 1140 0004 0940 2097 MemoN �s Qo r� ,oFS�Z009 Date: June 3,2009 qq�o�N t,M To: Janet Dionne,Health Agent op From: Joyce Redford,Director RE: Salem Tobacco Compliance Checks On Tuesday 2 June the North Shore Tobacco Control Program conducted tobacco 20o9 compliance checks in the City of Salem. In addition to Joyce Redford,Director,and Peter King,Inspector two under aged youth participated in these compliance checks. During the checks forty-eight permitted tobacco merchants were checked of those checked one violation of the Youth Access"Sales of Tobacco to a Minor"occurred. Statistically,a compliance rate of 98%was achieved Violations occurred in the following establishments: Establishment: Address: Offense: J&J Variety 207 North St. 41'Offense While issuing the above youth access violation we observed a violation of the Environmental Tobacco Smoke(ETS)workplace law. Therefore,an additional fine of$ioo.00 should be issued. Please see signed violation notice for details. Enclosed you will find a copy of the violation notices that were issued to each establishment at the time of the compliance check Should you have any questions regarding these checks please do not hesitate to contact me at 781-477-0432 1 Wi em - Board of Health r p , Tobacco Control Regulation - Violation Not ce O � •�� W�� 1 v� N({�� This notice is to inform you that your establishment violated the Salem Board of Health Youth Access (YA)� \�V 111 Regulation and/or Environmental Tobacco Smoke(ETS)Regulation. C-,\A1C 0` (^ r+ Name of establishment 1 Address I Date'of violation Time of violation Minor's age/gender Minor's ID# Inspector la-)o c � a-)o 4 � C ta� � Arck, (Ordinance,Section,Regulation),- r (Act Constituting Violation) Narrative information: r u\ c(_v c�.1,S�k , SCt'1 mo�v %.j c,,\\ uu.v) AU A�\l KY I Isaffirm,under the pains and penalties of perjury,that the above report is true to the best of my knowledge and ybeli�efi ( r ;1�� 1' (l I�c� \t k a ( o f,� 1 r Inspector(Signature) L"1 N (Print name) VENDOR STATEMENT: I acknowledge I received this Violation Notice on sr L—_ , 20 �l at . ( 0 t M�'PIv1�)and I am being given a carbon copy of this notice.I also ae that I have been infor ed that the Salem Board of Health willP rovide additional follow-up'information to this violation notice. 10' yV wn& an er/Clexlc-hSegnature,- (Print name) If vendor refuses`ihis'otice or if the inspector feels unsafe in delivering it,an explanation must be written on a note attached hereto.Mailing of this Notice is thus required. For further information,contac t the North Shore Tobacyo Control Program at 781-477-0432 9 Establishment-white NSTCP-yellow Board of Health-pink Memo JON ,s Y ?0 cr09 Date: June 3,2009 y QO qa0 OF To: Janet Dionne,Health AgentrN From: Joyce Redford,Director RE. Salem Tobacco Compliance Checks On Tuesday June 2,2009,the North Shore Tobacco Control Program conducted tobacco compliance checks in the City of Salem. In addition to Joyce Redford,Director,and Peter King,Inspector two under aged youth participated in these compliance checks. During the checks forty-eight permitted tobacco merchants were checked of those checked one violation of the Youth Access"Sales of Tobacco to a Minor"occurred. Statistically,a compliance rate of 98%was achieved. Violations occurred in the following establishments: Establishment: Address: Offense: J&J Variety 207 North St. 4f Offense While issuing the above youth access violation we observed a violation of the Environmental Tobacco Smoke(ETS)workplace law. Therefore,an additional fine of$ioo.00 should be issued. Please see signed violation notice for details. Enclosed you will find a copy of the violation notices that were issued to each establishment at the time of the compliance check Should you have any questions regarding these checks please do not hesitate to contact me at 781-477-0432 �t t Q f f V 1 r y f Salem - B41 oard of Health Pobacco Control Regulation -Violation Not c V / This notice is to inform you that your establishment violated the Salem Board of Health Youth Access(YA)N 1 Regulation and/or Environmental"Tobacco Smoke(ETS)Regulation Name of establishment T r` Address Dace of vi lation Time of violation Minor's age/gender Minor's ID# Inspector t l (Ordinance,Section,Re elation k / (Act Constituting Violation) Narrative information: t : ".EL ot,4 �A o ✓ 1 ' 11r�o t Y ` lA.f._1f� t� I affirm,under the pains and 4alties of perjury,that the above report is true o t e best of my knowledge an belief. i In—speccttor, Signa re �4 (Print names) VENDOR STATEMENT I acknowledge I received this Violation Notice an �3- 20 af' AM( l and I am being given a carbon copy of this notice.I also a knowledge that I have been infor cd thaf the Salem Board of Health will provide additional,follow-u I'nformation to this violation notice. wn nn a gnatur' (Print name) If vendor refuses once or if the inspector feels unsafe in delivering it,an explanation must be written on a note attached hereto.Mailing of this Notice is thus required. For further information,contact the North Shore Toba tlu Control Program at 751-477-0432 Establishment-white NSTCP-yellow Board of Health-pink � Y Memo JAN _5 ?009 Date: June 3,2009 qRp OpS�L�M To: Janet Dionne,Health Agent HATH From: Joyce Redford,Director RE: Salem Tobacco Compliance Checks On Tuesday June 2,2009,the North Shore Tobacco Control Program conducted tobacco compliance checks in the City of Salem. In addition to Joyce Redford,Director,and Peter King,Inspector two under aged youth participated in these compliance checks. During the checks forty-eight permitted tobacco merchants were checked of those checked one violation of the Youth Access"Sales of Tobacco to a Minor"occurred. Statistically,a compliance rate of 98%was achieved Violations occurred in the following establishments: Establishment: Address: Offense: J&J Variety 207 North St. 4th Offense While issuing the above youth access violation we observed a violation of the Environmental Tobacco Smoke(ETS)workplace law. Therefore,an additional fine of$1oo.00 should be issued. Please see signed violation notice for details. Enclosed you will find a copy of the violation notices that were issued to each establishment at the time of the compliance check Should you have any questions regarding these checks please do not hesitate to contact me at 781-477-0432 q. 1• - ,\ y off Salem- Board of Health 2 obacco Control Regulation - Violation Not c 4 / This notice is to inform you that your establishment violated the Salem Board of Health outh Access(YA)N� Regulation and/or Environmental Tobacco Smoke(ETS)Regulation. Name of establishment Address Date of vi lation Time of violation Minor's age/gender Minor's ID# Inspector u � 1N (OrduLtnce,Section,R ulation ( j (Act Constituting Violation) # 1 Narrative information: 'Au-, ' V""Auov ' AL1 V_ I`affirm,under the pains and p altias of perjury,that the above report is trueec o t ebest of my knowledge an belief. r i �\-3 Inspector(Signature) " ' (Print name VEN OR STATEMENT,: I acknowledge I received this Violation Notice on 20 af' Myand I am being given a carbon copy of this notice.I also a knowledge that I have been info ed haat the Salem Board of Health will provide additional,follow-u information to this violation notice. t wn n er/Cle gnatur' (Print name) If vendor refuses otice or if the inspector feels unsafe in delivering it,an explanation must be written on a note attached hereto.Mailing of this Notice is thus required. For further information,contact the North Shore Tobago Control Program at 781-477.0432 Establishment-white NSTCP-yellow Board of Health-pink 'Ft`.a .."..vr'..'},q bS'•+! bi.?M+.. '.+''. y� . U�W�P�.!e7P'4..,r .ee?"'r'""'y 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 Tvoe of Operatlon(s) Type of Inspection 4 - I(- Q Foodservice ('Routine Address �r}� \\ , fi U Risk Retail nRe-inspection 9 l Y Level ❑ Residential Kitchen Previous Inspection Telephone /1 ❑ Mobile Date: OwnerHACCP l YM El Temporary ElPre-operation R' f-.I� �P�Q ❑ Caterer ❑Suspect Illness Person in Charge(PIC)J Time ❑ Bed&Breakfast ❑General Complaint In: ElHACCP Out: inspector 0 l .1A/y1/1 JPermit No. El Other '`�fXJ.-¢.2� Each violation checked requires anvplanation on the narrative pagers)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)1=:J 590.009(F)A3- action as determined by the Board of Health. FOOD PROTECTION MANA- MENT E ti� ��„ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties "_F �t ❑ 13 Handwash Facilities EMPLOYEE HEALTH ,? c + •i�.i - aiga s =p �' Iq i, a ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROMCHEMICALSt pp ' q x - I`e +SL��,' i, 69 d � ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOUR El 15 Toxic Chemicals E] 4. Food and Water from Approved Source k TIME/TEMP£RATURE cDNTROLS(Potemfalry Na1-wa Foods) s°rw 4 ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating E],7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling _ - ' �� g ^'""� �'2 ❑ 19. Hot and Cold Holding € PROTECTION FROM CONTAMINATWN .�� „ ` -` `x+�.A.nri�.-.mmw`�uae e`#' k ,q,dv s.6:�,3Nr+s,�P...v�' ❑ µ8 Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ;;REQUIREMENT$FDR HIGHLY SUSOEPT)BLE POPULATIONS(HSP)4 El 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMEF.AOyISORYI ,q„.;' '°t �,�,r,,. § ;",,,,<a C]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 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-s)(sso.00s) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.067) 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:w SMlnspe Fom 14 E 1 (Q, Inspector's Signature: � d A Print: �/ PIC's Signature: - Print: Page_of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT r 8 Gross-contamination 1 590.003(A) Assignment ofRes pansibility� 3-302.11(An]) Raw Animal Foods Separated from 590.003(BZ Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Annual Foals Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1.1(A) Fotxl Protection* a Hearts* 3-30215 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 5%003(C) Re ortino b Person in Chariee* 3-306A,f(A)(B) Returned Food and Reset-vice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated - 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces _ 590.004(A-B) Compliance with Food Law* 4-501111 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 Shelf Eggs* Sanitization Temperatures* 3-202.14 E ,s and Milk Products.Pasteurized* 4-501.114 Chemical.Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Water from an A roved System* 4-601 A I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4-602 590.006(B) Water Meets Standards in 310 CMR 22.0* .11 Cleaning Frequency of Equipment Food- 590.006(B) Surfaces and Utensils Shellfish and Fish From an Approved Source - 4-702.1 t 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-Mot Water and 3-201.15 Molluscan Shellfish from NSSP I fisted Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Racularon,Aufhoi 2-301.11 Clean Condition-Hands and Arne;" 3-202.18 Shellstock Identification Present* 23(11.12 CleaningProcedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1.7 Game Animals* l.1 Good Hygienic Practices Receiving/Condition 2-401.11 Ealing,Drinking or Using Tobacco* 3-202.11. PH-Fs,Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-20115 Packa e hue it * Mouth* 3-101.11. Food Safe and Unadulterated'* 3-30112 Preventing Contamination When Tasting` 6 Tags/Records:Shellstock 1.2 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction` Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' _ 5-204.1.1. Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-5021.2 Reduced oxygen packaging.criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with A. roved Procedures" 6-301.12 Hand Dng Provision *Denotes critical item in the taxieral 1999 Pool Code or 105 CII.I R 590.000. r CITY OF SALEM BOARD OF HEALTH f Establishment Name: .�_C\ I ,f QQ+t Date: Page: of 7 I nam Code, C-Cnticai Itemf� DESCRIPTION OF,VIOLATION/ PLAN OF CORRECTION �_ Date r , .. `, > 4"'Or :. ,r'= .� tri, r; r rs No - 'Reference R' Red Item ' ' „'>, - " =°^' `"" `;` �� "' a. :, Verified- - ;= Sk _ A PLEASE PRINT CLEARLY \�L,-zA A UsCk t VP_, m Al'al —} 4cA * WA p 1 r�2'Vl�.liT7l1 (ile 1 I ran. ,� !1 �?P � �=1'\� , •.f^ ;4,—H-09 /2Op/1.t2/J/ o o �V -a) ,(k: wenn .7�f - v��x(i)_1 I 1 i �� v-aA n_i1 i1�.i a f3"} } yX o\ (-' ,vAX�nJ t .t I,An 0 -PP/)/1CJ1;�_l1" e 1_ ) 0Q I7e�_) �) �FYl �ct�.TFAn 0nn (1(aTT�0 X-) r> t Discussion With Person in Charge: Corrective Action Required: o No ❑'— es I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance E) 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 El Embargo Li Emergency Closure your food permit. �\ A&I 11 ❑ Voluntary Disposal ❑ Other: I ✓� i 3-561,14(C) PHFs Received a Tom ralares Violations Related to Foodborne Illness interventions and Risk According to Law Cooked to Factors(items 1-22) (Cont) 4 FF/45'T Wiflon 4 Hows, A5 Cooling M,thods for PHF.s PROTECTION FROM CHEMICALS �111� 3-501 P PHF Hot and Cold Holding 1=4 Food or Color Additives LL9 Hours. 501.16(B) Cold PHFs Mamv�ined at or beftev I 3-202,12 1 Add lives* 590 004(F) 4P/4511 F- led at or belle, 1 .3-302,14 protection floor Un ----4 3-50 I I 6(A) Hot PFIFs.Mashained at or abo" =F�l--tz,t 1-1)02 rot:�,9 11 LL5 Pooturous or Toxic Substances 140"F. 101 11 Identifying Infornallork-- Original 3-50176(Aj Roas is Hold at oi above 130"1,, ('oniainers 120 Time as a Public Health Control F102,11 1 Common Name - Workin,Cout.airter,*-- 3-501.19 Time as a Public Health Control' 7-202.11 Restricl�on-Pres&-nce and Use* 7-2 0 1.1=1 selaradon-st2La�- ttiLmLe( uenE [Me 7-20112 Conditions of Use" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE _7265—57:,,7i—,(.'Detamenl-projobitiolli, P4PULk7IONS HSP 7-204.11 Sanitizeis,Cuieria-Chemicals* 3_80t.11(A) kanpaleon/'zd pte-parmackaged Ance, aid 2�� 12 Chemicakfor'WashLig —7-- _L _ Be cos whii 204 1aAL�m �,.Crfteri,,f IketfPastaunredLes + 20511 Incidental [-(uX!CktrtaCt�IUbriCaWS' 3-$1,1 I I{D} , R tva or Parttalle fir;r1 Animal Fend laid -80 1 1 ILB L li-E0K IE-- Rostriufad 1, e Pe,Ircidos,Criteria' Raw Se ed Sicom,-Not sensed ;, 7-206.12 R(sletc Bolt Stations L3:EW t l(E bora coed I'axt Pasta e Not Re served. ?06.13 I Tracking Powders,Pest Control arei CONSUMER ADVISORY 12 1 Wi 11 Cousuroor Ad�;som Postat] for Consumption of TIME/TEMPERATURE CONTROLS ',roinad 1` atds I'haE art:Raw, Undercook , 16 Proper Cooking Temperatures for 1�ot Othtf wise Pnx�essed fo Eliffifflare ed u; PHFs P,t ugens. 3-40LIJA(l)(2) f.g&,- 155`F 15 S�,c, I I K Pa.qeunzcd Egg utsuary for Raw Shelf 7i— Comminuted Ftsh,Maws t Game Amnads- 15,5`17 15 %,ec. SPECIAL REQUIREMENTS -7i4i)ll likill)(1)(2T Peak and Beet Roast-13U t 1Z1 mint -TR—Ai I("sia) Routeti, ftjeocd kfe?,ts- 155F 15 ls n 59OA09(A)-(D) in cateringmobdettxid, temporary and .3 461 11(A) —TVdd Came, SnAked PiTr--s, jeaidenlW kitchen opelpitions Atould Ire , Staffing comallumFisbMeat, debited under the appropriate sections Poultre,or Ratites-1 651 15 s,ow, alxwe if rolaied to fisodhorric AlnM ((),,3) e-muscle,Intact beat Steaks and risk factors Other 145"T 590.009 violationq relmin, to-ood retail I 3-401,C2 Raw Anorval F(sids Cooked fit a pactices 3hould be debited under#24- iMicioeiave 16.S'F Spacial Requircmomt�- -40 1,11 OT Ell ) I)(Id Ml Othei PHFs- 145'T 15 see _7 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC 3403,11(A)&(D) PUN M6 T 15 sec, (Items 23-30) 7.403A—Ift Nfwrow7aw- 165'F 2 Moune,Standing C;Wraftjoal non-(rifwal vioiafiunj, which do ien gelate In!he 'time, foodborne illness imerventi0try imil riAjitoors 1"l-lu.4 above. con be 3-163.I I(C) Commercutily Pswessed RTE Food- fiund in the fiarlou-ing serfionv of the Food Code and 105 CAIR 146°F' 590,000, item Good Reta+t Practices TFC T 890.64p 3403 I I(E) Relnajnin�,, ulezkiced pertions of Beer 23, Mapisgemart and Personnel' C Food and Food P,olection FC--3 0( iB Proper Coaling of PHFs Iz— —,-� —'1125 1 14(,'e) CoalingCookedPHFs from WYFt ------ 26, �Watef.Phonon-and and Waste FC-5 '006 70�F Withol 2 flours and From 70`1� �1:h yEcKFw to 4 I'F/45'F Within 4 Hours. 228 1 —I Poisoreets or�Oxic Materials FC -7 008 3-5' 01 14(B) Cixting I1HFe[lade from Alabjent 25 Temperature Ingredients to 4101--'/45cF 1-3, other Within 4 Floupz* Denotes'ritwal Item 41 the leder'd 1999 Forst(:oAo:,r 165 CMR 590 WO, Commonwealth of Massachusetts s City of Salem Board of Health IGmberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/02/2009 ESTABLISHMENT NAME: J & J Variety File Number:BHF-2004-000025 207 North Sheet Salem MA 01970 LOCATED AT: 0207 NORTH STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1 Notes RETAIL FOOD BHP-2009-0342 Jan 2,2009 , Dec 31,2009 $70.00 TOBACCO VENDOR BHP-2009-0341 Jan 2,2009 Dee 31,2009 $135.00 Total Fees: $205.00 i PERMIT EXPIRES December 31,2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FI ) TEL. (978) 741-1800 �' KIMBERLEY DRISCOLL FAx(978) 745-0343 �� MAYOR IDIONNES SALEM.COM JAN — 7��9 JANET DIONNE C. ACTING HEALTH AGENT BOF RD OF f{ yrH 2009 APPLICATION FOR OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTs=I�Tr V/ypri kt TEL# q7% ADDRESS OF ESTABLISHMENT 0 7FAX# MAILING ADDRESS(if different) EMAIL- Business': Website: ? OWNER'S NAME X nn p S TEL#'777S -�23 1h] b ADDRESS (O "/ RAi(tt QW-Q I STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) q EMERGENCY RESPONSE PERSON yA OIA YY\ HOME TEL# DAYS OF OPERATION Mond `- -Tuesday: 1 Wednesday. ?4,.-Thursday. ' Frlda - 11 Saturday. . . 'Sunda HOURS OF OPERATION 6rn(}y) 6a a-` ) 7 A wl Please write in time of day. !&(2 rh_ BM ! S (For example 11 am-11 pm) �(`� ! yy TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. _$ 70 1000-10,000sq.ft. more than 10,000sq.ft. =$420 --------------------------------------------------------------------------------------------------------------ie-------------------------------------14------ RESTAURANT YES NO less than 25 seats =-S-14-0----- (Outdoor $140 _ (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------------------- ------------------------------------------------------------------------------------------------ BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES --------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO 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 and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state tax s required under the law. � '24A Id,- a9- d8 a0'9 704 - 7t9 Sigrg&e 0 Date Social Security or Federal Identification Number ------------------------------------ ---- ---- --------------------------- Revised 4/24/07 FOODAP2008.adm Check#&Date $ �) DEMAKIS LAW OFFICES, P. C. GREGORY C. DEMAKIS 56 CENTRAL AVENUE THOMAS C. DEMAKIS LYNN, MASSACHUSETTS 01901 SANDOR RABKIN TEL. (781) 595-3311 JOSEPH H. DEVLIN* FAX(781) 592-4990 *Also Admitted in N.H. March 12, 2008 -Ms:Heather Lyons Sr. Accounts.Clerk City of Salem Board of Health 120 Washington Street, 4th Floor Salem, MA 01970 Re: J & J Variety 2006 Food Permit Dear Ms. Lyons: Enclosed please find a copy of your January 24, 2008 letter to this office and a check in the amount of$150.00 as a replaced for the check you returned to us. Thank you for your patience: Very truly yours, Gregory C. Derr GCD/alt Enclosure c CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR ' 4 SALEM, MA 01970 TEL. 978-741-1800 FAX 978.745.0343 KIMBERLEY DRISCOLL JSCOTT@SALEM.COM MAYOR JOANNE SCOTT HEALTH AGENT January 24, 2008 Demakis Law Offices, P.0 56 Central Avenue Lynn, MA 01901 To whom this may concern; We miss filed your check and application in August 2006 and just recently found it. I'm sending back your old check for the J &J Variety 2006 Food Permit application. Please mail us new a new check for S 150. We appreciate your cooperation with this matter. Thank You, Heather L ns Sr. Accounts Clerk 978-741-1800 Mailed certified: 7005 3 110 0000 7160 4306 U.S. Postal Servim. r CERTIFIED MAIL. RECEIPT (Domestic Mail Only;No Insurance Coverage Provided) For delivery information visit our website at www.uspsxome postage C3 Certified Fee C3 A m Raw! Fee • v PS Fonn 3800,June 2002 See Fi rverse fcr Instructions Certified Mail Provides: ■ A mailing receipt (esreney)toot ewr'0M MO=l ed ■ A unique identifier for your mallplece ■ A record of delivery kept by the Postal Service for two years " Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail,or Priority Man®. ■ Certified Mall is not available for any class of International mail. • NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to rovide proof of delivery.To obtain Rehm Receipt service,please complete and attach a Return Receipt(PS Form 3811),to the article and add applicable postage to cover the fee.Endorse mailpiece'Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS,postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailplece with the endorsement"Restdcted Delivery°. ■ Its postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt andpresent it when making an inquiry. Internet access to delivery information is not available an mail addressed to APOs and FPOs. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH o 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 --'v TEL. 978-741-1800 FAX 978-745-0343 KIMBERLEY DRISCOLL JSCOTT@SALEM.COM MAYOR JOANNE SCOTT HEALTH AGENT January 24, 2008 Demakis Law Offices, P.0 56 Central Avenue Lynn, MA 01901 To whom this may concern; We miss filed your check and application in August 2006 and just recently found it. I'm sending back your old check for the J &J Variety 2006 Food Permit application. Please mail us new a new check for $150. We appreciate your cooperation with this matter. Thank You, Heather L ns Sr. Accounts Clerk 978-741-1800 Mailed certified: 7005 3110 0000 7160 4306 EXPLANATION AMOUNT 10400 10400 DEMAKIS LAW OFFICES, P.C. 56CENTRALAVENUE LYNN,MA 01901 53-179.113 PAY AMOUNT - 'OO DOLLAR -- CHECK i OF AMOUNT DESCRIPTIO CHECK � DATE TO THE ORDER O � NUMBER /Y'1 /� I o.+V.m 00 I 330 Eastern Bank = � � LYNN MA 01 W1 1BC0•EASTERNIeulemMnM.cOm ______ � 111010400111 i:01130i798l: 06 000 ?G SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A Sig w item 4 if Restricted Delivery Is desired. 1 0 Agent ■ Print your name and address on the reverse X rases so that we can return the card to you. B. i Nap) C. DateDelive ■ Attach this card to the back of the mallplece, _ or on the front if space permits. ° D. I still rff§te from Item 17 Yes 1. Article Addressed to: I YE rdelive below: 0 No --T?Gun.A k.SL 4a OfElclC1 r < I L� ✓t el I-IA Q I y of 3. Service t: Tr J V4rfi 0 Certified Mail 0 Express Mail 0 Registered 0 Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. L 4. Restricted Deliver yt(Extra Fee) 0 Yes 2. Mlclei '7005' 3110 '0000' 4306 mrrsns� - _ _ i f Ps Form 3811,FF�ebruawy k04 Domestic Return Recelpt 10259502-M-1540 UMTED STATES 2:15 mit o: • Sender: Please print your name, address, and ZIP+4 in this box I I I RECEIt=0F HEALTH MA 01870. 'JAN 2 8 2008 CITY U- bALEM BOARD OF HEALTH I I I i DEMAKIS LAW OFFICES, P. C. GREGORY C. DEMAKIS - 56 CENTRAL AVENUE THOMAS C. DEMAKIS LYNN, MASSACHUSETTS 01901. SANDOR RABKIN TEL. (781) 595-3311 JOSEPH H. DEVLIN* FAX(781) 592-4990 *Also Admitted in N.H. June 6, 2007 City of Salem Board of Health VIA UPS OVERNIGHT DELIVERY 120 Washington Street, 41h Floor Salem, MA 01970 RE: J&J Variety, 207 North Street, Salem, MA Dear Sir or Madam: Please find enclosed the 2007 Application for Permit to Operate Food Establishment, and $150.00 fee. This business is being sold on Monday, June 11, 2007. 1 was told to submit the application on or just prior to the closing. Please feel free to call me with any questions. Thank you very much for your time and cooperation. If you have any questions or need additional information, please feel free to call me at extension 105. Si ely ,'urs; J eph H. Devlin Enclosure ttorney at law CITY OF SALEM, MASSACHUSETTS • • BOARD OF HEALTH 120 WASHINGTON .STREET, 4TH_ FLOOR SALEM, MA 01970 " TEL. 978-741-1800 Fax 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, HS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT J&J Variety TEL# 978-741-9423 ADDRESS OF ESTABLISHMENT 207 North Street, Salem NA FAX#-same- MAILING ADDRESS(if different) same EMAIL--Business': u/a Owner's: n/a OWNER'S NAME D&S Market, Inc. , Vandy Duch, President TEL# 978-937-0454 ADDRESS 207 North Street Salem MA 01970 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) Vandy Duch CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON Vandy Duch HOME TEL# 978-937-0454 DAYS Of OPERATION Mandan Tuesday Wednesday Tharsdav Friday Saturday Sunday HOURS OF OPERATION Please writefetime aiday. 6am,9pm same same same : same same lam - 8 tFor examale Ilam 11nm1 pm TYPE OF ESTABLIS FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$50 1000-10,000sq.ft. 10 more than 10,000sq.ft. =$250 -- - - - -- - ---- -----------.._....-------------....-..... - RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 BEDIBREAK- - .F..AST- -----YES-,1- ----S- - --- ... ..-------- ---$I 00.. ... ....... .. . ....- -- -... ....... O - __ $1 --- ---- ...... ------ .... _ ..._....._....-_... -_.. --------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE Y - NO TOBACCO VENDOR CIES / NQS t$5 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 pairis and penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Vatnd Duh President � 20-8704719 Signature I1 DateI Security or Federal Identification Number -- ------ ------------------- ----------- ... - - Soci- - - - - - Revlsed 11/13/06 FOODAP2007.adm Checkft&Date 0207 North Street J & J Variety City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency 'Telephone: - Violations Related to Good Retail Practices (Blue Items) 1741-9423 Food and Food Protection FAIL Critical BLUE g Owner: Comment:There are many price labels obscuring expiration/sell by dates. This appears to be don intentionally. DO NOT obscue I D8:D market Inc.,Vandy Duc any expiration/sell by dates with price labels. {PIC: Repeat violations of this nature will result in monetary citations of$25.00 per violations being issued. Citations will be issued if Hay Seak these violations are not corrected by the reinspection. $Inspector: GENERAL COMMENTS: j David Greenbaum All other violations cited in the 1/15/08 inspection report have been corrected. Date Inspected:Correct By: 11/22/2008 IRisk Level: t _ 'Permit Number: BHP-2008-0029 Status: SIGNED OFF #of Critical Violations: , 1 ;Time IN: Time OUT: .Urgency Description(s): ) BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately ' or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 23,2008 ) Page 1 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. Jan 23,2008 ) Page 2 of Commonwealth of Massachusetts City of Salem Board of Health lQmbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 FoodBetail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: J& J Variety File Number:BHF-2004-000025 207 North Street Salem MA 01970 LOCATED AT: 0207 NORTH STREET. SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0029 Jan 3,2008 Dec 31,2008 - - $70.00 TOBACCO VENDOR BHP-2008-0051 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted n 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 3 of 4 o� QTY OF SALEM, MASSACHUSETTS atr, Inc BOARD OF HEALTH 120 WASHINGTONSTREET,4 FLOOR TEL. (978)741-1800 KIMBERLEYDRISCOLL FAX(978) 745-0343 ��C��V'/ ® MAYOR TSCO17110SALEM.ODM M JOANNE SCOTT, DEC 4— 2007 HEALTH AGENT CITY OF SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL# T&� �� ADDRESS OF ESTABLISHMENT FAX#gT (7 p 1— I 2 MAILING ADDRESS(if different) EMAIL-Business': Website: /� p {y OWNER'S NAME J) TEL# 7 N 7,2f- / ,,5 ADDRESS ff)46— LS STREET CITY STATI52 ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) �J ��(/ EMERGENCY RESPONSE PERSON 2 HOME TEL# - Z) /(� /��` — DAYS OF OPERATION Monday Tuestla Wednesda Thursday Friday Saturday Sunda HOURS OF OPERATION Please write in Gme of day. For example 11 am-11 m TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE ES 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 (Ouidcor Stationa—Food Cart$2101 25-99 seats =$280 more than 99 seats =$420 -----------------------------.. ...... ...:..--"--'---- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES ------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR C YE9 NO $135 ALL NON-PROFIT(such as church kitchens) 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 1,to my best knowledge and belief,have fled all state tax ret X�MZ'7 d under the law. 1),3-oz a08- 7D4- - !7/L S" nature Date � Social Security or Fed�dentification Number --'------'----'------'---'------ ----------------- ----- / =-----------------,------------------------------------- Revised 4/24/07 FOODAP2008.adm Check#&Date//0,2 O / $ _? '6 - Wk 0207 North Street J & J Variety City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency fTelephone: Violations Related to Good Retail Practices (Blue Items) 1741-9423 Food and Food Protection FAIL Critical BLUE 10wner: �y Comment:There are many price labels obscuring expiration/sell by dates. This appears to be don intentionally. DO NOT obscue D&D market Inc., Vandy DUc any expiration/sell by dates with price labels. -PIC: - The following items removed outdated: Hay Seak 4-Dole OJ Inspector: 6-welches OJ 1 -Swedish fish +David Greenbaum 1 -Ludens throat drops Date Inspected:Correct By: 2-Planters chocolate cashews 1/15/2008 3-Hall's cough drops 5-Hostess honey buns `Risk Level: 2-Hostess muffin loaf f 1 -Hostess donettes 'Permit Number. tfi-Life/waters 32- ange soda BHP-4008-0049 6- iet Dr.Pepper Status: - -Lays chips 32-20oz orange Fanta VIOLATIONkta 1 ,#of Critical Violations: 1 -Phuladelphia cream chess - ilfs ire arm Itatt a ) i 1 _ 1 -Hormel turkey Time IN: Time OUT: 4-Sunflower seeds s 1 -Chex mix Urgency Description(s): 1 -Betty Crocker frosting 'BLUE: 1 -Jiffy cake mix i 1 -shake-n-bake Violations Related to Good 1 -Hunt's tomatoe puree Retail Practices (Critical 3-packages milkway minis violations must be corrected 4-Campbells soup immediately or within 10 3-Old EI Paso taco kit days)(Non-critical violations 1 -Hamburger helper 18-Choco Brix nurser boner must be corrected immediately 2-Bullsey BBQ sauce or within 90 days) 1 -honey mustard 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. Jan 16,2008 ) Page 1 oft JON, Item Status Violation Critical Urgency RED. _ _ 4-chopped clams Violations Related to 1 -Horse radish sauce Foodborne Illness Interventions'. -1 Nesttla sauce and Risk Factors(Require 15 Neses crunch Stix ( Q 7-Butter finger Stix immediate corrective action) 9 15-Nestle crunch stix 2-instant oatmeal 1 -Rice krispies 1 -Shrek cereal. Owner must monitor all expiration dates. Repeat violations of this nature will result in monetary citations of$25.00 per violations being issued. Citations will be issued if these violations are not corrected by the reinspection. Equipment and ensils FAIL Non-Critical BLUE =meThere is an accumulation of spills and splatter on the walls of the walk in. Thoroughly clean the walls of the walk in. urds in the walk in have an accumulation of dust and grime. Thoroughly clean the fan gaurds. GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 16,2008 ) Page 2 oft 0207 North Street J & J Variety City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 741-9423 PIC Assigned/Knowledgeable/Duties PASS RED Owner: Non-compliance with: D&D market Inc., Vandy Du Anti-Choking PASS PIC: Hay Seak Tobacco PASS Inspector: John Gehan EMPLOYEE HEALTH Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS L/_1RED 6/18/2007 Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS RED BHP-2007-0512 Receiving/Condition PASS 0 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 19,2007 ) Page I of Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED immediate corrective action) Proper Adequate Handwashing PASS ❑d RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS RED Handwash Facilities PASS ❑d RED PROTECTION FROM CHEMICALS Approved Food or Calor 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 PASSd❑ RED CONSUMER ADVISORY Posting of Consumer Advisories PASSd❑ 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 19,2007 ) 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: A routine opening inspection has been conducted. This establishment has met all food code requirements: New owner to monitor all experation dates on food products. New owner to possess the license of a pest control operator for monthly check ups. 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 19,2007 ) Page 3 of f 0207 North Street J & J Variety City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-9423 Physical Facility PASS BLUE Owner: Comments:There are a few ceiling tiles that have holes or are damaged in front. Replaice or repair tiles. D&D market Inc., Vandy Du PIC: The walk in unit floor has has a missing tile. Replace tile. Jatinder Singh Saini There is a cracked and damaged floor tile by the two bay sink. Replace tile. Inspector: There are multiple water damaged ceiling tiles in the back room. Find source of leak and repair. Replace any dmaged tiles. John Gehan Date Inspected:Correct By: The walls in the back room require a thorough cleaning. 6/18/2007 The floor in the restroom has missing tiles. Replace any missing tile. Risk Level There are missing ceiling tiles above the restroom. Replace tile. i Permit Number: BHP-2007-0017 { GENERAL COMMENTS: Status: i All violations from June 14, 2007 have been corrected. SIGNED OFF I #of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 19,2007 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Gam' City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 19,2007 ) Page 2 oft 0207 North Street J & J Variety City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-9423 Physical Facility FAIL BLUE Owner: j --Comthen"Aere are a few ceiling tiles that have holes or are damaged in front. Replaice or repair tiles. D&D market Inc., Vandy Du PIC: �S17e walk-in unit floor has has a missing tile. Replace tile. Jatinder Singh Saini here is a cracked and damaged floor tile by the two bay sink. Replace tile. Inspector: There_are•multiple water damaged ceiling tiles in the back room. Find source of leak and repair. Replace any dmaged tiles. John Gehan Date Inspected:Correct By: ( iThe walls in the back room require a thorough cleaning. 6/14/2007 hoor in the restroom has missing tiles. Replace any missing tile. Risk Level: T ere are missing ceiling tiles above the restroom. Replace tile. Permit Number: BHP-2007-0017 GENERAL COMMENTS: Status: i A Routine change of ownership inspection was conducted. All violations to be corrected by Monday June 18, Open 2007. #of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 14,2007 ) Page 1 oft / Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) Cityof 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 14,2007 ) Page 2 of 1 CITY OF SALEM BOARD OF HEALTH Name of Establishment: J & J Variety Address: 207 North Street Owner(s): Hay Seak Phone: 978-729-9658 The proposed new owner of this establishment, Hay Seak, discussed plans for this establishment. A review was conducted in accordance with the State Food Code. Floor plan for this establishment was presented and no changes to floor plan have been indicated at this time. FOOD All food items displayed and offered to the public must be from an approved permitted source. • Refrigeration units must have easily visible internal thermometers. • Foods placed in the cold holding sections must be at a temperature of 41°F or lower prior to placement. Food in this section must be maintained at 41°F or lower. All Freezer units to be maintained at zero degrees F or below as mandated. • Coffee station to offer non-dairy creamers, or dairy creamers that are maintained at proper temperature of 41 degrees F or below as mandated. FINISHES All areas where food is displayed, stored or prepared must have finished floors, walls and ceilings. RESTROOM Employee bathroom must have a hand sink with hot and cold running water and wall hung soap and paper towel dispensers in the room and a sign that states that employees must wash hands before returning to work. f. i' EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. LABELLING Labels may not block "sell by" dates or other information on retail products such as baby foods. TRASH Property must be maintained in clean and sanitary manner. All trash must be kept in weather tight, rodent proof containers or dumpster. Outside area of premises must be kept clean and sanitary. Change of ownership inspection set for June ,2007 at3 P!n 1 Lim Janet - Dionne Date Senior Sanitarian Seak V Date CITY OF SALEM BOARD OF HEALTH Name of Establishment: J & J Variety Address: 207 North Street Owner(s): Hay Seak Phone: 978-729-9658 The proposed new owner of this establishment, Hay Seak, discussed plans for this establishment. A review was conducted in accordance with the State Food Code. Floor plan for this establishment was presented and no changes to floor plan have been indicated at this time. FOOD All food items displayed and offered to the public must be from an approved permitted source. • Refrigeration units must have easily visible internal thermometers. • Foods placed in the cold holding sections must be at a temperature of 41°F or lower prior to placement. Food in this section must be maintained at 41°F or lower. All Freezer units to be maintained at zero degrees F or below as mandated. • Coffee station to offer non-dairy creamers, or dairy creamers that are maintained at proper temperature of 41 degrees F or below as mandated. FINISHES All areas where food is displayed, stored or prepared must have finished floors, walls and ceilings. RESTROOM Employee bathroom must have a hand sink with hot and cold running water and wall hung soap and paper towel dispensers in the room and a sign that states that employees must wash hands before returning to work. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. LABELLING Labels may not block "sell by" dates or other information on retail products such as baby foods. TRASH Property must be maintained in clean and sanitary manner. All trash must be kept in weather tight, rodent proof containers or dumpster., Outside area of premises must be kept clean and sanitary. Change of ownership inspection set for June ,2007 at 3 h7 ane . Dionne Date enior Sanitarian 612 h7 FWj Seak V Date J & J Variety q�{ 207,lfrth Street, Salem, MA 01970 DOC< v uj 1 � j � at -4- ( baht ��t> t �- CITY OF SALEM, MASSACHUSETTS �� BOARD OF HE ALTii l r 120 WASHINGTON STREET, 4TH FLOOR - SALEM, MA 01970 3 0?008 TEL. 978-741-1800 ` FAX 978-745-0343 WWW.SALEM.COM Nom; r Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO `rH Mayor i HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT OI �'fV ^�` {{�� TEL# G7 s -7141-qO?-`3 ADDRESS OF ESTABLISHMENT D 7- Al OA& I &7 ,,cyn MR FAX#_ Ol I R '741-altZ 3 PIP MAILING ADDRESS(if different) EMAIL--Business': Owner's OWNER'S NAME J AT)rt F TEL# a"12 ADDRESSi 01'75- lA: - 93.7 A,MC- STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) -TC'-k\ <p CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) rr,,�� C� EMERGENCY RESPONSE PERSON �I A-T t: I t4 , R- P Pry' HOME TEL# I-T OAYS OFOPEAATION Monday Tuesday Wednesday Thursday Fridays Saturday Sunday HOURS OF OPERATION Please write to time of day. 6/FM-9P (for example nam•ndml G� - �iPAIL �/� 6 Cg -9Grr 7A PM i ,TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 ✓ rrlore than 10,000sq.ft. =$250 _..... ... -- ------- - Y-ES ------ -NO le----- ----- -------- ---....-- .......-- -- - - ..Ie ss- h t-....a-n_25--sea_ ts--....-.... RESTAURANT =$100 25-99 seats =$150 more than 99 seats =$200 _........_.. .... ------ YES S- ...N. - fl $100------ ------------ - --- _160-.----_ ---- ------ ------ - - .. _ .. BED/BREAKFAST ----- ------------------ --------- --- ---------- ---- _..._ ...... ....... I-- .----------- ......-..... ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES 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., (I W", '61 .SG- 2 3 So & 5- _ Signature Date Social Security or Federal Identification Number - - - ----------------- --- Revised 11/13/06 FO AP2007.arm Check#8 Date -OG $ -j-5 0 sop .:Ts• u✓r YYp 1i . r++w. i i. s 4�dsxy,>a•:� -•o- '4' 'Y wt /R.° ..hY�Y- r' `? "'ki -'�e � y ♦ Qi'.'H``'T +i t,': i > P`"•W�yt ^ r , dr'�4b.++»-„� wry ` •;CommonweSa7lth of Massachusetts ye v,i(E' 9 ' '4 'f�'t'^t,,t'f`tr r :t",..r "Board of Health "✓ Yvi`:' t 9 �!'� d3u 1 3R .`.,el . - , IGmbeliey OnSC011 .+ 1, , 120 Washington Street,4th Floor l. ke: a =� 3MdyOf P SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: J& J Variety File Number.BHF-2004-000025 207 North Street Salem MA 01970 LOCATED AT: 0207 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0017 Dec 19,2006 Dec 31,2007 $100.00 TOBACCO VENDOR BHP-2007-0039 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES iDecember 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 13 of 29 0207 North Street J & J Variety City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-9423 Food and Food Protection FAIL Critical BLUE Owner: Comment:There are price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels. Jatinder Singh Saini PIC: Repeat violations of this nature will be subject to monetary fines. Lucky Verma GENERAL COMMENTS: Inspector: 1029:AII other violations cited in the 11/22/06 inspection report have been corrected. David Greenbaum Date Inspected:ICorrect By: 11/29/2006 Risk Level: Permit Number: BHP-2006-0251 Status: SIGNED OFF # of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 ) Page 1 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®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 ) Page 2 of 0207 North Street J & J Variety City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-9423 Food and Food Protection FAIL Critical BLUE Owner: cpe Comment:There price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels. Jatinder Singh Saini PIC: Th/er/is food stored directly on the floor of the back room. All food must be stored at least 6.8 inches off the floor. Lucky Verma `fne following items found outdate at the time of inspection: Inspector: 4-Hershey shakes David Greenbaum 1 -package of salami 1 -salad dressing Date Inspected:Correct By: 2-Campbells gravy 11122/2006 2-Barbeque sauce 2-Stove Top stuffing Risk Level: 2-Mashe tatoes 1 -Chi en Helper Permit Number: 3-c emix 1 6- hexmix BHP-2006-0251 -Baby cereal Status: 46-Enfamil 1 -package of peanuts PARTIAL COMPLY j 1 -Pie crust #of Critical Violations: 1 -Turkey dinner 1 Owner must closely monitor all expiration dates and remove from the shelves all expired product. Time IN: Time OUT: Repeat violations of this nature will be subject to monetary fines. Equipme4antensils FAIL Non-Critical BLUE Urgency Description(s): BLUE: Amp energy drink cooler is missing a thermometer. Provide a visible accurate thermometer in this unit. Violations Related t0 Good .front Beverage air reach in needs a visible accurate thermometer. Retail Practices (Critical violations must be correctedT e front rue reach in needs a visible accurate thermometer. immediately or within 10 days)(NOn-critical Violations T walk in needs a visible accurate thermometer. must be corrected immediately or within 90 days) T�microwave needs a general cleaning. 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. Nov 22,2006 ) Page 1 oft �• Item Status Violation Critical Urgency RED: Physical Facility FAIL Non-Critical BLUE Violations Related to ommen "There is a front broken window. Repair window or have the window boarded up. Foodborne Illness Interventions and Risk Factors (Require Theps are many water stained ceiling tiles in the establishment. Investigate the source of the leak and repair. Replace all stained immediate corrective action) ce7ing tile . These is a hole in the wall under the bathroom sink. Seal all holes. GENCOMMENTS: 1012:Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 22,2006 ) Page 2 oft I IMPORTANT MESSAGE f FOR DATE M OF PHONE ❑ FAX AREA CODE NUMBER EXTENSION i O MOBILE AREA CODE BER 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 SIGNED FORM 40 MADE IN U.S.A. j NOTES __ __ 0207 North Street J & J Variety City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 741-942$ ,._. .o z' »° Food and Food Protection FAIL Critical BLUE Owner. j Comment:The following items removed from shelves at time of inspection: Jir atinder Singh Saini " 6-Twinkles PIC' , ix 2-Sugar donuts Jatinder singh Saini 4-Doritos Inspector: t 1 -Pint of milk i Y 8-Nature Valley granola bars David Greenbaum 1 -Wheat thins Date Inspected: Correct By: 1 -Slim Jim 1/18/2006 x 5-Ritz Bits 2-Mrs.Fields cookies Risk Level: 1 -Rice Chex 6-Jars gravy J , 1 -Saclloped potatoes Permit Number 4-Macaroni 8 cheese Owner must closely monitor all expiration dates. BHIP-2006-6251 ff Status' Some price labels covering expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels. SIGNED OFF #of Critical Violations: a Future repeat violations will result in monetatry fines of$25.00 per violation being issued. 1 s Equipment and Utensils FAIL Non-Critical BLUE TimeIN:�Q, Time OLT '- Comment:The Slush machine has an accumulation of food spills and splatter. Thoroughly clean slush machine. Urgency Descripti6n(sf.1 The microwave needs a thorough cleaning. BLUE Violations Related to Good The walls in the walkin cooler have an accumulation of food spills and splatter. Thoroughly clean the walls. Retail Practices (Critical _ The fan covers in the walkin have an accumulation of dust and grime. Thoroughly clean fan covers. violations must be corrected immediately or within 10 Physical Facility FAIL Nan-Critical BLUE days)(Non-critical violations '' Comment: There is a damaged wall outside the bathroom. Repair and seal wall. must be corrected immediately or within 90 days) +' All light fixtures need a protective cover. 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. Jan 18,2006 ) Page / of2 Item Status Violation Critical Urgency RED: Violations Related to GENERAL COMMENTS: Foodborne Illness Interventions and Risk Factors(Require 438:Owner will notify the Board of Health within one week that all violations have been corrected. immediate corrective action) 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. Jan 18,2006 ) Page 2 oft Commonwealth of Massachusetts City of Salem ' Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2006 I WHO'S PLACE OF BUSINESS IS: J & J Variety File Number:BHF-2004-0025 207 North Street Salem MA 01970 LOCATED AT: 0207 NORTH STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0251 Jan 3,2006 Dec 31,2006 $100.00 TOBACCO VENDOR BHP-2006-0252 Jan 3,2006 Dec 31,2006 $50.00 Total Fees: $150.00 PERMIT EXPIRES IDecember3l, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 2 of 3 I CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH j 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAx 978-745-0343 MAYOR www.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT—,T-4Lj�� 1 T_STEL#(;;A; R �r�—��a 3 ADDRESS OF ESTABLISHMENT_ C) 0(,TH Sapzc—GT MAILING ADDRESS(if different) OWNER'S NAME �) ATj �(� - CZ �A)NL TEL# 7SI -Q4$' O ff) ADDRESS '�-r, _ b �k-C-4^oo2 ��1ASS CITY STATE ZIP n I t� CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# `E -39b HOURS OF OPERATION: Monate_q-Tue.r;-�Wed.j-9 Thu.G'9Fri.j&,eLSat. r,9_Sun.,-4-& TYPE OF ESTABLISHM FEE (check only) RETAIL—STORYES N ES O2-,5F less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 67 -O 6more than 10,000sq.ft. =$250 - ........ .... .....................................................--- --..........I----------_-------------------- RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 - --------------------------------------------------- - -------........-------- --------------------------- - BEDIBREAKFAST YES NO $100 - ----------- --------------- --------------------------------........----------...------...---------....------------------------------------------ ADDITIONAL PERMITS MAKE (no"just serve) ICE CREAM, YOGURT, SOFT SERVE 1C $5 eTOBACCO-VENDOR NO $50 ALL:-NON-PROFIT(such as church kitchens YES N $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledand belief, have filed all state tax returns and paid all state taxes required under the law. 41Qa10s X62- ISO - 0 �cS Signature Dates Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date �$T6�/��5— ��0 I 4-mnr.•r'- Y�?'ir�-yd .^R(Shi' mF` :t$-�"p'- A .c:.� £ rt� s "}r9" �'Jt'�^/'�TM��tr�va��h 8, T sa4cE'k` .a+r •r < ,�.. 4 ,� i. .}�n "�'` R4 t. CITY OF SALEM, MASSACHUSETTS '' ' BOARD OF HEALTH e 120 WASHINGTON STREET, 4TH FLOOR - SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 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: J & J Variety Address of Establishment: 207 North Street Owner's Name: Jatinder Singh Saini Restrictions: Application Date: 12/3/2004 Permit for Food Establishment 159-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 40-05 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. i� HEALTH AGENT CITY OF SALEM, MASSACHUSET a CVo BOARD OF HEALTH O ifi/// 120 WASHINGTON STREET, 4TH FLOOR NOV 3 0 2004 c SALEM, MA 01970 1+ " TEL. 978-741-1800 CITY OF SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTJ g& J \1AlZ36TY- TEL# ADDRESS OF ESTABLISHMENT aO7 t�,bo 2T2TSTIZGE:T . S)ltrn MA55. 019'90 MAILING ADDRESS (if different) Y�6ov� OWNER'S NAMES TQ tfA4 eeTEL# $1-,'14.9 0$69 ADDRESS -3 6 HaT(-t¢S S� kee.1 CITY Me;a -Fo- cd STATE_(�j(.1 ZIP owls . CERTIFIED FOOD MANAGER'S NAME(S) ahs, ,, S- .5n.i vii CERTIFICATE#(s) a ci (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON al6oye_ HOME TEL#�81--�iGJ6-I1FZ1 HOURS OF OPERATION: Mon. -q Tue._G-9 Wed. -q Thu.6;_ Fri.��4 Sat.6-q Sun. TYPE OF ESTABLISH ME FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 05 more than I0,000sq.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 yo,6j 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 MPL ChaAi 2C, Section 49A, I certify under the pains and penalties of perjury that I, to my best know) b have filed all state tax returns and paid all state taxes required under the law. 6a - s Signatureate Social Security or Federal Identification Number --------------- --------------------------------------------- ---------------------------------- --- -------------------- --- ------ --- Revised 03103 FOODAP2.adm Check#&Date o< Massachusetts Department of Public Health Salem Board of Health M 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 Dae Type of Operationts) Type of Inspection Jf f / j r ❑ Food Service ]-Routine Address Risk 2,lTetail [I Re-inspection d 2 oo" Lev E] Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HAGCP Ytil E] Temporary [IPre-operation d ❑ Caterer ❑ Suspect Illness JA.Person in Charge(P C) Time ❑ Bed&Breakfast El General Complaint In: ❑ HACCP Inspector OUt: I 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 tg-t3. 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 T MENEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 16, 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) ❑ 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 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 #: 1-14-1by 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: S U. Inspector's Signatur c Print: PIC's Signature: Print: Page1!of.-Pages r. Violations Related to Foodborne illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT_ 8 Cross-contamination 1 590.003(A) Assignment ofRes onsibility` 3-3102.11(A)(1) Rate Animal Foods Separated from 590.003(B) Demonswation of Knowledge* Cooked and RTE Foods" 2-103.11 Person in char e-duties Contamination from Raw Ingredients 3-30111(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Others, 2 590.003(0) Responsibility of the person in charge to Contaminafion from the Environment require repotting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char-0 Contamination from the Consumer 590.003(G) Re or n by Person in Char e* 3-306.14(A)(B) Retorted Forel and Reservice of Food* 3 590.003(1)) 1 Exclusions and Restrictions's Disposition of Adulterated or Contaminated 590.003(P) Removal of Exclusions and Restnerions Food 3-701.11. Discardutg or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food" 4 1Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Com limcc with Food Law* 4-001-111 Manual WaFe washing-Ilot Water 3-201.12 Food in a Hermetica Sealed Container* Sanitization ILmperature* - AL3-201.13 Fluid Milk and Milk Products* 4-501 112 MechanicalNarewaahing-Hot Water 3 202.13 Shell E�Is- S nutm anon Temperatures* -203.td Ewes and Milk Products.Pasteurized* 4-SD1-174 Chemteal Sanitization-temp.. pH, concentration and hardness 3-202.16 fee Made From Potable Drinkin Nater' 4-601.11(A) Utensils Cl Food Contact Sadaees and 5-1D111 Drinking Water from an }roved System* LRenslls Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Waua-Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recrearionally Caught Molluscan Food Contact Surfaces of E. ui ment* Shellfish* 4-703.11. Methods of Sanitization-'Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.1 1. Clean Condition-Hands' and Arms'* Re utato Aathori 3-202.18 Shellstock Identification Present* 2-301.12 (`leaning Procedure* 590.004(C) Wild Mushrootnsx 2-301.14 Wlten to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices E5- Receiving/Condition 2-401.11 Eatin�,Drink ing orUsiaTobacat* 3-202.11 PHFs Received at Pro tet Tem teraturer" 2-401.12 Discharges Froin the Byes.Nose and 3-202.11Packagelnte4'rit,* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Pretentitty Contamination When Tastin*" 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-2fYL.18 Sbellsrockldenrificarion* 590.004(E) PreventingContarninationfrom 3-203.12 Shellstock Identification Maintained* Ent dwas s' TagsiRecords:Fish Products 13 Conveniently ndwash Facilities 3-402.11 Parasite Destruction* Nninbetenttylocatedand Accessible 3-402.12 Records.Creation and Retention" 5-203.11 Numbers and Ca ernet s* 590.004(7) Labeling of Ingredients' S-20d.11 Location acid Placement* 7 Conformance with Approved Procedures 3-205.11 Accessibility,Operation and Maintenance lHACCP Plans Supplied with Soap and Nand Drying 3-502.11 SecializedProcessin>Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanscr.Availability 8-103.1.2 Conformance with Approved Procedures" 6-301.12 Hand Drvin>Proi7eion *Denotes critical item in the federal 1999 Food(ode or 105 CNIR 59),000. CITY OF SALEM BOARD OF HEALTH J Establishment Name: Jed toA* x ry Date: Page: 2 of 2 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—.Red Item' - Verified .: PLEASE PRINT CLEARLY /P • u J s r 2-4. At4 3JI.Lra do a .. /'Ya �rrr F I" r eJ cF r Jt4c.r , A- ^ t' -oat y � Ld r w a /��fltf• J3aar 2- S�4/� .fivFf�r Dwwait oA%Ij!r- fit. t wfdNq t"i.t AA aaotr%mrfee Ortirw , c'A PAir x+- 04, z J. Mh YX ri eC0. w r P LZ 1�F,1a+na,rr 6- �tiMtvrnor� _ sJ wP9 n Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that lllinoncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure II your food permit. ca�-: Ac*C S ❑ Voluntary Disposal ❑ Other: 3-501,14(C PHFs Received atTenificratures, Vioiations Related to Foodborne Illness Interventions and Risk According to taw Cooled to Factors(Items 1-22) (Cont.) 41 T!45'F Within d Hour s- PROTECTION FROM CHEMICALS 3-501.15 Coolim,Methods for PRFsF-14- ---Food orColorAdditives Lfq - PHF Hot and Cold Holding 202-12 -Add--Aiv-es�� 3-501.16(B) Cold PIIFs Maintained at or below 590.004(17) 41"745'l,, 3-302.14 Protection from T-napprowd Additives" --- r 3-501.16(=1)16(A) I for PHFs Maintained at or above Llb- Poisonous or Toxic Substances 140'F, 7-101.11 Identifying information-Original 1 3-501,16(A) Rousts Held at or above 130°F. Containers* 7-10111 Common Name-Workin- Containers' 20 Time as a Public Health Control 3-fiol�I Time as a Public Health Contro" 7-101.11 Separation-Stoi acc- ........ 7-202,11 Restriction-Presence and Use* 19;00�1)0 4�(14)�� Variance Ra uirement 7-202.12 Conditions,of Use- 7 1-203,11 Toxic Count net -Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizeis,Critenu-Chemicals* POPULATIONS(HSP) 21 3-801,11(A) Unpasteurized Pre-packaged Juices and 241.12 Chemwah,for Ww hin�'Pjoduoe'�Crltorle-- I 7-204A Beveraces with Warnine I zlals� 4 7-205.11 incidental Food Contact, Lubricants* 3-801.I1(B) Use of Pastcullzel Epos* 3-801A I(D) Raw orPaitially Cooked Annual Foal and 7-206.11 Restricted Use Pesticides. Criteria* Raw Seed Spr 7�2 ouis Not Seived. ;' , 0612 Rodent Bail Stations:' 3-so 1.11(C) Uno cued£nod Parka<=e Not Re-served. Y` 7-206.13 Tracking Powders,Pest Control and -- Monitorins* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603 1,11 Consumer Advisors Posted for Consumption of Consumer 15 Proper Cooking Temperatures for Annual Foods That are Raw,tTndcrcookrd or Nor PHFs Not Otherwise Processed to Eliminate I � "I 11'th � 3-40:1.11A(1)(2) Eggs- 155 T 15 Sec. 3-302.13 oliell"�- Eckis-hinnickliate Service 14501"1 5sec* T3-302 Pasteurized Eggs Subxdtute ba, Raw Shell EsIgs, 3-401.11(A)(2) Comminuted Fish,Meals &Came - Animals- 155'F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(13)(1)(2) Pork and Beef Roast-130`F 121 min* 3-401.11(A)(2) Raines, firriected Meats- 1.55°F 15 590.009(A)-(D) Vicillifloris of Section 59().0()9(A)-(D)in sec. ' I catering, mobile food,temporary, and 3-40L11(A)t_3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish. Meat, debited under the appropriate sections 22ultx or Ratites-i 65°F 15 sec. above it'related to foodborne illness 3-401.1 1(C)(3) Nkliole-muscle, Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 7 401.12 Raw Animal Foods Cooked in a pi actices should be debited kinder#29- Murowave 165'F Special Requokrrneirts. 3,401 II(A)(1)(1)) All Othcr PHFs 145'F 15 sec, 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3 403.11(A)&(D) PHFs 165'F 1.5 sec. - (Iteins 23-30) 3-40.3.11(B) Microwave- 165'1-'2 Minute Standing Critical acrd non-critical violalionv, ,itnch do not relate to the Time* foodborne illness interventions and risk)I actors listed above can be _T4�3.Vi(C) Commercially Processed RTE Food- feand in the ddhoring sections of the Food Code and 105 CMR 14WF* 590.000. 3-403-1.1(F) Remaining Unsliced Portions of Beef Item Good Retail Practices-- -FC - 59-0.00-0 Roasts" -23. Manaqamera and Personnel FO 2 .003 1g Proper Cooling of Fs 24. Food one Food Protection FC 3 .004 25E -4-501.14(A) Cooling Cooked PHFs from 140'F in __E9diaricenjand Utensils -F0 4- 005 26� Water,_Fl -Ec 5 006 70:'F Wuht a 2 1 lours and From 70°F 2-i -_Phy-Lik:WF - :c:qLtyFG-i3 007 to 4 t"F/4-5'F Within 4 Hours. Poisonous or Toxic Materials FG-7 .008 3-501.14(B) Coaling PHFs Made FromAmbient 299 SpWal ABPOuirements .009 Temperature Ingredients in 41'F145"F 30, Other -- Within 4 Hours* "Denotes mucal item in rho federal 1999 Food Co&or 105(:T,,IR 59(),000, CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR "ra 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: J & J Variety Address of Establishment: 207 North Street Owner's Name: Jatinder Singh Saini Restrictions: Application Date: 12/11/2003 Permit for Food Establishment 163-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 39-04 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 1 a CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR DEC 4 -2Uti3 e 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 TAH J �'/(]`�I` fit- TEL# �t�F� X41 -q�23 ADDRESS OF ESTABLISHMENT 00q OT°}h My=k-'S- MAILING ADDRESS (if different) S ,/—\h0 V e— OWNER'S NAME jA-TJ:"D .p _SIt�1C H S/__\r"J TEL# }8} X48-04691 ADDRESS _�', G V4 AIt�JCS S'TR Cc--T. CITY_-meQ( o(2D___________ STATE MIA ZIP C7atSS _ CERTIFIED FOOD MANAGER'S NAME(S) Ac 'o�_hrw e-_ CERTIFICATE#(s)333D8G R (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL#-ISL HOURS OF OPERATION: Mon CZgf Tue:, P Wed: Thu.E�,�Fri�q�SatQ,7ji, TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 4,,,1000-10,000sq.ft. =$100 I '0 more than 10,000sq.ft. =$250 RESTAURANT YES NO ! 3 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, S FT$J=RVE YES NO $5 TOBACCO VENDOR ,o QES) NO $50,-, ALL NON-PROFIT(such as church kitchens) YES NO $25 Please Nay tO'al L't vne Cha_ck payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number ------------- ----------------Is=_ = , -------------- - s_o�s------------------ Revised 11/03/0 AP2.adm Check#&Date. 3Y_��- SQ. 11 � ,c CITY OF SALEM, MASSACHUSETTS D BOARD OF HEALTH _ 120 WASHINGTON STREET, 4TH FLOOR �fc SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT March 22, 2004 J&J Variety 207 North Street Salem,MA 01970 Dear Owner, On February 18,2004 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. J&J Variety 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 dollars($100)for the FIRST offense. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office,120 Washington Street,4" Boor,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, anne Scott Health Agent JS/bas Cc:North Shore Tobacco Control Program Christina Harrington,Board of Health Chairman N2 2146 City of Salem - Board of Health Violation Notice- Tobacco Sale to Minors 4%two This notice is to inform you that during a tobacco sales compliance check,your establishment violated the Salem Board of Health regulation#24 prohibiting the sale of tobacco products to persons under 18 years of age. Name of establishment �1 21771 NOV FEB 2 4 2004 Address + " A • OA 1(7 . 4 c rn 1l tet_ - - . Date of sale Time saleMinor/'s age/gender Minor's ID# Y Adult supervrs rs Narrative report of incident and description of seller by adult supervisor who will testify at the Salem Board of Health meeting including a description of the seller: affirm,under the p ' s and p alties of perjury, that the above report is true to the best of my knowledge a -belief Adult sup orSignature) 1 AAtlult'supervisor ( rnt ante) VENDOR ST MENT: I acknowledge I received this Violation Notice on , +9 _ M and I am being given a carbon copy of this notice. I also acknowledge that I have been told tha a letter regarding Board of Health follow-up to this violation will be mailed to me at ;theabove addressner anger/Clerk gfioture) TS�t�'Z'DC- L t\; a -i S�,A 1 NJ Owner/Manager/Clerk(Print name) If vendor refuses this Notice or if Adult Supervisor feels unsafe in delivering it, an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information,contact the North Shore Tobacco Control Program at 978/741-5646. Board of Health-white/NSTCP-yellow/Establishment-pink Massachusetts Department of Public Health Salem Board Health S p ,20 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 Da Dg of Operations) T e of inspection Name J _C J_ � ��e { �} ® Food V'Routine Address C C Risk ❑ Retail [IRe-inspection Level ❑ Residential Kitchen Previous Inspection Telephone _ CIV, ,3 / ❑ Mobile Date: Owner IiACCP Y1N ❑ Temporary ❑ Pre-operation �,y 7n �/ ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑General Complaint In: ❑ HACCP inspector a !� Z 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) ❑ 590.089(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 PROTECTION FROM CHEMICALS'. -- t ❑ 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 _.. __ JIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18, Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding `G'S Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑. 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY,SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing )-CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑22. Pasting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions Z immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2}(590.003} order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (Fc-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. E 30. Other DATE OF RE-INSPECTION: 5: 14 d. inspector's Iignatturret) Print: PIC's Signature: 1 Print: Page ofZPages Violations Related to Foodborne Illness ' Interventions and Risk Factors(Hems 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 I 590.003(A) Assignment of Resonsibility* 3-302.1[(A)(]) Raw Animal Focids Separated Imm 590.003(B) Demonstration oflfnowtedgel Cooked and RTE F(x)ds* 2-103.11 Person in charge-duties Contamination from Raw Ingredients 3-302.11(AX 2) Raw Annual 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 employees and 3-30-A 1(A) Food Protection' t a tlicants4' 3-362.15 WashingFruits 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(6) Reporting by Person in Charge* 3 306.14(A)(B) Returned Food and Reservice of Food* 3 590.piY3(D) Exclusions and Restricnons* Disposition of Adulterated or Contaminated _596.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE food" 4 Food and Water From Reautated Sources 9 Food Contact Surfaces aw 590.004(A-B) _Compliance with Food Law" 4-561.111 Manual Warewashing-Hot Water 3-261.12 Food in a Hermetically Sealed Container" Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashinb Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 Ea=s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp., pH, 3-202.16 Ice Made From Potable Drinking-Water` concentration and hardness. 4-601A I(A) Fjuipment Food Contact Surfaces and 5-'101;11 Drinking Water from an Approved SvstenY" Utensils Clean* 590.006(A) 'Bottled Dnnkin Water* 4-(102.71 ClranilsClealuencyafEquipmentYood- 590.006(B) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and f Equipment 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 E ui meat* Shellfish* Water an 4-703.11 Methods of Sanitization-Hot 3-201.15 Molluscan Shellfish from NSSP tasted d Chemical* Sources* roper10 Pro Adaqua te Handwashin p , 9 Game and Mushrooms Approved by 2-301.11 Clean Re Mato Authority Condition-Hands and Arms" Aul 3-202.18 Shellstock Identification Present" 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-20L17Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 240111 Eating,Drinkini,or Using Tobacco* 3-202.11 PHFs Received at Proper Tem eratures* 2401-12 Discharges From the Eyes, Nose and 3-202.1.5 Package hitearity1c Mouth* 3-101.11 Food Safe and Unadulterated* 3-301..12 Preventing Contamination When Tasting* 6 TagsiRecords:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-20111 Numbers and Capacities* 590,0040 Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205 11 Accessibility.O reratian and Maintenance tHACCP Plans Supplied with Soap and Hand Drying 3-502.11 specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-31)1.11. Handwashin Cleanser,Availability 8-103.12 Coil futmance with A t roved Procedures* 6-303.12 Hand Drying-Provision `Denotes eriticid item in the tederd 1999 Food Code or 105 CMR 590.000- CITY OF SALEM BOARD OF HEALTH Establishment Name: 7 e Date: / A U 4/ Page: of 2 Item Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY s 3!� s 6e d e i a 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/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: S 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41."F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 9 PHF Hot and Cold Holding 3-501 16(3) Cold PUFs Maintained at or below 3-202.12 Additives" 590.004(F) 4'1°/45°F 3-302.14 Protection from Una roved Additives'` I; 3-501..16(A) Ikx PHFs Maintained at or above Poisonous or Toxic Substances 40't 7-101.11 1lentifying Intixmati n1-Orig nal 3-50 t.16(A7 Roasts Heid at or above 13(1°F. Containers" 7-102.11 Common Name-Working Containers' 20 Time as a Public Health Control 201.11 Separation-Storage" 3-501.1.9 Time as a Public Health Control* 7-202.11 Restriction-Presence and Ilse* 590.004(H) vainance Ree uirement 7-202.12 Conditions of Use" 7-203.11 Toxic Containers-,Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals' POPULATIONS HSP) 7-204.12 Chemicals fur Washing Produce, Criteria" 21 3-801.11(A) Unpasteurized Prcpackaged Juices and 7-204.14 Drving Agents,Criteria* Beverages with Warning Labels* 7-205,11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Egos« 7-206.11 Restricted Use Pesticides,Criteria* 3-801A 1(D) Raw ar Partially Cooked Annual Food and Raw Seed Sprouts Not Served 7-206 12 Rodent Bait Stations* - 7-20(1.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-served. Monitoring' CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 1.6 Proper Cooking Temperatures for Ani mal Foals That are Raw. Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.°°e0ec0.r v"11201113-401.i1A(1)(2) Eggs- 155`` IS Sec. 9-302.1.3 Pasteurized Fg=s Substitute for Raw Shell E-s- Immediate Sen•ice 145'FLSsec* 3-401.'tl(A)(2) Comminuted Fish.,Meats&Game Egs Animals- 155'F 15 sec. * 3-401,11(B)(1)(2) Pork and Beef Roast- 130'F121 mut* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meat- 155'` 15 590.0G9(A)-(D) Violations of Section 590.009(A)-(f))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°17 15 sec. * above if related to foodborne illness 3-401A l(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 Annual Foods Cooked in a practices should be debited under#29- Microwave 165'F s Special Requirements. "s 3-401.11(A)(1)(b) All Other PHFs- '145'F15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1.1(A)&(D) PHFs 165'F 15 sec. '0 (Items 23-30) 3-403.11(3) Microwave- 165'F 2 Min il'e Standing Critical and non-crilical violations, which do not relate to the Time` foodborne illness interventions and riskfactms listed above, can be 3-403.1.I(C) Commercially Processed RTE Food- found in the following sections ofthe Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Lkam Good Retail Practices FC 390.000 Roasts* 23 Mona sment and Personnel FC-2 .003 tg Proper Cooling of PHFs 24. Food and Food Protection_ _ FC- ' 3 004 FC4 00 3x01.14(A) from 14WF to I2a Emnd Utensils 7aPandWasteFC-5 .006 7)FWitin flours andFron170'F ' 2 . Physical 5 FC-6 007 to 41'F/45'F Within 4 Hours. * 28 _ Poisonous or Toxic Materials FC-7 .008 3-501.14(3) Cooling PHFs Made From Ambient 1_29 Special Requirements .009 30. Temperature ingretlienis to 4l°`14:5°F 1Other - .-..-.--- � -.-------- Within 4 Hours* *Denote,critical item in the federal 1999 Feist Cckle or 105 CvIR 590-0611. CITY OF SALEM9 MASSACHUSETTS .31 BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978.741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner' s Name : Jatinder S . Saini Name of Establishment : J & J Variety Address of Establishment : 207 North Street Type of Establishment : , RETAIL FOOD Application Date : 06/18/2003 Restrictions: Permit for Food Establishment 304-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 68-03 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 .. v6�. e CITY OF SALEM, MASSACHUSETTS qP � BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR ^ SALEM, MA 01970 TEL. q78-741-1800 FAX 978-745-0343 STANLEY LISO VICZ, JR. JOANNE SCOTT, MPH, RS. CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �//:�RI CT y TEL# 9�C5 -�q� -GILj;23 ADDRESS OF ESTABLISHMENT r�O'7 (�,k92 TH 5T• /SI 1�Zit r f�f MAILING ADDRESS (if'different) OWNER'S NAMES )Qu o�e� r��. 1 ti b1Qh`w cer c J TEL# 3��-1� 7 t ADDRESS S6 GtTY �bt n(�b STATE NA ZIP 02L5S' CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSONG A Lrjcr X�t`Ut` HOME TEL HOURS OF OPERATION: Mon. V ,Tue._ fVWed. _Thu. V,� Fri.,,_A/� Sat. ./ Sun. Am 41DCt-f M TYPE OF ESTABLISHMENT ,63 FEE check only RETAIL STORE E NO less than 1000sq.ft. _$50 1000-10,000sq.ft. $1 0 more than- 10,000sq.ft. 50 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR (Sj NO �g Q $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. r Signature Date Social Security or Federal Identification Number Revised 71l OODAP2.adm _� Check#8 Date�a�,