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JADE HOUSE REST - ESTABLISHMENTS UADt RZ511. z. i I o e s r G 4 : A i COND12•gya, City of Salem, Massachusetts € Board of Health 9 e 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 Public Health Prevent. Promote. Protect. Iramdin@salem.com Kimberley Driscoll Larry Ramdin, MPH, RENS, CHO Mayor Health Agent FOOD ESTABLISHMENT PERMIT posted on the Premises of the Food Establishment (must be a 1 2016 Permit Number: FM-1646 Permit Type: Food Establishment 25-99 seats Goods &Services: Food Service: 25-99 seats Name of License Holder: Jade House/Fahong Wang Name of Food Establishment Jade House Address of Food Establishment 331 Lafayette Street Salem MA 01970 Restrictions: This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2016 unless sooner suspended or revoked. Permit Fee: $280.00 Issued: 1/1/2016 1 CITY OF SALEM, MASSACHUSETTS > xeairh BOARD or Hew:rir `.`.. •.", , .,. 120 WASIIING'I ON S'nkui.r,4M Fj,ocm KIMBERLEY DRISCOLL TFL.(978)741-1800 FAX(978)745-0343 LARRY RANIDIN,RS/IU:I-IS,CHU,CP-FS MAYOR Iramdin@salem.com salem.com H1S,\uri i ACEN'F Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: o 97 J 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: x' `?nt , 3 0 VY C 5) Applicant Name&Title: 6) Applicant Address: ;fie v 0 7) Applicant Telephone No: I / 4 Hour Emergency No: ' 'g mail: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address corporation �} 1i� An individual CJ lX h c 020 A partnership Other legal entity 12 Person Directly Res onsible For Daily Operations Owner, Person in Char e, Supervisor,Manager,etc. Name&Title: Address: r 1 LI"] 0 ! Telephone No: /, -,?,- 13) Fax: Email: Emergency Telephone No: b'q" - � 7i 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: h ��y Check#: G� Date:1��2<i7//!/'1 Amount: f Food Establishment Information 1natr Source: 15) Sewage Disposal: Dic Water Supply No: (if applicable) 16) Days and Hours of Operation: 30— =3U 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 10/112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures( if 25 seats or more): / Yes No 20) Location: 22) Establishment Type(check all that apply) F ❑ Retail( Sq. Ft) ❑Caterer Perl anent Struc ure 17 Food Service-( Seats) O Frozen Dessert Manufacturer Mobile Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments---------------------- 41 heck one) RETAIL STORE RESTAURANT nnual Less than 1000sq.ft. $70 13Less than 25 seats $140 Seasonal/Dates: 000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑More than 10,OOOsq.ft. $420 `d25-99 seats $280 ❑ More than 99 seats $420 Temporary/Dates/Time: - --d- a- ,§r---------- ------- -"--- -----...-------- - -- --'----------me,------------------------------------------------ ------- ❑ Bed& Breakfast/Childcare Services/Nursing Home $100 ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT' $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF-potentially hazardous food(tlmetemperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperature controls required) (check all that apply): RTE-ready-to-eat foods Ex.sandwiches,salads,mutons which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commerciqlly Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly re-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Deliv—e-r7ltifftelft—ed PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under ISI 25) Social Security Number or Federal 26) Signature of Individual or Corporate Name: ✓�)��1 Vt( 'vd� .a' ��DND1Tq�o City of Salem, Massachusetts g m Board of Health q 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PlliblicHealth M g D Prevent. Promote. Protect. Iramdin@salem.com Kimberley Driscoll Larry Ramdin RSIREHS, CHO, CP-FS Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM-15-104 Permit Type: FOOD SERVICE ESTABLISHMENT Goods &Services: Food Service: 25-99 seats Name of License Holder: Jade House/Fahong Wang Name of Food Establishment Jade House Address of Food Establishment 331 Lafayette Street Salem MA 01970 Restrictions: This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: $280.00 Issued: 1/1/2015 -0 CITY OF SALEM, MASSACHUSETTS 1?ub1fc13eatth BOARD OF HEALTH 120 WASI'IINGTON S'IREEP,4T11 FLOOR KIMBERLEY DRISCOLL TEL.(978)741-1800-Ft�x(978)745-0343 LARRY RAMDIN,HS/REFIS,CI 10,CP-NS MAYOR Iramdin a salem corn HL,Ari-I ACiENP Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: so A, A (. / 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: W9 7<1 4 3 � 6 u 5) Applicant Name&Title: y( VVW 6) Applicant Address: . G��f IYOINIXE 51 � 1 Y-1 C\. �/l�� e 2—k I 7) Applicant Telephone No: 24 Hour Emergency No:�I/ �(j�J 29'/>Email: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An associate Name Title Home Address corporationAri t Fr_ I" W ey- uoVjvzL St, Gu\% A partnership � �� Other legal entity 12 Person Directly Responsible For Daily Operations Owner, Person in Charge,Supervisor,Manager,etc. Name&Title: vi Addeess: J Telephone No: �/ Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: Date: /�� Amount: '. , Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation ( 3� IZ' 17) No.of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) O Caterer r0emian ructur EA ood Service-( 36 Seats) ❑ Frozen Dessert Manufacturer Mobile EA Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home `U Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: ........ ••... -----••••••••-•-•••-----••••-••••---•• Breakfast Establishments A(�check one) RETAIL STORE RESTAURANT [] Less than 1000sq.ft. $70 ❑Less than 25 seats $140 Seasonal/Dates: 01000-10,000sq.ft. $280 ❑Residential Kitchens $140 ❑More than 10,000sq.ft. $420 la'25-99 seats $280 13 More than 99 seats $420 Temporary/Dates/Time: -,, '-,, ---- '------- -- ----------- -- -------------------------------------------------------------- ....... ❑ Bed&BreakfastlChildcare Services/Nursing Home $100 --------------------------------------------------------------------------------------------------------------..................--------- ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 0 ALL NON-PROFIT' $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs—non-potentially hazardous food(no timaltemperature controls required) (check all that apply): R —rea -to- t. ods Ex,sandwiches,salads,muffins which need no further processing Sale of CommerciallyHot PHF Cooked and Cooled or Hot Held ooked to Order Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as,public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non. Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 1 /j 24) Signature of Applicant:/ /\ c Pursuant to MGL Ch.62C, sec.49X I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: .46 4 - O 2 4- 7 3 I �lJ�h 26) Signature of Individual or Corporate Name: Delilah Castro From: David Greenbaum Sent: Tuesday, November 18, 2014 8:10 AM To: Delilah Castro Subject: FW: today Attachments: 5-7 West 11-15-14 beforejpg; 5-7 West 11-17-14 after.jpg; 37 Fort 11-17-14.jpg From: Jeffrey Cohen Sent: Monday, November 17, 2014 1:02 PM To: David Greenbaum; Larry Ramdin Subject: today SaturdayZsng ues: n Saturby dump behind Jade andwas overnowing...back today and still not emptied. The dumpster at 14-16 Chen re ul rl ridays.Rugs2 Desmol� � �y�� 1118 Laurel V ' •,;� �AJI/r I( 27 Beach � 1t.j"I/t/"\ lM�l TV's letters sent _ I 0 75 Canal 11 Carlton Overflow Fort 37 Fort 37 F Thanks for recycling! Jeff Jeff Cohen Mandatory Recycling Enforcement Coordinator City of Salem 120 Washington St, 4th Floor Salem, MA 01970 978-619-5672 icohen(a)salem.com 1 ' S , k� a h t F y r^)• � S •)Fat M � � + Y FJ' S. �!�.� fir¢,. i , {• .. ♦ Fig' z` } $ 11 ' .t�� I�ry♦1�y�J,�..y.Y}�."1A� syr d�f/1 , •t Yy Y _ ��iC,)••_ a J u�h to �"' `a16raa .p� R.car �'iiy,._ a '4 �..,'Aw a <tl'" ♦ t'$3+1t 1 ::��. . ,: �� .. +l =tg � Y_ + �,. e.3:- �� ', r � a "','. 3'.�a k' •, aC ' c 3�. � aN4�k� P��6i + u gbik� .. >sk k � ° $ �N ,.a A l Y� fx-* �� „, ,�"ih" �, . ."�"y�,Via, w f ,'a"4,�'f L.. �4 3h^ W" a . �; �[ Win. :v 5! #�� r 9'x . tN �Y. 44}"* F rA4 6'd ti.{. rt '� i✓aeil�F. vi�P _ !s v ��}1 i� Fy U^ � _ P 4�r4 r i > y y 3 � �� {+v d „ k SSW' ?:+} ✓ * Ji F �� y �y �r V y � IMPORTAWT MESSAGE FOR L)I- DATE / c@ 114 TIME M OFJ u 1�0 PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED X PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS.TO SEE YOU RUSH RETURNED.YOUR CAL" WILL FAX TO YOU MESSAGE I rr C64 t^PA II e 1C G,- is o . SIGNED ONIVERSAL. 48005 MADE IN U.S.A. NOTES _ ._ Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division Of Food end Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENYINSiteTION REPORT Tel. Name D t Typ f Operation(s) Type of Inspection ood Service ❑RDutine Address Risk ❑ Retail a inspection Telephone Level ❑ Moble Residential Kitchen PrevDate: u spQd on El Mobile Date: `(fin �)��''{{/�'/'�Z/� Owner HACCP YM ❑ Temporary ❑ Pre-U, re- a ❑ Caterer ❑Suspect Illness Person-in-Char a(PIC) � Timell 0 CP ❑ Bed&bpre El Complaint inspector r In: I Permit �jo ❑.Other No. Out: Each violation c ee requires a ex ria on on the narrative pa e(s)and a citatio o specific provision(s)violated. Non-compliance with: Violations Related to Foodborne illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) ' FOOD PROTECTION MANAGEMENT_a _ _ _ _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 'EMPLOYEE HEALTH ❑ 13. Handwash Facilities - _. _ _ _ _ --• ;PROTECTION FROM"CHEMICALS- ❑ 2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD'FROM APPROVED SOURCE -'-- "" TiMEttEMPERATURECONTROLS P. - - ._: ❑ 4. Food and Water from Approved Source _ ( otetrtiallyllaaardous Fggds) ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17..Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION _ •- .�� _j ❑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-$USCEPTBLE=PO_PULATIONS';(HSP)- ❑ 10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices 'cONSUMERADVI$ORY _ _._ - _ _ - 1 E]22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3X6690.000.00 s)4) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5X590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or T is Materials (FC-7X590.005) and submitted to the Board of Health at the above address 29. Special Req rem nts (560.006) within 10 days S receipt of this order. C" I "J 30. Other DATE OF RE-INSPECTION: t/{�„ s o-u.d« Inspector' ignature: Print: PICS Signature: r Print: rl ( Page ot4-11ages Violations Related to Foodborne Illness Interventions and Risk Factors(Hems 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 1 590.003(.0) Assi ment of Responsibility* Cooked and RTE Foods* 590.003(B) I Demonstration of Knowledge Contamination from Aaw Ingredients 2-103.11 Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* - require reporting by food employees and 3-302.15 W'ashin Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Focal Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Chan e* 590,003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Food dlon of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* d Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food.Law* 4-501..1.1 I. Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem ratures*- 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water* concentration and hardness.* 5-101.11 Drinking Water.from an Approved System` 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkmL Water* Utensils Clean* 590.O06(B) Water Meets Standards in 310 C MR.22.0* 4-602.11 Cleaning Frequency of Equipment Food Contact Surfaces and Utensils*. Shettfish and Fish From an Approved Source 4-702.1 t Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Mollusa.n Foal Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and- 3-201.15 Molluscan Shellfish from NSSF Listed Chemical* Sources" 10Proper,Adequate Handwashing Game and uushrooms Approved try At Aegu/story Authority 2-±01.11 Clean Condition-Hands and Arms* 3-202.18 Shellstcck identification Prescnt" 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices S Receiving/Condition 2401.11 Eating,Dr nking or Using Tobacco* 3-202.1.1 PHFs Received at Proper Tem raiures* 2'401.12 Discharges.From the Eyes,Nose and 3-202.1.5 Package Integrity* - Mouth* _ 3-!01.11. _ Food Safe and Unadulterated* 3-301.12 Preventin 'on Intuition When Tasting* 6 Taas/Rerords:Shelisteok 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F,) Preventing Contamination from 3-203.12 Shellstock Identification Maintained'kEmployees* Tags/Records:Fish Products is 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402. * 5-203.11 . Numbers and Capacities* 12 . Records,Creation and Retention 590.004 Labeling of Ingredients' 5-204.11 Location and Placement* (1) 9 9 7 Coniormance with Approved Procedures 5-205.1.1. Accessibility,Operation and Maintenance' /HACCP Plans Supplied with Soap and Hand Drying . 3-5D2.11 Specialized ProcessingA4edicxlo* Devices 6-301.1 L - Handwashin Cleanser,.Availabilit 3-502:12 Reduced oxygen packaging,criteria* 2 Hand 8-103.!2 Conformance with Approved Procedures* 6-301.1DProvision 4 Denotes critical iwni lathe federal 1999 Fwd Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: l Page:_Y7� of Rem Code I C-Critical It DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY 1116 C4 (,21 fSj 12�2 Discussion With Person in Charge: Corrective Action Required: No O Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. t I/I/ ' 1 I 0 Voluntary Disposal ❑ Other: J 3-501,14(C) PHFs Received at Temperatures ( Violations Related to Foodborne 111ness Interventions and Risk According to Law Cooled to t Factors(Hems 1-22) (Cont./ 41'F145`F Witirm 4 Hours. * PROTECTION FROM CHEMICALS 3-501..15 Conlin Methods for PHFs 1 14 Food or Color Additives 19 PHF Hot and Cattl Holding I 3-501.16(6) Cold PIfF's Maintained at or below ( 3-202.12 Additives* 590.004(F) 41'!45'F* 3-302.14 _ Protection from Unapproved Addhives'Y 3-50i.i6(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 7-101.11 Identifyinginforma.tion-Original 140`F. * „ 3-501.16(A) Roasts Held at or above 130'F, Containers* 7-102.11. Common Name-Workin Containers* 20 Time as a Public Health Control 1 7-201.11 Separation-Storage* 3-501,19 Time as a Public Health Control* 7-202.11 ,Restriction-Presence and Use* 590.004(H1 VarianceR uirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Snnftizers.Criteria-Chemicals* - 21. 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.1.2 Chemicals far WashingProduce,Criteria* 7-204.14 in encs.Criteria" .Beverages with Warning Labels* ! 7-205.11 Incidental Food Contact,Lubricants* 5-801.11(6) Use of Pasteurized Eggs* 7-2116.11 Restricted Use Pesticides;Criteria' 3-801.11(1)) Raw or Partially Cooked Animal Food and Raw Seed Serums Not Served. 7-206.12 - Rodent Bait Stations* 3-801.11(C) Unopened Fcxttl Package Not Re=served. 7-206.13 Tracking Powders, Pest Control and q Monitmin * CONSUMER ADVISORY S TIME/TEMPERATURE EMPERATURE CONTROL$ 22 3-603.12 Consumer Advisory Pasted for Consumption of ? Temperatures far Animal Foods Thai are Raw,Undercooked or 16 Proper CO CONTROLS t PHFs Not Otherwise,Processed to Eliminate j 3-401.1IA(I)(2) Eggs- 155'F 15 See. P O " r Eggs-immediate Service 145'F15sec* 3-302.13 1 E seeurized Eggs Substitute far Raw Shell r 3-401.Il(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec.° SPECIAL REQUIREMENTS 3401.11(6)(1)(2) Pork and Beef Roast-130'F 121 min* 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.004(A)-(D) Violations of Section 590.009(A)-(IJ)in sec * catering,mobile food,temporary and t 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be ` Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. ' above if related to foodborne illness f 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3403A f(A)&(I)) PHFs 165-F 15 see. * (Itefns 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical,and non-cril£cal violations,which do not relate to the Timc* foodborne illness interventions and,ish_factors tested above, can be 3403.1l(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. ,c 3-703.11(E) Remaining Enticed Portions of Beef ( item ! Good Retail Practices .FC 590.OD0 i tRoasts" 23. 1 Management and Personnel FC-2 .403 1S Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 j 3-50LI4(A) Cooling Cooked PHFs from 140`F to 25. Equipment and Utensils _ _ FC-4 .006 j g 26. . 4Jater.Plumbingand Waste FC-5 .006 70'F Within 2 Hours and From 70'F 27. iPhysical Facility FC-6 007 to 41`FI45'F Within 4 Hours. * 1 26_ Poisonous or Toxic Materials ` FC-7 .008 3-501.14(6) Cooling PHFs Made From Ambient 1 29. Special Requirements .009 Temperature ingredients to 41'F145°F 3-0 I other Within 4 Hours"` Denotes critical azin in the L-d=1 1999 Foal Cale or 105 QdR X90.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTAUIAHMENT INSPECTION REPORT Tel. Name Da TY8041,Operadonfs) Type of nspection LLf Food Service ine Address Risk [:1 Retail El Re-inspection Telephone Level El Residential Kitchen Previous Inspection P ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge-(PIC) T erson-in-Charge(PIC) Tim E] Bed 8 Breakfast El General Complaint In: L '� P ❑ HACCP Inspector Out Permit No. ❑.Other Each violnt*6ti checked requires an explanation on the narrative'15age(sj and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD.PROTECTION MANAGEMENT - .. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 'EMPLOYEE HEALTH - - - - ❑13. Handwash Facilities _ PROTECTIONFROWCHEMICALS- ❑ 2. Reporting of Diseases by Food Employee and PIC - ❑ 14.Approved Food or Color Additives El 3, Personnel with Infections Restricted/Excluded FOOO:FROM APPROVEDSOURCE ,' - - ❑ 15.Toxic Chemicals " _ " - TIMErrEMPERATURE:CONTROLS(Potentlell - -' ❑ 4. Food and Water from Approved Source y Hazardous Fgpd;i) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements y1heating ❑ 7. Conformance with Approved Procedures/HACCP Plans oling PROTECTION FROMCONTAMINATION ... • t and Cold Holding ❑ 8.Separation/Segregation/Protection - ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSUSCEP7tBL'E=POPULATIONS:(NSP);_: El21. Food and Food Preparation for HSP ❑10. Proper Adequate Handwashing - _ _ ❑ 11.Good Hygienic Practices CONSUMERADmioRY _ r ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations market) must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2x order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3X5990.000.004)) 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 (FCsx590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6x590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address 29. Special Re ' ements (s9o.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: � II d 1 ALI � . I , / /7 1 Inspector's Signature. Print: PICsSignature: Print: r ,/) Pagel of ages Violations Related to Foodborne Illness Interventions and Risk Factors(Nems 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 11Cross-contamination 1 590.003(0) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* �590.003(B) Demonstration of Knowledge" Contamination from Raw ingredients 2-1.03.11 Person in charge-duties 3-302.11(A)(2) Raw Anirmd Foods Separated from Each Other' EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(0) Food Protection* require reporting by food employees and 3-302.1 S Washing Fruits and Vegetables applicants* 3-304.11 FooclContact with Equipment and 590.003(F) Responsibility Of A Frxxl Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 590.003 G Reporting by Person in Charge' 3-306.14(Aj(B) Returned Food and Reservice of Food* 3590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food law* 4-501..1.11. Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Scaled Container* Sanitization Temperatures* 3.201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water . 3-202.13 Shell Eg s* Sanitization Temperatures*. 3-202.l4 Eggs and Mills,Products.Pasteurized* 4501.114 Chemical Sanitization-temp.,PH, 3-202.16 Tee Made From Potable Drinking Water" concentration and hardness. 5-101.11 Dri nking Water from an Approved System* 4-60L 11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinkine Waier" Utensils Clean* .590O06(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food Shellfish and Fish,From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and - 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* Food Contact Surfaces of Equipment* 4-70311 3-201.15 Molluscan Shellfish from NSSF I�sted - . Methods of Sanitization-Hot Water and Chemical* Sources* 10 Proper,Adequate Handwashing Regulatory Authority Game and i+shrooms Approved by 2-301.11 - Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present' 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.11 Game Animals* 11 Good Hygienic Practices 5 ReceivinglCondition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Tern rahues* 2401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.1 i _ Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shelistock 12 1 Prevention of Contamination from Hands 3-202.18 -Shellstock Identification* I 590.004(E) Preventing Contamination from * 3-203.4.2 Shellstock Identification Maintained'" Em 10 es TagslRecords:Fish Products 13 Handwash Facilities 3-40^^<.1 t Parasite Destruction* -- Conveniently Located and Accessible 3-402.12 Records,Creation and Rmentiun* 5-203.11. Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* F7 Conformance with Approved Procedures 5-205.11 Accessibility,operation and Maintenance ±ACCP Plans Supplied with Soap and Hand Drying 3-502.11. S" ecialized Processing Methods* Devices 3-502.12 Reduced nx gen acka"ng.criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.!2 Conformance with A roved Procedures* 6-301.1.2 Hand Drying Provision *Denotes ciitiad heat in the federal 1999 noxi Cade or lU5 CMR 590000. s �t IN FMr rig«•+ �_.,,� . ► . �._ � � ., _ ►, rims 9MR07= it � �r�1/1IL it _ ...�� i IM�'r' _ r . u.. �L.Rrs ff __ 3-501.14(C) PHFs Received at Temperatures '! Violations Related to Faadborne fliness.Intermrillons and Risk Acardia,to Law Cooled to Factors(items 1-22) (Cont.) 41-F145°F Within 4 Hours.* PROTEC71ON FROM CHEMICALS3-501..15 Cuolfn Methods for PHFs i 14 Food or Color Additives 19 PHF Piot and Cold Holding 3-501.16(B) Cold PIE Maintained at or below 3-202.12 Additives*, 3-302.14 Protection from Unapproved Additives" �{F) 4101450 F"° j 59U. 3-50L16(A) Hot PHFs Maintained at or above . 15 Poisonous or Toxic Substances 140°F. s 7_10L11 Identifying Information-Original 3-501.I6(A) Roasts Held at or above 130'F. ° Containers* 7-102.11. Comtrmn Name-WorkingContainers* 20 Time as a Public Health Control 7-201.11 Separation-Stora * 3-501:19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* - 594.004(H) Variance Re uirement " j 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-20421 3-841.i 1{(AA)) U:11 Sanitizers.Criteria-Chemicals' POPUnpasteurized Pte-packaged Juices and HSP 7-204.12 Chemicals for Washing Produce,Criteria*;;a* i Beverages with Warninglabels* 7-204.14n eats.Criteria' 7-245AI lncidenod Food Contact,Lubricants* 3-801.3-801.11(8 11(D} Raw or Partially Use of PastRaw Seed S ICooked Animal Food and Pasteurized E ° 7-206.11 Restricted Use Pesticides,Criteria* Sprouts 7-206-12 Rodent Bait Stations* ts Not Served. 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Packs Not Re-served. Monitorin * CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumes Advisory Posted for Consumption of 16 _ Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs - - Not Otherwise Processed to Eliminate I Pada "*Fere i 3-401.I1N1)(2) Eggs- 155`F 15 Sec. Eggs-Immediate Service 145°Fl5sec* 3-30113. Pasteurized Eggs Substitute for Raw Shell P Eggs' b 3-401.11(A)(2) - Comminuted Fish.Meats&Game y Animals-155°F 15 see. " SPECIAL REQUIREMENTS 3.401.I1(B)(1)(2) Pork and Beef Roast- 130°F 121 miu* 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.409(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and 3.401.1l(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections 'r Poultry or Ratites-165°F 15 sec, ' above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and Tisk-factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practice-s should be debited tinder#29- Microwave 165°F* Special Requirements, 3-401:11(A)(1)(b) All Other PRFs- 145'F 15 sec.¢ 27 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3403.41(A)&(D) PHFs 165"F 15 sec. * (Items 23-30) 3403.11(B) Microwave 165°F 2 Minute Standing Critical,mrd non-critical violations,which do not relate to the Tithe* foodborne illness interventions and tisk.facrors listed above, can be 3403,l i(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000, 3-40111(E) Remaining Unsliced Portions of Beef Item GnodRataJtFractiees FC 390-wo { Roasts* 23. Management and Ps sonnei FC-2 .003 j1g Proper Cooling of PHFs 24 i Feed and Food Protection I FC-3 .004 25. Equipment and Utensils I FG-4 .DOS i 3-501.14(A) Cooling Cooked PHFs from 140`F to i 26, ! Water.Plumbing and Waste t FC-5 .006 1 70`F Within 2 Hours and From 70`F 27. Physical FacilityFC-6 007 to 4VF145°F Within 4 Hours.* 128. Poisonous or Toxic Materials i FC-7 .008 3-501.14(.[3) Cooling PHFs Made From Ambient ~29. "Special Requirements .009 Temperature Ingredients to 41°Ft45°F `30. 1 Other r Within 4 Hours" sa�tma 'a.cc 'Denotes critical ivm in the f-derai 19999 Food Cade or 103 CMR 390-()X IF. 1 i CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page:_ of Item Code C-Critical eem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY 1 L4� 1 a 6-0)4 IV All Discussion With Person in Charge: Corrective Action Required: ❑ No Via, I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion p Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines o w my-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. /j VV ❑ Voluntary Disposal ❑ Other: ` 3-501.14(C) PHFs Received at Temperatures 1 Violations Reiated to Foodborne Illness Interventions and Risk According to Caw Cooled to ` Factors(Jreem;1-22) (Cont.) 41'Ft45°F Within 4 Hours. �l PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 - Food ar Coiw Additives 19 PHF Hot and Cold Holding 3-20112 i Additives* 3-501 .16(B) Cold PHFs Maintained at or below 590.0&4 3-302.14 Protection from Una 3-50L4((7 Ho Unapproved Additives* t�}5°F* 1g Poisonous or Toxic Substances 3501.16(A} Hot PHFs Maintained at or above t 140°F. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1.300(. Containers` 7-102.}1. Common Name-WorkingContainers* 20 Time as a Public Health Control -V 3-501,19 Time as a Public Health Control* 7201.11 Separation-Storage* - 590,004(H) Variance Requirement -- C 7-202.11 .Restriction-Presence and Use* - y 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULAYIONS HSP ' 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.17(A) Unpasteurized Pre-packaged Juices and r Severnes with Warning Labels* 7-204.14 Drying Agents.Criteria* Incidental Foo Contact Lubricants* 3-80113(B) Use of Pasteurized E 7-245.11 r 7-206.11 Restricted Use Pesticides,'Criteria' 3-801.11(D} Raw or Partially Cooked uel Food and d. 7-306.12 Rodnnt,Bait Stations* Raw Seed Sprouts Not Served. 3-801.11(C) Unopened Food Racic_age Not Re-served. � 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIMEff EMPERATURE CONTROLS Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for PRFsNot Otherwise-Processed to Eliminate . - mo°ero gn.�xt ( 4 40L}lA(1)(2) Eggs- 155°(15 Sec. Pathogens.* j Eggs-' Immediate Service 145'F15sec* 3-3.02.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fisb.Meats&Game Eggs' i Animals-155°F 15 sec. " 3 401.31(6)(1)t27 Pork and Beef Rpt- 130°F 121 miu* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in Sec * catering,.mobile food,temporary and 3-402.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate Sections Poultry or Ratites-165'F 15 sec, * above if related to foodborne illness 3-301.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 745°F* 590.009 violations relating to goad retail .3-401.12 Raw Animal Fails Cooked in a practices should be debited ander#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding WOLATIO}VS RELATED TO GOOD RETAIL PRACTICES 3-403-I I(AWD) PRFs 165"F 15 sec. * (Items 23-30) 3-403A I(B) Microwave I65=F 2 Minute Standing Critical and non-critical violations,which do nor relate to the Time* foodborne illness Interventions and risk factors listed above, can be 3403.t 1(C) Commercially Processed RTE Food- }'bund in the following sections of the Food Code and 105 CMR 1400F* 590.000, 3403-1I(E) Remaining Unsiiced Porticos of Beef Item 1 Good Retail Practices J .FC 540.120o 1 Roasts„ 23, i Managementnel and Person : FC-2 .003 i 24 Food and Food Protection 1 FC-3 18 Proper Cooling of PHFs 1 25, I ERuipment and Utensils 1 FC-4 _ .00.5 1 3-501'.14(A) Cooling Cooked PHFs from 140°F to 126. Water.Plumbing and Waste I FC-5 I .006 70°F Within 2 Hours and From 70'F 27. ftysical Facility1 FG-6 007 to 41'(/4.4'(Within 4 Hours. * i 28. Poisonous or Toxic Matenals FC-7 .008 I 3-501.14(6) Cooling PRFs Made Froth Ambient 129. S ecial Requirements .009 ) a Temperature Ingredients to 41'FI45°F 30. i Other Within 4 Hours* "Denotes ccitica,irwm in the Lc-deral 1999 Food Cade ut IV CMR X90.000. Commonwealth of Massachusetts + City of Salem = Board of Heath s Kimberley Driscoll - 120 Washington Street,4th Floor;: Wlayor } £ f `SALEM,MA 01970 t , T• " Food/Retail Establishment Permit F, DATE PRINTED: 12/11/2012" _ ESTABLISHMENT NAME: . _ ._,- ' " ' Jade House- Ghang,V�ang Inc , :� F n. { ' File Nm_ber:BHF-2004F331�UfaytteStreet.00007 ey _ s xV �� Salem - MAm 01970 - - /-y 's LO TED T: 0331 LAFAYETTE STREET; w. y SALEM,-MA -019.7.0 Permit Y Permit No: Permit Issued-``;Permit Ezp�res Fee Restrictions/Notes .� y" r FOOD SERVICE BHP-2013-0110 Jan'1,2013 '- Dec 31,2013 "a$: 00 ESTABLISHMENT �" s Total Fees: €��$280 00, E ' 4k '1 ' lip ,e P au Gh � � ♦ irk c tl ;�. Y R PERMIT EXPIRES Decembei 31, 2013- Board 013 Board of Health 1� S ° This Permit is not transferable anernust 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 egmpment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, lu�- MASSACHUSETTS PobticHealth BOARD OF HI?AI:TT-I 120 WASHINGTON S'MEUT,4'11'FI,.00R KINIBERLEY DRISCOLL Tei,.(978)741-1800 FAX(978)745-0343 LARRY RAMI)IN,RS/RFI IS,CHO,CP-FS MAYOR Ixamdin(a)salein.com Hi,' IV iiIAGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) (/ 1) Establishment Name: LAI6- �AAIC, /G a/ 74 OE UOUSE- 2) Establishment Address: 3 1 LA FA y t TT IF S T S A LEMS MA 01.0/70 3) Establishment Mailing Address(if different): SOME 4) Establishment Telephone No: -7 T , 74/lf" 3 3 5) Applicant Name&Title: WAN G S H I �I R u 10 6) Applicant Address: 2q SoSzopAve S,#Ajt-2VtLLL� MA OZfY 7) Applicant Telephone No: 37-330-29/Y 24 Hour Emergency No: 3'17'330-29/'Email: 6) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers orP artner. An association Name Title Home Address A corporation An individual . Apartnership PArv�SH/ Re . UR �''1 .805-0r✓ AV E42— Other legal entity. SL�Cf2M S SKVdL(,L ,(Ao4 CWV AiR ' 12 Person Directly Responsible For Daily Operations,Owner, Person in Charge, Supervisor,Manager,etc. (/l/ Name&Title: A- VVI J C )T } 7 /)/?P5 [OfW-r /3e/n MANA Address: 2 Ll Bas-r 1v Ute 4 Zz SOM GeV I L Lr- ,(0 02-/y Telephone No: g.'7 Y°/-3 3 60 Fax: Email: Emergency Telephone No: 3 q-7- 3 30- 29 I y 13) District or Regional Supervisor(if applicable) A/A Name&Title: Address: Telephone No: Fax: Email: J / Check#: L' Date: �� /� Amount: Food Establishment Information 14) Water Source: /1 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) X -7 13 h ys 16) Days and Hours of Operation: 'I (AM - I t PM 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) cl ❑ Retail( Sq. Ft) ❑ Caterer Permanent Structure )k Food Service-( Seats) ❑ Frozen Dessert Manufacturer obile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: - ------------------------------------------- Breakfast-Establishments------------------------ check one) RETAIL STORE RESTAURANT nnua ❑ Less than 1000sq.ft. $ 70 Less than 25 seats $140 ,easonallDates: ❑1000-10,000sq.ft. $280 Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 ❑25-99 seats $280 ❑ More than 99 seats $420 Temporary/Dates/Time: -- - - - - - - i ----- ----------- ----------------------------------------------------------- ❑ Bed&Breakfast/Childcare Services/Nursing Home $100 - ------------------------------------------------------------------------------- ------------------ ADDITIONAL PERMITS ❑ MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare 8 private clubs 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperature controls required) check all that apply): RTE-ready-to-eat foods(Ex.sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs X for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other a plicable law. I have been instructed by the Board of Health on howto obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: X t VV h l d PRer &W7 if Pursuant to MGL Ch. 62C, sec.49A,I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: `2-J — 3(, 3 i 0 o 2- 26) 26) Signature of Individual or Corporate Name: C HAO G- W A &-. fie_ Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4a' Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTABLISHMEI INSPECTION REPORT Tel. Name Date TT�ypeyyFOperation(s) Typeofinspection LJ-Food Service online -Address isk ❑ Retail ❑Re-inspection Telephone ✓� Level ❑ Residential Kitchen Previous Inspection 1 ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑Pre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge( Time ❑ Bed&Breakfast ❑General Complaint Izt . [IHACCP Inspector Out: Permit No. ❑.Other Each violation chec ed requires an explaPC on on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: / -- Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ ❑ corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) rFOOD.PROTECTi-ON MANAGEMENT_ _-,-_. j [312. Prevention of Contamination from Hands El1. PIC Assigned/Kno- edgeable/Duties �3. Handwash Facilities -- - - LEMPLOYEEHEALTH '-� --� --- rL" rPROTECTIONFROM'CHEMICALS � Ll 2. Reporting of Diseases by Food Employee and PIC -- ❑ 1 .Approved Food or Color Additives El 3. Personnel with Infections Restricted/Excluded 15.Toxic Chemicals - � �.-, �EOODFROMAPPROVEDSOURCE_ _ -,_•_��„_-� -- . ..,T �..�__�__- ❑ 4. Food and Water from Approved Source JIMEITEMPERATURE.CONTROLS(PotentlaIt Ha¢aidous Food_;;)- ❑ 5. Receiving/Condition [116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling PROTECTION FROM CONTAMINATION_ _ _ _ j ❑19. Hot and Cold Holding OK4�,8Separation/Segregation/Protection ❑20.Time as a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing fREGUIREMENTS FORNIGHLYSU$CEPTIBLE=POPULATIONS'(HsP)'_ L'V ❑10. Proper Adequate Handwashing El 21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices �.p'�C�)16UMERADVIgORY_ .__ !lam{' ',VQ`22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical(N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3X590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-5Xe90.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-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 is order. 30. Other DATEOFRE-INSPECTION: lattetoros Signature: Print: Ll PIC$Signature: j Print: - Page of ages �skct e 2vot- I,uGvk " u-�- A. .--.r yr 1 .� - �. �). ...+.-a �-,I� � !. �N 'r�`r-' ,rY�.r. . ._ .. �-•/'^•.o_ �. . � .-�- f r , Violations Related to Foodbome Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION _FOOD PROTECTION MANAGEMENT S Cvss-contamination 3-302.1.1(1)(1.) Raw Animal.Foods Separatedfrom 590.003(1) Assignment of Responsibility* Cooked and RTE Foods* -�590.003(B) Demonstration of Knowledge* Contamination from Raw ingredients 2-10 .11Person in charge-duties 3-302,1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by foot!employees and 3-302,15 WashingFruits and Vegetables a Responsibility 3-304.11 Food-Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or A Utensils* APP P Applicant To Report To The Person In ' Contamination from the Consumer Chat *- 590.003(G) Rein by Person in Charge* 3-306,14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 5!D0.003(E) Removal of Exclusions and:Restri'etions 3-70111 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE rood* 4 Food and Water From Ragufeted Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.1.11 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3.201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinitting Water* concentration and hardness.* 5-101_11 Drinking Water from an A roved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water's Utensils Clean* 590.006(,B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food Shellfish and Fish From an Approved Source Contact Surfaces and Utensils'p' 4-702.1 I. Frequency of Sanitization of Utensils and 3-201.,14 Fish and Rec ea.itnxaliy Caught Molluscan Food Contact Surfaces of Equipment* Shellfish" 3-201.25 Molluscan Shell4-703.11 Methods of Sanitization-Hot Water and tish from NSSP Luted Sources* 10 Chemical*Proper,Adequate Handwashing Game and Authority ority ooms.4pproved try 2-301.11 Clean Condition-Hands and Anes* Re Mato Authority 3-202.18 sheIlstock Identification Present* 2-301.12 CleaningPrcxedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 1 Good Hygienic Practices - - 3 Receiving/Condition 2401.11 Eatin ,Drinking or Usin Tobacco* 3-202.21: PHFs Received at Proper Temperatures* 2401,12 Discharges.From the Eyes,Nose and 3-202.15 Package hcte,i '' Mouth 3-10i.I I _ Food Safe and Unadulterated* 3-30L 12 Preventing Contamination When Tasting* 6 Tags/Records:Shelistock 12 - Prevention of Contamination from Hands 3-202.18 Shellstock Identification" 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained', _ Em plo es* 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(1) Labeling of Ingredients' 5-204.11. Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibilit , ration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.17 Specialized Processing Methods* Devices 3-502:12 Reduced oxygen packaging,criteria* - - 6-301.11 Handwash!2E Cleanser„Availabilit 8-103.12 Conformance with Approved Procedures* 6-301.1.2 1 Hand Drying'Provision *Denotes critical new in the f derail 1999 FaA Code or 105 CMR 590.000, 1 � � . . - ray _ • . _ . . � . . - -- / . • . . MW oil ate_64 ... .�� '�.�. i►l li�l/t�� • FOAMPIN I�'�' �.. A _-_ •:.J �.. WWRIN .r VIM, l ��i?1l►�' - WA 10 Flow ® -� i ��(1 i 11 �• " �i� d .. ./_�. �a�1��\� .� a OEM Pig �J10 1 VIM fall see 0 - 3-501.14(C) PHFs Received at Temperatures - Violations Related to Foodbarne illness Interventions and Risk According to Law Cooled to Factors(Rents 1-22) (Cont.) 4l'Fi45`F Within 4 Hours, PROTECTION FROM CHEMICALS 3-501..15 Coolie Methods for PHFs .._..-.......ON FR ..--- 1g PHF Not and Cold Holding Food or Color Additives 14 3-501.16(B) Cold PHFs Maintained at or below 3-202_12 Additives*' 590.004(0 410145°F* 3-302.14 Protection from Unapproved Additives '% 153-501.16(A)or Toxic Substances 3-SUt.16(A) _ Hot PHFs Maintained at or above 140'F. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* - .,0 Time as a Public Health Control 7-102.11. Catmnon Name-Working Containers* 7-201.11 Separation-Storage. 3-501:19 Time as a Public Health Control' 7-202.I1 .Restriction-Presence and Use* - 590.004(H) Variance Rerluirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria' 21 3-801.11(A) Unpanernixed Pre-packaged Juices and 7-204.14 n encs.Criteria* Beverages with Warning Labels* 7-205.11 incidental Food Contact Lubricants* 3-801.11(B) Use of Pas Bally tl ok 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1 i(D} Raw or Partially s Not S Animal Food and Raw Seed Sprouts Not Served, 7-206.12 - - Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re=served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEti EMPERATURE CONTROLS 22 3-603.11 Consumer Adiisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs - Not Otherwise-Processed to Eliminate Pathogens.* { 3-401.11A(1)(2) Eggs- 155'F 15 Sec. rt 3-302.13 Pasieuzized Eggs Substitute for Raw Shell Eggs-Immediate Service 145FI5sec E 3-401.11(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec.* ISPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* - 3-401.111A)(2) Ratites,Injected Meats-155°F 15 590.tx79(A)-(D) Violations of Section 590.009(A)-(D)in tI 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-I65°F 15 sec * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other ( 1450F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foals Cooked in a practices should be debited under#29- S Microwave 165F* Special Requirements. r 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec.* (I;terns 23-30) 3-403.11(B) Microwave-165`F 2 Minute Standing -Critical,and non-critical violations, which do not relate to the Tits* - foodborne illness interventions and risk•factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections.gf the Food Code and 105 CMR 140°F* 590.000. 3403_II(E) Remaining Unsliced Portions of Beef i � Good Retail Practices _ , .FC .690.00Q ' - - Roasts* 1' 23. Management and Personnel -FO-2 .003 + lf3 Proper Cooling of PHFs 1 24.. Food and Food Protection I FC-3 .004 i 125. Equipment and Utensils 1 FC-4 .005 1 3-501.14(A) Cooling Cooked PHFs from 140'F to 26, Water.Plumbing and Waste FC-5 .006 70'F Within 2 Hours and From 70F 27. i Physical Facility FG-6 007 to 41'F/45'F Within 4 Hours. * L28. Poisonous or Toxic Materials E FC 7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S cat R uiremams - .009 I Temperature Ingredients to 4PF/45°F i Otho - -- 1 Within 4 Hous* t *Denotes critical heat in the federal 1999 Fend Calc w 103 CMR 590.000. 1AMMrM AM �►.�..� = x:517 � ,.i <<'��3��• �_ .. 1 !.fir ��-.. I�. ,,�, .�11'��t!�!-� -.�1�111!!A[�. �. � _ IU +FMM' ! A AN AMM rJurpOlmo 'A _ � . � �. a .�.� • ,..,_ SO ralwa Mon POMACM�J _ .�1�� li�i,_ F. c._. a� ,!C . ' �A �_171.�1'6�,� .� � • .r�e�WA �.I u. .. r 1 - . 3-501.14(C) PRFs Received at Temperatures Violellons Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Hems!-22) (Cont.) 417145°F Within Hours. " PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs .._............___. Iq PHF Hot and Cold Holding Additives*' 14 ., ddi iColor Additives � 3-50IA6(B) Cold PRFs 44ammmed at or below 3_202.12 � 590.004(F) 41'/ 5°F* 3-362.14 Protection from Unapproved Addiuvest i 3-501.16(A). Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances _ 1400F. 7-101.11 Identifying Intormation-Original 3.501.16(A) Roasts Field at or above 130-F. Containers"` 7-102.11. Common ATame-WorkingContainers* 20 Time as a Public Health Control * 3-501:19 - Trott as a Publicl* menitb Centra 7-201.11 Separation-Stn 590.064(H) Variance Requirement 7-202.11 .Restriction-Presence and Uses - eent 7-202.12 Conditions of Use* 7-203. oxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 11 T � POPULATIONS HSP 7-204.11 Sanitize".Criteria-Chemicals* 7-204.12 Chemicals Feer Washin Produce,Criteria' 21 3.1301.I I{A} Unpasteurized Pre-packaged Iuicas and 7-204.14 Drying Asents.Criteria* _ :Beverages with Warnin*Labels* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-80LI I(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served 7-206.12 Rodent:Bait Stations* 3-801.11(C) Unopened food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and o Monitorm * CONSUMER ADVISORY _ TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer:Advisory Posted for Consumption of F6 PAnimal Foods That are Raw,Undercooked or Proper Cooking Temperatures for F6 PPropHFa Not Otherwise.Processed to Eliminate - Patbogens.*C?fOS0x67"r 340t.]IA(1)(2) Eggs- 155F IS Sec. I Eos-Immediate Service 1450FISsec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game -Eggs Animals-i55°F 15 sec. * SPECIAL REQUIREMENTS 3.461.11(6)(1)(2) Pork.and Beef Rout-130°F 121 min* 3-401.11(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.009{A}-(D)in i sec.* catering,mobile food,temporary and 3-401A I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other - 145°F r' 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements, 3.401.11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Balding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES y 3-403:44(A)&(D) PRFs 165"F 15 sec. * (Items 23-30) i 3-403.11(8) Microwave--165`F 2 Minute Standing -Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-103.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400P 590.000. 3403.1 1(E) Remaining Unsiiced Portions of Beef item ( G Retail Practices FC 680.400 Roasts* 3 23, 1 Management and Personnel ! FC-2 .003 lg Proper Cooling of PHFs i 24. 1 Food and Food Protection FC-3 .004 .` 25. 1EEquipment and Utensils ( FC-4 .005 3-501.14(A) Cooling Cooked PRFs from 140°F to t 26, 1 Water.Plumbinq and Waste 1 FG-5 .406 I 70°F Within 2 flours and From 70°F 27. 1 Physical Facility i FC-6 - .667�, to 41`F/450F Within 4 Hours.* L28. 'Poisonous or Toxic Materials FC--7 .008 t 3-501.14(8) Cooling PRFs Made From Ambient 2g�S�eciai R uiremams .009 Temperature Ingredients to 41'Ff45°F 30. i Other Within 4 Hours` s. rm -rxm: "Detmu%aihcal ivm in the federal 1999 Foo!Cotle or 105 C.MR 590.000. n CITY OF SALEM `XX` BOARD OF HEALTH Establishment Name: "A0 le— Date: lL-9'j Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Rem Veri led PLEASE PRINT CLEARLY M<q4A', �. 0 e. 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 allILI,"Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to d/ Exclusion p y Re-"Re ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that � .l Ovt9 t�1rJ^l noncompliance may result in daily fines of twentt,-five dollars or suspension/revocation of Li Embargo ❑ Emergency Closure your food permit. l ` ❑ Voluntary Disposal ❑ Other: - 3-501.14(C) PHFs Received at Temperatures - i Viciations Relati d to Foodborne illness lnterientions and Risk According to taw Cooled to Factors(Rema 1-22) (Cont.) 41'2/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501,15 .Coohn&Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501,16(6) 3-.202.12 Additives* Cold PHFs Maintained at or below 590.004(F) 41°745°F* 3-302.14 Protection from Una roved Additives" 3-59L16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. 7-101,11 Identifying Information-Original 3-501.16tA1 Roasts Held atotabove. 130'F. * Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* - 3-501A9 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.I2 Conditions of Use* 7-203.tl 'Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULA710N s H&P 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels* > 7-245.11 incidental Food Contact,Lubricants* 3-801.11(6) Use of Pasteurized B ( 7-206.11 Restricted Use Pesticides;Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and ? 1} 7-206.22 Rodent Bait Stations* Raw Seed Sprouts Not Served, 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and ' Monitoring* CONSUMER ADVISORY _ TIMEfTEMPERATURE CONTROLS 22 3-603.11 Consumes Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Fouls That are Raw,Undercooked or E6 Proper Cooking Temperatures for PHFs - Not Otherwise Processed to Eliminate Pathogens.' 3-40LIIN1)(2) Eggs- 155`F 15 See. tri tn, r ? - Eggs-immediate Service 145°Fl5sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game - E Animals-155°F 15 sec. } 3401.11(B)(1)(2,) Port:and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3.401.11(A)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section .590.009(A)-(D)in sec.* catering,.mobile food,temporary and 3-401A t(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited tinder#29- Microwave 165°F* Special Requirements. 1 3401:)1(A)(1)(b) All Other PHFs-- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES r 3-403.1I(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) ' 3-403.11(B) Microwave--165`F 2 Minute Standing Critical,and non-critical violations, which do not relate to the Time* - foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1 140°F* 590.000. 34031l(E) Remaining Unsiiced Porcim5 of Beef j Item i Good Retail Practices .FC $90.000 lRoam ., 1 23. i Management and Personnel FC-2 .003 ' lg Proper Cooling of PHFs 1 24.- Food and Food Protection i FC-3 .004 125. - E ui mare4 and Utensils I FG-4 .tN75 I 3-501.141A) Cooling Cooked PRFs from I40`F to ?, Water.Plumbing and Waste FC-5 7"Within 2 Hours and From 70°F 27. ( Physical Faciti FC-6 .007 r to 41`F/45'F Within 4 Hours.* j 28. Poisonous or Ttmic Materials ! FC-7 .008 i 3-501.14(6) Cooling PRFs Made From Ambient 29, Special Requirements .009 } Temperature Ingredients to 41°F/45°F 3-0. i other --� t Within 4 Hours" 'Dem tee u4iicat uzni in the L-derai 1999 Ford Cale or 105 CMR 390.000. ':i C 4(r2G Commonwealth of Massachusetts • City of Salem Board of Health 120 Washington Street,4th Floor Kimberley Driscoll SALEM,MA 01970 Mayor Food/Retail Establishment Permit DATE PRINTED: 12/29/2011 ESTABLISHMENT NAME: Jade House- Chang Wang Inc. File Number:BHF-2004-000037 331 Lafayette Street Salem MA 01970 LOCATED AT: 0331 LAFAYETTE STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions!Notes FOOD SERVICE BHP-2012-0130 Jan 1,2012 Dec 31,2012 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December 31; 2012 Boardof 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 Commonwealth of Massachusetts s : City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 FooWlIetail Establishment Permit DATE PRINTED: 12/28/2011 ESTABLISHMENT NAME: Jade House- Chang Wang Inc. File Number:BHF-2004-000037 331 Lafayette Street Salem MA 01970 LOCATED AT: 0331 LAFAYETTE STREET SALEM, MA01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOODSERVICE BHP-2012-0130 Jan 1,2011 Dec 31,2011 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES Oecember31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code;beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved.by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS ;I Y Bcmm OF HEALTH 120 WASHINGTON STREET,4°1 FLOOR Tm- (978) 741-1800 - KINIBERLEY DRISCOLL Fnti (978) 745-0343 MAYOR / hamdiin(misalem.com LARRY RANHAN,RS/RF:1-IS,CI R),CP-FS I-1 F:u:n i AG rNri, 201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT .dad P dUllSD 0A?Af& lnl��&/1`/��i �L# 97�_ Nye 46 ADDRESS OF ESTABLISHMENT 6Z ( �R Ra a �'�. C'aI4 F MAILING ADDRESS(if different) EMAIL- Business': Website: p OWNER'S NAME h-)k[Ai TEL# 7yV - 3 a4 ADDRESS r) q- 4.sic)' Al A2g o2 &W-PA✓AL NA 1)N V 4 STREET_, CITY STATE ZlPr CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) - - EMERGENCY RESPONSE PERSON HOME TEL# DAYS OF OPERATION. +. Monda Tuesday Wednesday 1 k o-Thursdak--,,'f!., Frid 1 Saturday Sunda HOURS OF OPERATION j i I Please write in time of day. For example Ilam-11pm) ) _11M / AM . l /IDI 114X-/ -/ _TYPE OF ESTABLISHMENT _ FEE check only) RETAIL STORE YES NO less than I000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ----------------------------------------------- ------ - RrS,A..rtA" iT ,�EJ NtJ 1LUJ ti�:r,25 seats C'�AC Stationary Food Cart$210 i' 25-99 seats = 0 more than 99 seats =$420 BEDBREAFAT --------------------YES------146--- $100 CHILDCARESERVICESINl1RSING HOM------------------------------------------------------------------------------------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YESNO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains 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_^ r(j p Date x L^ 1 LJ 1) _ Social Security or Federal Identification Number ----------------- Updated 523/1 l FOODAPZOI l.adm C k#&Da[e � �lp r ` �4 $�(! n ... � ^+„.ay . -F....A,or4 t... .r .`'.4..'. i +I� 7 .:4 v.•,i,w .-., . . -?.'.d:.» ,:.Rh x�'?+i�r-^ r b 4 @ j,,r.`' Y.,a • - k.$,ry - a.o-. 1' '1 /ryvA'Ptr+ '�t'1Eb.,�4�F..•,�;'.�`.pF. ._'C�'!st.'.,; ' 0.:•K`4_... i • a { it lVassacuse htts Department of Public Health Salem Board of Health p 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 NameDate Type of Overation(s) Type of Inspection a' Jdd12 "DUSp_ �a)�� f11 Food Service ❑ Routine Address' I e ! � Q Jf( Risk ❑ Retail ElRe-inspection t uu Level ❑ Residential Kitchen Previous Inspection Telephone (,�'1G _ %� 4 , 3300 El Mobile Date: Owner `I�t ll 1 '� Yw HACCP Y/N El Temporary El Pre-operation Vv ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast General Complaint In: ❑ HACCP Inspector-M (U� y ik; Out: Permit No. Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTE&iON MANAGEMENY."27� El 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities e cc -rf� y i ^:as wre EMPLOYEE HEALTH . . _ . . . . . ..1 �,? c `.t �, r. __ •.v ao- i.t.,.a_. r i PROTECTION FRbM GHEMIALS ❑ 2. Reporting of Diseases by Food Employee and PIC - ❑ 14.Approved Food or Color Additives ❑ 3.. Personnel with Infections Restricted/Excluded F yx Fv�t amm^= ❑ 15 Toxic Chemicals i,'FOOD FROM APPROVED SOtlRCE �;oy d�.. ..0 x d _u=, TIMEfTEtdPE�iATIJRt?CbNTRpLS tPotendapy Hazardous Fonda) ❑ 4. Food and Water from Approved Source 1 I 1 „U f ❑ 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'S+i t"�• � �` �x '?}"�' El 19. Hot and Cold Holding ❑ 8 Separation/Segregation/Protection ❑20.Time As a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing pEQUIREMENT$FtfA HIGHLY 6U0014 'IBLEP1111 1 , TIONs;(fISP}'„i 0 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices [122. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 7` 24. Food and FoodProtection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-a)(5so.00s) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you K }( 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)(59o.00s) 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 501nsp tFcm&14.dw Inspector's-Sig"attire: <�VA `.� r � / �� yI/ Y/ - PIC's Sign j re: _ / // it - 21c Print6� ( <a (411 D Page_of Pages Violations Related to Foodborne Illness r Interventions and Risk Factors(items 1-22) _ PROTECTION FROM CONTAMINATION_ FOOD PROTECTION MANAGEMENT S Cross-contamination 1 596.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11. Person inch Contaminatlonfrom Raw Ingredients 3-302.11(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other,- 2 ther`2 590.003(C) ,Responsibility of the person in charge to Contamination from the Environment require reporting by foot[employees and 3-302.11(A) Food Protection* a xlicams c 3-302.15 Washing F_r_uits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charg0 3-306.14(A)(B) Returned Food and Reservice of Foal* 3 590.003(D) Exclusions and Residctions* disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.11 I Manual Warewasbing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* - - 3-201.13 Fluid Milk and Milk Products,* 4-501.112 Mechanical Warewashing-HotWater 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp., pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.11 Drinking Water from an Approved System- 4-601.1 I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(8) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish from an Approaught ed Source 4.702 11 Frequency of Sanitization of Utensils and 3-201.14 Fish and ReereafianaBy Caught Molluscan Food Contact Surfaces ofui 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 Regulatory Authorit 2.301.11. Clean Condition-Hands and Arens" 3-202.18 Shellstock Identification Present* 2-30112 -Cleaning Prccedu e* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Usin Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401,12 Discharges From the Eyes, Nose and 3-202.15 Package Inte it * Mone 3-101.11. Food Safe and Unadulterated* 3-30I,12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock L12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F,) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Ent to gees* Tags/Records:Fish Products 13 Handwash Facilities 3-40211 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Ca acities* 590.004(7) Labeling of Ingredients' 5-21)4.11 Location and Placement* ? Conformance with Approved Procedures 5-205.11 Acressibilit O aeration and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11. S ecialized Processin Methods* Devices 3-51Y2.12 Reduced oxygen packaging.criteria* 6-3(71.11. Handwashing Cleanser, Availabilit 8-103.12 Conformance with Approved Procedures' 6-301..1.2 Hand Drying Provision *Denotes critical item in the federal 1999 rel Code or 105 CMR 590,000. t CITY OF SALEM BOARD OF HEALTH 'r Establishment Name: Date: Page: a of Item Code c-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verifled I PLEASE PRINT CLEARLY _ n Dv?),-vnf- I (�QGI/. \, mr �t-i�4 ,fh,�_ 4�r1 -� Nrl�rnn.S 1�Iol�dJJ t _ _ ,. �Llt�1 1 Y1c, <z:6L3fi <lVL (\A PA QS(o lPl�_ r --rtt1 ,v_ �s fiia h l i.�1 ru Q c� \�Q s also i _n �n tom(/C Q. ccs S vd -l1/-its, -h i i.ck- Afus ' (rlA,( rl I_g s h'(I In n(r_r A J1 6 V94/U R q I VV�A)Pr_-h a_V� Y\A,J 1 OCC C, 2 r V1,A- '3 'IAA ri' YVtau a t 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 L) 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 yciu food permit. 0 Voluntary Disposal ❑ Other: •li �- r 3-501,14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk Aczvrding to Lau,Copied to Factors(Items 1-22) (Cont.) 41°F/45'P Within 4 How's. ' PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs F4 Food or Color Additives 19 PHF Hot and Cold Holding -- 3-501.1602t) Cold PHF s Maintained at or below 3-202.12 Additive.;* 5911 004(E1 41`/4>°l _ 3-302.14 Protection from Unapproved Additives* 1-51911,16(A) Hot PHF 15 Poisonous or Toxic SubstancesMaintained at or above !01.11 Identifying Infomanon -On in41 _ Cont un r." 3-501,16(,) 1 kt-sts Held at or above 130"T. H722 I0_2.11 Common Name �>'�rliit_ nuc to•r;.* �.-2- �— _.. t Time as a Public Health Control 1 7 20Sia Reouon-Stun rg.: —�� nUi 1> �� i tut as c Tub1t�i'teaith Control' -` .)0.0(}ir-a V n.nc�. Rc�4ui remtnt ' 202.11 1 st to nn Pr u neo--uu' t "�: t '— - --.- --- —7-202,12 Condmun of Use 203.11 l"o is Cutt amex P ahtbr nu REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSPS_ 1 71104.)1 SanmzeK, Criteria Chcnucds �- it -{— "'204.12 Chum alc frar vR i�h 1 nitncc Cnteriar- 1 _ -&t_ 31tAj Uop ieurizcd Picoaclaged Juices and 7-204% 4 Dram,At entc.Criteria'i l' t _ 3cs m es will) N truing labels* ---� .-Sul 11!131 ` LI of Pa.te•rtzcdF SUS I t Lorin nlal t wA r c nlat lath ica Rs-` -j-- �� `c-Wl itD) ftttw r 1'aitiall Ctv1.-d Animal F"KI and 7206.!1 Re. n e ,c Pr he..cidClrira r - - t.: } d S iiia!!,'Not 4rtcd j 7-206.12 yRcxlrn l3 ut i:ahons I �.aC! i C �� - -- __ --_.ir .� o'c't:xxi lac ._;;. 3`u R served. - r 106.13 1 r.uf„nc Youdcr } f:ontr I u d ..djj ' - - - CONSUMER ADVISORY 22 3-603 11 t nsmucr 10 isoiti Post i ort>r( nnmtios of T1hiEITEMPERATURE CONTROLS ( vor<i 1 cd that are Rawl+R{eru ed of 1 76 PHFs Proper Cooking Tompeiafurus for [ No'Other, ti)tic. Pricel, Elimina'e s 1!)i.I.11t1 ' t 555 S .. nrtmcdo to Se iec ( 51 15,e 0" t f ktry t F a,-c5 tbs lot Ra Raw Shell 1 "e IL4—, lti is- 1r i t ve 'ULI'rf§r i Pot r I and fl el Ri) ei 7 t I min"- SPECIAL REQUIREMENTS - 1—._ .s L RE —_---� a Gtrlv t}t vaBl ita it 0iSeoLiOl )flif{}�fA -{� in 411.1!(,3 t � (an1c:. Injcc.ti llcat5 t F i� 1 I ) � 3 s,�% whip,raa and 44 t. iA} Zi 1'nt+<ry 1 1iJ Salne Srn tC(l I Fs, cord rid kitch(n of i-noa, ,lnudd he j SudTr i i C,,nt c a bis(i. Rt a, t kWhated under flit appy p:iale ,cc corns _, i c lr t A i 9J ii:ix"Tl < t I a iii. stat F r: 1i 17 1 - . tot Hot Hokftq VIOLA PONS REI-S TED F'C7 GOOD RE'TA,'L PRACTICES �,. tJ3.tls _'7 � i llenJ6y. - _ ... ___.i — 1 tltenr5 23-3/3) -dG3.1J(B; Micros lvc- Its"h2 Rpt tut S;:mding G+,i z z ''r r r ':.i' u t s anri u. u•' can t tin: 1 1 n - 3 rh< ne, i.`l z r-.r tt os .iiia r i nt a li c</ t r�,r_ can br 3-4,13.1110 1 C m oarciaffi 4hrx. dR It-, foand n.;h" ser o ' s,�'hc _�FU F JOU 4(73.?tit t 1 It it unm' t n<nred Po: roes of t3,(, 1 _hent ' Good Retail Practices _ FC 590.Ct)u _ " Man genie t 3 C Par r ei _ rt. > o 0- ; ]g Proper Cooiinq of PHFs ;_24 F axt trd caxt Praierto _ FC i W4_ 2b utnroent and Ulens 3 F ,. a 05 5111.kt(A) C ox hn Catk d PHI<bow _. _ = `2`s tlatel at t� vw J a _ 1 FCOU.;._ i 7(i1Within ' tlou nd From r 3°l- � I-a7% Physr Fa 't _ FC h 007 I 4l1-/15,f 4i ttl.n Fi att _ 1 226 pot33 r nxt 3, t a, rC-7 J6° i C, 50! 14iR i ('iiolwg PHF. MiOz Front Ambient i r ° �1,�i 3 k in in['n' OvB � 30 Om - - Tetnp��raturc h r n_�a;s ¢ 1.7 t5`} ,_ _ Within 4 ltcnn ` CITY OF SALEM /�/ i � BOARD OF HEALTH Date: `71�1 O Q Page: of j� Establishment Name: y — Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION - .Date 4 No. Reference R-Red item .Verified 1122 __ PLEASE PRINT CLEARLY � r� r 'fA - t oyl '��,� )NN(- f_ ,I + n�' (a � V c•1 tr,, A-\o YTH7iy)n rip (z 471 k Fr nvu " r� E�7t V1 n At ( t IA I YA )9(1 ;k I I YJ 9 ( /vvA 'rL�P ( VIA — _ � C iypm T car f n pY) ��t hrvt 1i )ho 1nc�P( fry. Qt c1 . elf ('"wo, Im P,t�,4et)t 1tnrCuc�m(x rka r, AviA tktlin(tw -h-3 6e_ o A . ^-)1An.r' k)YUvA-(tS 9-r ,n 'm ,'5V-P*j s-PJA o1/A- wl OP r —;41 cIC cka:�nJ_ \ \as -h)Q ny)tr 60 tw& pvut/t , -Pan quyt " /7 G a 1,10 hei n G SA tJ / VW_A 6 r\yjk a S -V2 Vit n2P�'9 0 h / h o . ids, bbd J cyui k ri <� t i 1 C A ^,o u1 taeA_ \ I.,(1-s \avlAo_ I -in n F ��-tpc\ m-\ A-' u 2- —Uek GT A (}-k i1A_ r 4 I Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes e I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion � P ❑ Re-inspection Scheduled ❑ Emergency Suspension *comply with all mandates of the Mass/Federal Food Code. I understand that .noncompliance may result in daily fines of twenty-fiveAolIarslor�suspension/revocattion of ❑ Embargo ❑ Emergency Closure yo. r food permit. Z/(/j� L-'4C/ ❑ Voluntary Disposal ❑ Other: o j 3-501.).4((.'.) PHFs Received at TemNratures Violations Related to Foodborne Illness Interventions and Risk .Amwiling to Law Cooled to Factors(Ifmw 1-22) (Cont) _ 41'F/45'F Within 4 Horn's } _ PROTECTION FROM CHEMICALS 3-501,15 Coolimr Mcthods for PHFs _ ly RHF Mai and Favid Holding 14 ---rFood or 1-202.12 Adrlitiver"Color Additives� 1-501.16(B) Cold PHF+Maintained at orbelow 590.(ti)4(E) 410/45°1 3-302.14 Protection front Unapproved Additives` 3-501,16(i%) Hot PHI v Maintained at or above 15 ' Poisonous or Toxic Substances14017. * I(11.11 Identityinglnfoimanon-Ori-onal l above — a 5(J 76(A) Rimms Hold at or tet:oiwun r�` r 102.1( Cotmoon N otic A tr 6i_ C nut ur rl —� r{i Ttme as a Pubiic Health Canlro# j 7-202.11 1 1 , imp as tPuhli HealthContr.�l'� ) It t on Pr u n vtd L e ; _ )0:l!04(H), G ,u;e 02 11 R c 2c�a_ir Hent ---� 7-202.12 C ondn (At of i s REQUIREMENTS FOR HIGHLY SUSCEPTIBLE (�t0i.U Toxic f o x gnu Proh t bm � j POPULATIONS(HSP) 204.11 ( )mth7eo ernett+ ehuntc;, �-- --- --_. 7 .rJ4.7° Chulocals for\3arhuF k wda (trema" �1� ±-8iii i i(—A r Unp, reu Ind Pre-packaged acF Zge4 Jun-es and 1 R<ti razes wil iia mn g I .abds' �7 704.14 Dn�u At enta.Crim,t _ t < R01 Ill-Bi Fisc of Pa.lvuh e d k F; rt`5_I I lncid nt d ''— i Ra,� or 1'somik CA tA, d Anmtat t=oad and I 0206 ;I R,v_1 d 1sr Pr. iCide,e. Ct t-ttt'` { j , i -t.--. _ - --.'i Rav, Seedsp rat tierSet ved ! i 7-206_12 Rexlt at b,r .�_ . '--�--_._� l.Rs .t'ar„ -u..to t,cd}zx; ,_ s X! Pacn.t” .�R_scnc.(. ';-M6-'I� M f� el,,'o.e de i s',C'antr-1.tad j _ --._f _1 CONSUMER ADVISORY r----0-- -t- TIMEffEMPERATURE CONTROLS 2� 3 �f1 f (<-rsuine r_ +,-s : t'osrzej lttr CE�n uu',Ittion.,; t unj ' l sat ` ;I ra kw,c. c9i x rum wd o I ;6 PH per Coaktt a lempei nfures for i I { t t Ort ,< a (xs .. a o ' in .nu _. .— .._.._ P H { �r157'! Lunhcl nt Se i 5 3 1 : c 1 L.. 6,m, ,t 1 Raw h{tell_ •i?i.lt.t,(<. ! C r, �ntta:ec" '2, ,.... ,c. t a ate � L 1 , yr SPLCIALREQi113EMENtS 7 i { "uteri to mo> c t xx. iie,rtpt tairy and >-401.1't Ar 3) I r'xu tc_Wild ,t r. Stu9 rd t'HFS� resid n.�sl kIlChCn L}pcts1i0:,Nelkild Fr j -t�it_ f V } rt �_ _,.,. t.➢,.�,t ro-.c ,,. ,. :-�.. as!: u:tt- _ i i , . ,c ,tom,: s ..., _ t. z_tr_ ,:,t_;nS tC,n9 ,iOLA,TIONS RELATCD T GOOD f9Et,tL F'RACT!X-- 'S it Utli3; 1111 , iIo i <c j ilicttt5 23 39h V,ituvavo i+ z 2 ~43iau St.:ad;n, 'wn-, dt6:al .ir .n, a_ n+rcf,.'r, r.rrt c a,� r,,W �1 t 1 rrr,r�rni iita e , tt,t ,< rnr -r, '<rr, 2:y;'d tn•r rzua hr i(C) C to r,ereia.31 °2IE1 Fikxi --� z nr in chi , uei :g�n ,ur, e, ,ic "llod .ode an ? (MR Item C,orrd Retial('practices -- 590.000 { -_ ...-- -. __. 4.taa9r m ni a d P r rr e _ 13 Proper Cooling of PRFs '_'+ Paxrand Poco Pi to PC + v04_ i rniline Cam aPHltC, to Itt, Pts, �C_ � C 7P7VP Within t trees . x1From TPF , c r3 GC'' e 1 i7"j-F . n to .. H,t zt as nn a r rox„ P r ,ass -L 7 00=- i - i d1 t4tBp Coc'lud PHF Sl is Fam 1!,hien! f,<ir rt'mtry, , OCt ?v on, - -- f at r<unre t, re.trot=,t F/d5'F -_ i \ti ttJ it .l - 't ,t+•,rlI_n.Cm m,h;I nai, l Commonwealth of Massachusetts s 4 I City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 N Food/Retail Establishment Permit DATE PRINTED: 11109/2010 e F ESTABLISHMENT NAME: Jade House - Chang Wang Inc. File Number:BHF-2004-000037 331 Lafayette Street Y f Salem MA 01970 LOCATED AT: 0331 LAFAYETTE STREET SALEM, MA 01970 E Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes t FOOD SERVICE BHP-2010-0596 Nov 9,2010 Dec 31,2011 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health 4"40 {ki f, 4 y, This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted t' in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonatlons,improvements,or equipment changes are made, ` all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 f; 3-501.14(0) PRFs Received at Temperatures Violations Related to Foodborne lltness.Interventions and Risk According to law Cooled to Factors(Items I-W) (Cont.) 41°F/45`F Within 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Addltives 19 PHF Not and Cold Holding 3-50116(B) Gold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 15140°F.Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-PresenceandUse* 590.004H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS POPULDNS ( FOR HIGHLY SUSCEPTIBLE ATIHSP 7-204.11 SanChemicas.ls Criteria i Chemicals. 21 3-80.1.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Cheanicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Food Contact,Criteria*Lubricants* 3-801.11(B Use of Pasteurized Eggs* 7-205.11 Incidental FFoa3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served. * 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Aminal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 Sec, pato e *E""e a rnx u Eggs-Immediate Service 145°Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3.401.11(,0)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 3-401.11(A)(2) Ratites,Injected Meats-I55°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering,mobile food, temporary and 3401.1l(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3.401.11('C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. ether 145°F 4' 590,009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)Fc(D) PHFs 165F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3403A I(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef (tem Good Retail Practices .FC 590.600 Roasts': Management and Personnel FC-2 .003 .I 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 3-501.14(A) CoolingCooked PHFs from 140`F to 25. E t em and Utensils FC-4 .005 i 26. Water.Plumbing and Waste FC-5 .008 1 70'F Within 2 Hours and From 70`F 27. Physical Facl FC-6 .007 to 41°F/45=F Within 4 Hours. * 28. Poisonous or Toxic Materials I FC-7 .008 i 3-501.14(B) Cooling PHFs Made From Ambient 29- Special Requirements - ,009 Temperature Ingredients to 41`17/45°F 30. J Other - ---J Within 4 Hours* *Denotes critical mm in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date. No. Reference R—Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ I Exclusion violations ations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that > noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑, Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: F ' 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness,Interventions and Risk According to Caw Cooled to Factors(Items 1-22) (Cont) 41°F/45"F Within 4 Hours, PROTECTION FROM CHEMICALS 3-501.15 CoolingMethods for PHFs 14 Food or Additives19 PHF Hot and Cold Holding 3-501.16(B) Cold PRFs Maintained at or below 3-202.12 Additives* 104((•) 410/45-F* 3-30114 Protection from Una 3-501.16(A) -50 Unapproved Additives* 15 Poisonous or Toxic Substances 3-50 L 16(A) Hot RIFs Maintained at or above I40°F.* 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers* 7-102.11, Common Name-Working Conminer.0 Time as a Public Health Control 7-201.1.t Separation-Storage* 3-501.19 Time as a Public Health Control" 7-202.11 .Restriction-Presenceand Use* 590,004(H) Variance Requirement 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 for Wishing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning-Labels* 3-801.11(B Use of Pasteurized E * 7-205,11 Incidental Fowl Contact.Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Foot and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts No Served.* 7-206.12 Rodent Bait Smuons* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.1IA(l)(2) Eggs- 155°F 15 Sec. PCO e *Epi z� Eggs-Immediate Service 145°FlSsec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3401.I1(A)(2) Comminuted Fish.Meats&Game Em* Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* - 3401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat; debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.004 violations relating to good retail 3-40112 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-40131(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-4011.10)&(D) PHFs 165°F 15 sec.* (Items 23-30) 3-403.11(B) Microwave 165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness nuerventions and risk factors listed above, can be 3-403.11(C) Commercial ly Processed RTE Food- found in the following sections of the Food Code and 105 CMR )40°F* 590.000. 3-403.11(E) - Remaining Unsliced Portions of Beef Nem I Good Retail Practices I FC 590.000 Roasts* 23. 1 Management and Personnel 'FC-2 .003 18 Proper Cooling of PHFs - 24. Food and Food Protection i FC-3 .004 I 25. Equipment and Utensils I FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water Plumbing and Waste I FC-5 A06 ' 70`F Within 2 Haus and From 70'F 27. Physical Facility FC-6 .007 to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials ` FC-7 .008 i 3-501.14(B) Cooling PHFs Made From Ambient 29. -Special Rerluirentents I .009 Temperature Ingredients to 41'F/45°F 30. Other 1 - Within 4 Hours* s.±m ,m xc.z nx 'M-nows critical ju nz in the federal 1999 Food Code or 105 CMR 590.000, CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- NO. Reference R-Red Item Vied PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ .No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ 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: gOOD p Lo 'TIS NA` oNAL REGisTRY OF FOOD SAFM PROFESSIONALSO 06 CERTIFIES y ,yta. Ty i ` e WTNY SHI '•G ." } HAS SUCCESSFULLY SATISFIED THE REQUIREMENTS FOR �F THE FOOD SAFETY MANAGER CERTIFICATION E7lAMINATICN a President: _. mr. I Y Lawrence J. Lynch,CAE � k t ` ISSUE DATE.OCTOBER 13,2010 CERTIFICATE NO; EZZ0555021 " g' TEST FORM. EZCO 1 lLis'Wificnlr h om,Aid for marc IMPORTANT MESSAGE FOR 11 �7/ DATE lI tVA M TIME P.M. M fink-y_ OF PHONE AREA CODE NUMBER EXTENSION G FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE S - _ugTfo c Lo,-P�, d.Pce I--I'emocro d- /SIGNED fly NIVERSAL_ 48005 MADE IN U.&A. NO-I-ES _ _._. _ _ _ IMPORTANT MESSAGE FOR ��Z DATE �� -'�-1 ' �� TIME �� P. M )0 OFad?�'n rC. \)tzt-Y' �SS 1a PHONE AREA CODE NUMBER EXTENSION O FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN ANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE LLSI.].� 10;3 SIGNED FORM 4009 q%ps MADE IN U.S.A. NOTES CITY OF SALEM —� BOARD OF HEALTH / Establishment Name: L 1r4��G �� 25P Date: t! O Page: of nem Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORREC710N per` No. Reterence R-Red ttem - Verified PLEASE PRINT CLEARLY l Y t 2ii t J l C 1 t (Zant} (1�4 OP i tC) /o LIJ'InG VE nCba� J yy Y �( i. �� T" t�'k ms_s -4-('e-5 in Ins, i1\0 -r\ V - t - -ts t ,C. . 'c � � ca 1) V oa rl4 _ C't r 'S o t /' CT 1r4 P-, t ( `-C cRl( I rread Person in Charge: I .3 Corrective Action Required: ❑ No 0 Yes 1 ❑ Voluntary Compliance ❑ Employee Restriction/ I report, have had the opportunity to ask questions and gee tocorrect all Exclusion e the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension mandates of the Mass/Federal Food Code. I understand that noncompance may result in daily fines of twenty-five:dollars or suspension/revocation of ❑ Embargo ❑ Emergency closure your food permit. . �.i" ,:"t L 'fir) ❑ Voluntary Disposal C3Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(item 1-22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 _ Additives* 590.004(F) 41'/45°F*, 3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 7-101,11 Identifying Information-Original 140°E 3-501,16(A) Roasts Held at or above 130'F. Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*' - 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance I uirement - 7-202.12 Conditions of lose* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* pppULATIONS HSP 7-204.11 Sanitizers-Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801A I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels* 3-801.118) Use of Pasteurized 3 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served* 7-206.12 - Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY - TIMElTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(i)(2) Eggs- 155°F 15 Sec. Pathogens,* E Immediate Service 145'F15,wc* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game E Animals- 155°F 15 sec. * 3-401.11(3)(1)(2) Pork and Beef Roast-130°F 121 rein* SPECIAL REQUIREMENTS 3.401-11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and 3401A I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec, * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 340L12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs- 145°F 15 W. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403A I(A)&(D) PHFs 165"F 15 sec.* (Items 23-30) 3403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR l40°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beefttr em I Good Retail Practices .FC 590.000 a Roasts4° 23. Martairement and Personnel FC-2 .003 18 Proper Cooling of PHFs i 24. Food and Food Protection FC-3 .004 i 25. Equipment and Utensils i FC-4 .005 i 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water.Plumbing and Waste FC-5 .006 70°F Within 2 Hours and From 70°F 27. Physical Facility FC-6 .007 to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials ` FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .003 Temperature Ingredients to 41017/45017 30. 1 Other Within 4 Hours* ]-notes critical ium in the federal 1999 Fool Code a 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: �CtC��P OCz 5E'. Date: QWC� Page: Of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION °' PIo. Reterence, R—Red nam - Verified....P EASE PRINT CLEARLY (J W& CP _ O 1 © Yf? lO � JV Ccs (V) i P,t r �s t e Kd 1 . fo 0 v Y [violations ussion With Person in Charge: Tofo ve Action Required;jUEN0101 Yes ve read this re ort, have had thea ortunit to ask uestions and a ree to cntary Compliance riction/ p opportunity Q 9 Exclusion before the next inspection, to observe all conditions as described, and nspection Scheduled ❑ Emergency Suspension ply with all mandates of the Mass/Federal Food Code. I understand that compliance may result in daily fines of twenty-five do'lars or suspension/revobargo ❑ Emergency Closure r food permit. untary Disposal 0 Other: 3-501.14(0 PHFs Received at Temperatures Violations Related to Foodbome illness.Interventions and Risk - According to taw Coated to Factors(items 1-22) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-50116(B) Cold PHFs Maintained at or below 3-30214 Protection from Unapproved Additives* 590.004(F) 4101450 F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140 7-101.11 Identifying Information-Original Containers* 3-501.16(A) Roasts t.s Held at or above t 30°F. 7-102.11. Common Name-WorkingContainers* 20 Time as a Public Health Control 7-201.1 l Se aration-Stora e* 3-501.19 Time as a Public Health Control* 7-20111 .Restriction-PresenceandUse* 590.004(H) Variance Re uirement 7-202.12 Conditions of Use* 7-203.11 Toric Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washing Produce.Criteria* 21 3-801AI(A) Unpasteurized Pre-packaged Juices and 7-204.14 'n encs.Criteria* Beverages with Warning Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B Use of Pasteurized t E ed 7-206.11 Restricted Use Pesticides,Criteria* 3-80111(0) Raw tc Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY _ TIMEJTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3.40f.11A(l)(2) Eggs- 155'F 15 Sec. pyo *Exnavrat Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 sec. * catering,mobile foal, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-40112 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(AWD) PIFs 165"F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 340311(0 Commercially Processed RTE Food- found in rhe following sectionsofthe Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) - Remaining Unsliced Portions of Beef Nem I Good Retail Practices i FC 590.000 1 Roasts* 23. 1 Management and Personnel FC-2 _003 .i 1$ Proper Cooling of PHFs 124. Food and Food Protection I FC-3 .004- 3-501.14(A) Cooling Cooked PHFs from 140°F to 25. Equipment and Utensils FC-4 .W5 26. 1 Water.Plumbing and Waste - FC-5 .006 I 70°F Within 2 Hours and From 701F 27. Physical FacilityFC-6 .007 to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials i FC--7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. Omer - - Within 4 Hours* ssocx :az cM. *lhnotes critical item in the federal 1999 Food Cade a,105 CMR 590.000. CITY OF SALEM 1` BOARD OF HEALTH Establishment Name:_ SY PJI zS� Date: Il �g �I Page:-a of Rem Code R-Red Red Item- l Rem R No. Reference DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- ttVerified PLEASE PRIM CLEARLY i(� a�10 atl t cmmnw noir- -to cern c f� rvt ,t I'� t .� yv vcEu f 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 noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �I ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Caw Cooled to Factors(ftems 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 19 PHF Not and Cold Holding 3-50L16(114 Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 410/45'F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 140'F. * 7-101.11 Identifying Information-Original 3501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11, Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora e" 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use' - 590,004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS POPULATIONS FOR HIGHLY SUSCEPTIBLE HSP 7-204.11 SainChemicalszers,Criteria i Chemicals, 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* 7-204.14 DryingAgents.Criteria* Beverages with Warning Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(11) Use of Pasteurized E ggs* 7-206.11Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Ani mall Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.1IA(1)(2) Eggs- 155°F 15 Sec. Pathogens.*Ex`ve v"f Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 31401.11(A)(2) Comminuted Fish.Meats&Game Eggs Animals-155'F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-90Li1(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to goal retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements, 3.401i11(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3.403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Hem I Good Retail Practices J .FC 5 Roasts* - 23. Manarlement and Personnel I FG-2 .003 18 Proper Cooling of PHFs 24. Food and Food_Protection i FC-3 .004 t 25. Equipment and Utensils _ 1 FG-4 _ ,005 3-501.14(A) Cooling Cooked PHFs from 140'F to 26, Water.Plumbingand Waste i FC_-5 .006 t 70T Within 2 Hours and From 70'F 27. -Physical Facility FG-6 .007 to 41'F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials i FC-7 A08 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41'F/45'F 30. Other Within 4 Hours* s:frrr .hxs.z m,. *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM c- BOARD OF HEALTH Establishment Name:_ �c�r4 pT�z�e Date: Page: / of Hem Code C- item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,No. Reference R-Red Item Item Verified PLEASE PRINT CLEARLY _)� , o r o &' , , j 1 1 . M '_14- t � �n C _ A f q, � . '+ ( tco ,ip r . l'K) IYi f'G' '� .C (� S7Y') ✓n ��i rc ( TJ li k f ' _ i I O i :d A Discussion With Person in Charge: Corrective Action Required: ❑ No ❑> :Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that EI Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty,five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. VV V� 0 Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne fitness.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 PRFs 14 -rFood or Color Additives 19 PHF Hot and Cold Holding ii 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41.0/45'F* 3-302.14 Protection froth Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140°F. 7-101.11 Identifying Information-Original 3 50I 16(A) Roasts Held at or above 130°F. Containers* 7-102.11. Common Name-Working Containers* 20 Time;-s-a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control" 7-202.11 .Restriction-Presenceand Use* 590.004(H) VarianeeRe uixement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* pppULATIONS HSP 7-204.11 SanChemicrs.als Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chenncals for WashingProduce,Criteria* Beverages with Warning labels* 7-204.14 ants.Criteria* 3-801.11(8) Use of Pasteurized Eggs* 7-205.11 Incidental tal Food Concis,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 -Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(I)(2) Eggs- 155°F 15 Sec. Pathogens.*E9 ,c .+Aman ..4ggswlmmediateService 145'F15sec" 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155'F 15 sec.4` SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in set. * catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3.401:11(A)(1)(b) All Other PHPs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs 165T 15 sec.* (Items 23-30) 3403.11(B) Microwave 165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Tithe* foodborne illness interventions and risk factors listed above,can be 3-403.11(C) Commercial ly Processed RTE Food- found in the following sections-qf the Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef [ Nem I Good Retail Practices J .FC 59O.Wo 1 Roastst, 23. i Management and Personnel I FC-2 .003 1 18 Roper Cooling of PHFs 24. Food and Food Protection I FC-3 .004 C 25. Equipment and Utensils - j FC-4 .00.5 I 3-501.141 A) Cooling Cooked PHFs front 140°F to 26. Water.Plumbing and Waste j FC-5 A06 70'.F Within 2 Hours and From 70'F 27. - Physical Facility ! FC_-6 .007 to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7008. 3-501.14(B) Cooling PHFs Made From Ambient 29. -Special Requirements .009 Temperature Ingredients to 410F/450F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Cale or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Narne: � 1CPdC-' �n��SC. Date: IO�to Page: � of / item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date` No. Reterence R—Red hem verified �: yy PLEASE PRINT CLEARLY �p .'i S �L.at if IS Malt iC7i1MIS h �, th If'75 C 1 J 1 (� 1/ l( IC C , t . . � l - f��,crn r czrt Discussion With Person in Charge: Corrective Action Required: ❑ .No O Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ p pP Y 9 9 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 4 noncompliance may result in daily fines oflt'wenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. \' t n �/� u voluntary Disposal ❑ Other: � yf� 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cont.) 41.'F/45"F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 _ Food or Color Additives _ 29 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3 202.12 Additives* 590.004(F) 410145'F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained of or above 140'F. * 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1300F. Containers* 7-102.11, Common Name-Workin Containers* 20 Time as a Public Health Control 3-501.19 Time as a Public Health Control* 7-201.t 1 Separation-Storage* 7-202A I .Restriction-Presence and-L'se" 590.004(H) Variance Requirement 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 for Washi Produce,Cclteria* 21 3-801.11(.4) Unpasteurized Pre-packaged Juices and 7-204.14 n encs.Criteria Beverages with Warning labels* 3-801.11(8) Use of Pastemizul E gs* 7-205.11 Incidental Food Contact,Lubricants* 7-206.11 Restricted Use Pesticides,Criteria" 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed S arts Not Served- 7-206.15 erved 7-206.12 Rodent Bait Stations" 3-801,11(C) Unopened Food PackageNot Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME✓TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs - Not Otherwise Processed to Eliminate 3 401.1 lA(1)(2) Pathogens.' Eggs- 155'F 15 Sec. Eggs-Immediate Service 145'F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals- 155'F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(6)(1)(2) Pork and Beef Roast-130'F 121 min* 3.401.11(A)(2) Ratites,Injected Meats-155'F 15 590.0590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec * catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poul or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave I65'F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165"F 15 sec.* (Items 23-30) 3-403.11(B) Microwave 165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in rhe following sections of the Food Code and 105 CMR 140'F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item I Good Retail Practices I Fc 5W.000 Roasts* 21 3. Management and Personnel FC-2 .003 111 Proper Cooling of PHFs i 24. Food and Food Protection FC-3 .004 i 25_ Equipment and Utensils _ FC-4 7005 i 3-501.14(A) Cooling Cooked PHFs from 140'F to p8. Water.Plumbing and WasteFC-5 .006 ; 70'F Within 2 Hours and From 70'F 27. Physical Facility 1 FC-8 .007 . ; to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14() Cooling PHFs Made From Ambient 29. -Special Requirements 1 .009 Temperature Ingredients to 41'F/45'F 30. Other Within 4 Hours* .rsveresze *thnotes critical hernia the federal 1999 Foal Code or 105 CMR 590.000. 10/05/2010 02:09 9787450343 PAGE 01 • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STR?'s7?-C,41O 14LOOR TEL. (97$)741-1800 ICIM ERIEY DRISCOLL PAX(978)745-0343 MAYOR DGRFF.NBAllhI(Q),.&XJX' .CONI nAvro GREENBAUM, ACTING T-JF.At-n-T AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTASLIStH-�MENT NAME OF ESTABLISHMENT C �b/ EL# / ADDRESS OF ESTABLISHMEN OJi1 FAX# MAILING ADDRESS(if different) t ve Q EMAIL-Business': N ,// Webstte: N r I 330 nr/ ' f^ - OWNER'S NAME teTEL# 330-- 91 f ADDRESS2 � n/V2 OW q STREET CRY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) / )a" 4 , CERTIFICATEMS) (Required in an establishment where potenfially hazardous food epared) EMERGENCY RESPONSE PERSON k4mat HOMETEL# 341-330 -zq[54 DAYS OF OPER ATI ON Monday_ Tuesda W�nesd Thursday FAday- _ -_ _Saturday Sunday HOURSOFOPERATION J/-.301 jl.�pA. /�. j _3a � �pyj Qpey( F�ax�o;;m.;°�` 10-30 /M f �o /1"00 M /l:oo /ono ease TYPE OF ESTABLISHMENT FEE (check onlyl RETAIL STORE YES NO less than 1000sq.ft. =$70 1000.10,000sq.ft. =$280 more than 10,000sq.ft. X420 - ...... - RESTAURANT YES NO less I han 25 seats _41 (Outdoor Stationary Food Cart$2 5-99 seals =$28 more than 99 seats =$42U-- - --------------- - BED/BREAKFAST/ YES O $100 CHILDCARE SERVICES lNgBSINGHOME_-"---__------------- ADDITIONAL PERMITS MAKE(not just serve)ICE CREAM, YOGURT/SOFT SERVE YESNO $25 TOBACCO VENDOR YES $135 ALL NON-PROF!!'(such as church kNchens) YES NO $25 "Please pay total with one check payable to the City of Salem, This Permit Is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all pians for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 1320,$actlon 49A,I certify under the pains and ponalHes of penury that I,to my best knowledge and bell ef,have filed all state tax m velus and paid all stale taxes required under the law. 2 -3 D .Z Sigriat T /t I)Ate © Social Security or Federal Identification Number Revised 424/07 FOODA'..J;,sdm -- Chock#&Date $ itk " 1 Yuki Wong <yukl.attorneycoleman@gmall.com> American Red Cross of Massachusetts Bay - American Red Cross Training 1 message noreply@chapterneighborhood.org<norepy@chapterneighborhood.org> Tue, Oct 12, 2010 at 2:43 PM To: yuki.attorneycoleman@gmaii.cwm Please do not reply directly to this e-mail. All replies go to an unmonitored mailbox. If you have any questions or comments, please contact us at massbaycourseregla-usa redcross org Student Name: Wang Shi Address: 24 Boston Ave, 2FL City: Somerville State: MA Zip: 02144 Email: Phone: 347-330-2914 Invoice/Transaction Number: 96268 Class Registration information Name of class: CPR/AED-Adult Code Schedule: 3226919 Date: 10/23/2010 Time: 9:OOAM - 1:30PM / Location: 1495 Hancock Street, 3rd Floor, Quincy, MA, 02169 I Cost: 60 CCC Total: 60.00 --------------- Thank you for selecting the American Red Cross to serve your training needs. In the next several days you will receive an additional e-mail confirmation, which will include important information regarding your upcoming training, including directions and policies. If you have any questions, feel free to contact Course Registration at 617-274-5261 Monday through Friday 8:30AM -4:30PM. We look forward to seeing you in class! 1 of 1 10/12/2010 2:44 PM I yxosr=L%� "1 COMBINATION SPECIALS MAKE YOUR OWNG' o a Served All Day Except Special Occasions 1DINNER PLATES r 735"1 Substitute Lo Mein for Frietl Rice kPick 6,tliXerent Items Irom bllowinga y,. ♦ s gum 1. Pork or SubChow Meln Chi B. Chickenen 3 with Broccoli or Moo Goo Gal Pan 4 {(Double Item E1 Pork Fried Rice with Ba. Egg Roll or Spring Roil... ...7.00 • Egg ROII ry tizm• Pork flletl Rice 1a. Egg Roll or Spring Roll....................... . ..5.25 8b. Chicken Wings ... .. ...7.25 rd a ChlOken Wing ;$ ,1 • Polk.Lo Meln `y 1b. Chicken Wings .. ..5.35 6c. Chicken Finger. .. ... . ....7.35 tc. Chicken Finger .. ...5.55 ad. Crab Rangoon a......TOO Chicken Finger; #=ah.e White fit CHINESE RESTAURANT td. Crab Rangoon...................................... .5.25 Be. Boneless Spareribs _7.20 �.Chicken Teriykia • Beef Terlyekl ew 1e Boneless Spareribs. .575 iii. Teriyaki(Beef or Chicken) ...J.40 (Former Salem Jade) 1i Teriyaki(Beef or Ch cke ). . . ..6.00 eg. Frietl Shrimp ......J.00 `" e,Qreb RengOOn p 3V f• Frierf•Shdmpt�„ •' tg. Fried Sfnmp . ... _ }" � Szechuan Mandarin & . ..5.50 E• Boneless Spareribs • Spring r 9.'-Twice Cooked Pork or Kung Pa Chicken Cantonese Cuisine 2. Egg Foo Young Pork Fried RICO with 9a. Egg Roll or Spring Roll...............................7.00 ytit�B 2a. Egg Roll or Spying Roll...............................5.25 9b. Chicken Wings..............---......................... .00 2b. Chicken Wings.....---..............____........5.25 9c.. Chicken Finger......_._........._...._................7.35 DINNER 2c. Chicken Finger...... ....._5.60 ad. Crab Rangoon..........................................-.7.15 COMBINATION PLATES 2d. Crab Rangoon............................................5.30 9e. Boneless Spareribs_......................_...........7.35 2e. Boneless Spareribs.....................................5.50 W. Teriyaki(Beef or Chicken)..........................7.40 D1. Beef Mushrooms,Boneless Ribs, Z. Teriyaki(Beef or Chicken)...........................5.75 9g. Fried Shrimp.-.................... --- .--..-- -..zoo Chicken Fingers,Pork Fried Rice.........8.35 �Q 2g. Fried Shrimp...............................................5.40 D2. Shrimp Lobster Sauce,Boneless Ribs, 10. Shrimpw.Lobster Sauce,Pork Fried Rice with P 3. Lobster Sauce,Pork Fried Rice with 10a. Egg Roll or Spring Roll ........ .6.70 Chicken Wings,Pork Fried Rico............8.35 .................... 3a. Egg Roll or Spring Rall...............................5.55 10b. Chicken Win95.............................................6.]0 D3. CBeefhic en ccoli,Wing ,PorkBoneless Ribs, 3b. Chicken Wings....__...__.............................5.55 10c. Chicken ....................6.75 3c. Chicken Finger..........................................6.00 Chicken Wings,Pork Fried Rlce............8.40' too. Crab Rangoon ......................................6.65 ) 3d. Crab Rangoon....._........._......................._.575 10e. Boneless Spareribs.....................................6.95 Be. Marco Polo Delight,Boneless Ribs, } �� 3e. Boneless Spareribs.__..._.____.._....__......600 10t. Teriyaki(Beef or Chicken).-........---.........7.00 Chicken Wings.......................................8.20 / /� 3f. Teriyaki least or Chicken)...........................6.35 1bg. Fried Shrimp................................................6.5D 1� 3g. Fried Shrimp....._........................................6.10 D5. Moo Goo Gel Pan,Boneless Ribs, 11. Chicken 8 Beef w.Veggle,Pork Fried Rice with Chicken Wings,Pork Fried Rice............8.20 4. Chicken Chow Mein or Chicken Chop Busy, 1 is Egg Roll or Spring Roll................................7.25 D6. Beef Teriyaki,Boneless Ribs, WE DELIVER ALL DAY Pork Fried Rica With 111c. Chicken Wings.........................- ----7.40 4a. ................. ..... ... 5.55 Chicken Wing,Pork LA Mein.................8.30 Egg Roll or Spring Roll...... 11c. Chicken Finger............................................].]5 (To Salem&Marblehead,$2 Charge) 46. Chicken Wings............................................6.00 11 . Crab Rangoon...........................---.............].35 D7. Egg Roll,Boneless Ribs, 4c. Chicken Finger............................................6.00 tte. Boneless Spareras ibs.....................................].50 Chicken fingals,Polk Lo Mien..............8.30 ad. Crab Rangoon.... .........................-...6.75 11f. Teriyaki(Real or Chicken)-........................7.95 4e. Boneless Spareribs.....................................6.35 11g. Fried Shrimp...............................................7.65 De. Chicken Fingers,Boneless Ribs, TO Place Your Order, Please Call 4f. Terlyaki(Beef or Chicken)........_................675 Crab Rangoon,Chicken Lo Mein..........8.55 (978) 744-3360 4g. Fried Shrimp.....____..._ .. _ .___..............._.6.00 12.\General Gau's Chicken or Orange Chicken Be. Chicken Wing,Boneless Ribs, S. Sweet 8 Sour Chicken,Pork Fried Rice with or Sesame Chicken,Pork Fried Rice with Egg Roll,Chicken Lo Mein....................8.55 5a. Egg Roil or Spring Roll ........ 12a. Egg Roll or Spring Roll................... 7.55 y Fax: (978)744.2984 . ..5.]5 D10.Chicken Terl ak1,Boneless Ribs, 5b. Chicken Wings ................... 12b. Chicken Wings .. . .... .. .._.7.55 -3 ...6.00 12c. Chicken Finger . . .... ....170 Crab Rangoon,Shrimp Fried Rice........8.50 5c. Chicken Finger __.. .. .].00 12d Crab Rangoon 7.55 3.31 Lafayette Street 5d. Crab Rangoon .. .6.25 "' Y Se. Boneless Spareribs- ... .. .6.55 la.12eBoneless Spareribs... .. 7.95 12g Fried Shrimp o Chicken) .. .].95 , Salem, MA 01970 5f. Teri aki Beet or Chicken ..6.]0 F y ( ).. 12g. Fried Shrimp ... ].95 w WHITE RICE PLATES 59. Frietl Shrimp .. . ...fi.25 t s 1- a -0-" Chleken or Baet w Bean Curd on Rica xE 6.'�Szechuan Chicken,Pork Fried Rice with 15. Fried Shrimp,Chicken Wings,Beef Terlyaki, r HOURS /d30 Chlekea'or Beef w S[ring Bean on Rlee4+'. Sun 12 noon to 9:30 pm So. Egg Roll or Spring Roll ... . .6.25 Boneless Spareribs 8 Park Fried Rice 8.45 " q Shrimp w SMngiBean on Rlee r (� r Mon•Thurs 11:30 am- a' D 6b. Chicken Wins . .6.40 II ✓ BPRi/ -3 Wings., 16. Crab ld,Boneless Fingers, t Oc"" 6c. Chicken Finger 7.00 Shrimp:,w Scrambled Eggron Rlee 1 Fri 8 Sat 11:30 am-1&.981 Teriyaki,Boneless Ribs 8 Pork Fried Rlce..8.45 BCrab Rangoon .. ...........................6.45 Veg¢tarlens DaligM od'Alce y ars �7s •! f �//f'� Be.eBoneless Spareribs............. J.10 17. Chicken Wings,Chicken Beef Terlyaki, • *ir+ • �,t 6f. Teriyaki(Beef or Chicken).. .......Z25 Boneless Spareribs,8 Porkrk Fried Fried Rlee.......e.95 °Scallloe Beef on Rlee(87 25) .� ,F., �, ,,�� Our Restaurant is not sewing Big. Fried Shrimp.__............._..........................7.00 18. Beef Teriyaki,Chicken Terlyaki,Pork Ships, raw or undercooked food. Chicken Wings 8 Pork Fried Rice................B.45 EXTRA SAUCE 7. Pepper Steak or Beef with Broccoli, a Pork Fried Rice with A. Pork Fried Rice,Chicken Wings, Mustard............................-..........(cup)0.50 (pine 2.50 1 va. 7a. Egg Roll or Spring Rall...............................7.0) Boneless Ribs...............................................6.20 Duck Sauce...................................(cup)0.25 (Pint)1.50 No Personal checks accepted. ]b. Chicken Wings-........... ...........7.15 B. Pork Fried Rice,Chicken Fingers, Ginger Sauce................................(cup)0.25 x` 7c. Chicken ringer............................................7.25 Boneless Ribs...............................................6.20 Hot Sauce......................................(cup)0.25 4 7d. Crab Rangoon........_..................................7.15 S ]e. Boneless Spareribs.....................................7.35 C. Pork Fried Rice,Chicken Fingers, Sweet 8 Sour Sauce.....................(cup)0.30 s ]f. Teri aki Beef or Chicken)..... yg 7%Mass.Meal To. Y I ._..........==>.7.10 Crab Rangoon...............................................6.20 f All prices subject lc change due ro seasonality and avalability. ]g. Poetl Shrimp............................___............7.1D it Hot and Spicy Dishes B Nor responsible for lost ourlse Mild or non-apity available upon request 8e APPETIZERS ameu age FRIED RICE CHICKEN a,ruili targe HOUSE PU PU PLATTER For Two.......................... Wi ands of subgum Filed trice w-m cents mcse) smell faros .........18.75 Chicken with Broccoli.....tables..................5.35 8.75 2Egg nAdis Fingers, Remixes ilcmene,4 c Fdean,con ,A Meatless.......................................................4.00 5.25 Chicken with Mixed Vegetables..................5.25 8.65 SPECIALTIES Chicken FnBers,Boneless Sparedbs,a Geb Rangoan. Vegetable........................_............................4.35 6.00 Chicken with Pea Polis.......................... . .5.50 8.55 PU PU PLATTER For One(Half quantity of above)....9.]5 Roast Pork....................................................4.50 6.25 Chicken with Straw Mushrooms.................5.35 6.75 [N�,Genfifiral same Beef or Chicken.....................10.50 ' Golden Fried Wooton...................................1.75 2.75 Chicken.........................................................4.80 6.50 yer�eeeefud:aerr ae,asnm won ses�mes�d Chicken with String Beans..........................5.00 8.05 p Egg Rall........................................................1.85 3.50 Ham...............................................................4.50 6.25 Chicken Cashew Nuts.................................5.30 8.25 Gau's Chicken.........................10.15 Spring Roll....................................................1.75 3.25 Beef...............................................................4.85 7.25 Moo Goo Gal Pan.........................................5.00 8.00aChicken Wings.............................................4.35 7.15 Shrimp..........................................................4.85 7.25 Hung Sue Gai............................................._4.95 8.35Chicken Fingers...........................................4.75 7.75 House Special Fried Rice............................5.50 8.00 Curry Chicken..............................................5.05 7.95 ange Flavored Chicken or Beef.....10.50 Pork Strips or Ends......................................4.35 7.00 Plain White Rice........................................... 2.00 T.ms,m�.Wade+a.me<bee,neea�m'saa,m.,wwree Hawaiian Chicken........................................5.05 8.05 Barbecued Spars Ribs....Spareribs ..................5.00 8.50 Deliseemeght o Scallion Chicken......................................................8.35 .......10.00 Barbecued Boneless Spareribs..................4.25 7.95Delight of Three.............................. Fried Jumbo Shrimps..................................4.25 6.95 CHOW MEIN or CHOP SUEY \Szechwan Chicken...................................................8.65 r�n.nm w;mpa,ma..n,,.,e„bed,,®aeee wm Nl kinds of su cdresewpeubueme,ad aeibmd esus. Teriyaki Beet.................................................4.95 7.95 I bBum end CniraBo style w-mcan�s ams) ung Pao Chicken with Peanuts.............................8.40 smeu faros N Yfi Hsiang Chicken.......................................5.45 8.60 Delight of Four.......................................11.95 Teriyaki Chicken...........................................4.85 7.75 Shierrp.mcmnlxxf.%odowwnhm'rbmwnmuw. French Fries n..............................................1.50 2.75 Meatless.......................................................4.00 6.50 Four Happiness......................................11.95 Crab Rangoon.. 7.75 Pork..............................................................4.00 B.50 BEEF smd, tarda GEmdCdresemazl ra'kwm eomadbed.anmmmerre Peking Ravioli..........................................................5.00 Chicken.........................................................4.50 7.50 Beef with Broccoli........................................5.80 8.85 em�mwm mre mkss,n an vacswmfmaa�.mesa nuly-tfisnforyourserm Scallion Pancake................ Beef...............................................................4.50 7.55 ......................................4.25Beef with Mlxetl Vegetables........................5.75 8.75 Gal Poo Lo Mein(for 2) 15.25 Shrimp..........................................................4.55 7.55 ........................ Tltllose Rift, ,Chi..........,sm.........hone.............................8.55 Beef with String can Onion.......................5.50 8.25 c,waemmmlurr meemnwur,.u�ee mn.nam.lemmannmpe sores.Rins,cnicken Flrgers.Fded snnmpa,Cnirxen woes Beef with String Beans................................5.70 8.55 �^ee°w/�e^m woemaeamebaeawn�,Web. Tidbit#2...................................................................8.35 LO MEIN Mushroom Chow Yoke.................................5.90 9.15 Marco Polo's Delight.............................10.00 Boneless Sparedne,Chicken Rogers.Egg Roi Por,ships Beef with Pea Polis.............. - F,KII lu,ao ebk,mema barn,rmmwm acne,aeuwan e Tidbit#3..................... Sdinoodlasa,xt eneNcetn nenles ........................5.95 9.25 bmdpeelumecoeue. Bon .............gs.Beef....................8.55 mixed hogeber win musnmoma, Beef with Black Bean Sauce.......................5.75 9.00 Tidbits spared...,egg Roll.cnid,en wings,6ea.7edr%a weber cheamma era Pea rods. Seafood Supreme..............me...............13.60 TidbitSiXesre...........................................................l,C8.35 smeu 6.25 Beef with OYaw Sauce....x.......................5.90 10.75 rummn�me .mdse.me,duwuo.sea,ese wm,a.m.aama Vegetable......................................................4.25 6.25 Beef with Straw Mushrooms.......................5.95 9.15 wChveearegefeble. Bonaiess Sparedns,Egg Roll,Chicken Flngers.Crab Rangoon Roast Pork....................................................4.55 6.75 Beef Hawaiian..............................................5.85 9.00 k Salary Beef..........................................10.40 Chicken.........................................................4.95 7.50 Beef with Black Mushrooms........................5.95 10.25 1,Beef with Black Peppercorn.............10.15 .SOUPBeef...............................................................5.00 7.85 ',Scalllon Beef..:.........................................................9.50 kSpicy Boil Beef..................................10.15 Arno, Lenge Shrimp..........................................................5.15 7.85 tiKung Pao Beef with Peanuts...................................9.35 Chinese Vegetable.......................................2.05 3.95 Peking Sauce Noodle(with ro,k).................................6.75 lSzechuan Beef.........................................................9.25 E99 Drop......................................................2.05 3.95 House Spacial Lo Mein................................5.55 8.10 N Yu Hsiang Beef.............................................5.95 9.25 SEAFOOD Smd, Lary. Chicken Noodle or Rice...............................2.05 3.95 (with andmp,nam,ahickenand mesh pork) Lobster Sauce..............................................3.50 6.05 Pork Strip Wooton........................................2.05 3.95 Pad Tal(midwr,aril erm,p) .......7.25 Squid with Black Bean Sauce.................................6.95 Pork Strip Yaks Mein...................................2.05 3.95 Pan Fried noodles........................................3.50 5.50 PORK Mixed Vegetable Squid............................................7.]5l Hot and Sour Sou ......................................2.05 3.95 Garlic Noodle...............................................4.25 6.25 smd, Le,4e Spiced ti Squid................................................8.05 Kong Bok Toy with Roast Pork..............................4.35 7.25 l Kung PaooSquid.......................................................7.75 Hon Shue yoke.............................................4.50 7.35 'l Curry Squid..............................................................7.85 SWEET & SOUR CHOW FOON or ge, Pork with BroccOil........................................4.50 7.50 Shrimp with Mixed Vegetables....................4.95 8.50 .men 6.75 RICE NOODLE Pork with String Beans................................4.50 7.50 Shrimp with Lobster Sauce.........................4.95 8.50 Sweet and Sour Pork.en.............................4.25 6.75 Pork with Mixed Vegetables........................4.35 7.25 Shrimp with Broccoli...................................4.95 8.50 Sweet and Sour Chicken.............................5.75 8.25 Stir Fded Chow Foon with Beef or Chicken...........7.25 Twice Cooked Pork..................................................7.95 Shrimp with Pea Pods..................................4.95 8.50 Sweet and Sour Shrimp...............................5.50 8.50 Beef or Chicken with Black Bean Sauce Shrimp with String B Sweet and Sour Wooton..............................2.75 4.35 k-Ma P Pao Pork....ork...............................................8.00 p 9 sans............................4.95 8.50 Chow Foon or Rice Noodle...................................7.25 '<Ma Po Tofu with Pork...............................................7.25 Shrimp with Cashew Nuts.......................................8.50 Beef or Chicken with Vegetable \Spicy Salted Pork Chop...........................................7.95 Butterfly Shrimp.......................................................8.50 Chow Foon or Rice Nootlle..................................7.25 'l Peking Style Pork Chop...........................................7.50 Shrimp with Black Mushroom..................................9.95 EGG FOO YOUNG Shrimp with Black Bean Sauce %-Yu Hsiang Pork.............................................5.25 8.10 N-Szechuan Shrimp.....................................................8.95 (Pll kinds of Subgum 75 cams amid) Chow Foon or Rice Noodle...................................8.55 Kung Pao Shrimp with Peanuts...............................8.95 Shrimp with Vegetable Pork Egg Foo Young................................................6.25 Chow Foon or Rice Noodle...................................8.55 MOO SHI STYLE VEGETABLES . Meatless Egg Foo Young.........................................5.75 kSingapore Rice Noodle............ ... . .....7.25 Moo Shi is a classic Mandarin cooking, Vegetarian's Delight.................................................6.85 p, Ham Egg Foo Young................................................6.00 Rice noodle w/roast pwk,shdmonion,bean sprout,s,a curry sauce. these dishes contain meat,mushroom,cabbage and eggs, Chicken E Foo Young served with six cakes far wr in S ,f refer. Broccoli with Hot and Spicy Saute.........................6.95 99 9..........................................6.25 Chinatown Rice Noodle.p.onio...dean........aric..........7.25 Pan app 9� h. � P Shrimp Egg Foo Young...........................................7.25 Am noodle won roast pods andmP.onion,bean sprout antl egg. Fxha pancake are 30 cents each. l Spicy String Beans..................................................6.85 Mushroom E Foo young Bean Curd,Family Style..........................................6.85 99 Y 9.....................••...............7.25 Beet Vegetable with Pan Fried Nootlle..................7.25 Moo Shi Vegetable...................................................6.65 kGeneral Gal Tofu...................................................6.85 Beef E99 Foo Young................................................7.25 Chicken Vegetable with Pan Fried Noodles...........7.25 Moo Shi Pork............................................................7.00 SauteedPea Polis....................................................7.15 Shrimp Vegetables with Pan Fried Noodles...........8.55 Moo Shl Chicken......................................................7.50 Sauteed Broccoli......................................................6.95 \Hot and Spicy Dishes Betsy Udon Noodles with Beef or Chicken............8.00 Moo Shi Beef............................................................8.35 fi�-Yu Hsiang Broccoli...................................................6.95 Mild or�spic,Y inellable upon request (Barbecue sauce) Moo Shi Shrimp.......................................................8.35 l Yu Hsiang Vegetables..............................................7.25 CITY OF SALEM BOARD OF HEALTH Date: October 14, 2010 Name of Establishment: Jade House Address: 331 Lafayette Street Owner: Wang Shi Phone: 978-744-3360 The proposed new owner of this establishment Wang Shi and Andrea Kor, Paralegal, presented a Floor Plan and Menu for review in accordance with the State Food Code. Both are approved as presented. Any changes to the approved floor plan must be approved by the Board of Health prior to implementing them. CERTIFICATION There must be a Certified Food Manager working at this establishment full time. A "Person in Charge"or"PIC' must be available at this location when the CFM is not present. The PIC must have knowledge of sanitation techniques, holding temperatures, operations, etc. Please forward copies of all Certificates to the Board of Health FLOOR PLAN A Hand Sink must be located in each food prep and service area. The hand sink must have a wall hung soap and paper towel dispenser. These must be stocked at all times. The hand sink must be used for hand washing only. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. This includes any storage of these items in the basement. Storage must be at least 6 inches off the floor. A three bay sink for washing, rinsing and sanitizing all utensils equipment, dishes are available. MENU/FOOD PREP All food must be purchased from a wholesaler licensed by the State. Fruits and vegetables must be washed prior to preparation. All food must be held at 41°F or lower, or 140"F or higher, at all times. Food may not be added to containers in holding unit. Instead, a sanitized container with new product may replace the existing container and the old product may be placed on top of the new product. There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used when handling such food. There will be no service of Sushi at this time. If sushi is to be served in the future pians for sushi service must be presented to the Board of Health for approval prior to beginning service. UNDERCOOKED FOODS Foods are not prepared raw or undercooked at this time. If food will be prepared to order then and advisory must be added to the menu. CHOKE SAVING A person trained in choke saving techniques must be available whenever this establishment is open for business. Please forward choke saving certificates to the Board of Health EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. SANITIZING SOLUTION Sanitizing Solution must be accessible at each prep station and for the patrons' tables. Test strips corresponding to the kind of sanitizer, must be on hand to check concentration of solution. Solution must be made daily, tested, and the results recorded on a log sheet for examination by Board of Health inspectors. Solution may be prepared in the P bay of the 3-bay sink and spray bottles may be filled there. Spray bottles with clean paper towels may be used, as well as wiping pails with wiping clothes always held in the solution in the pail. These must be clearly marked "sanitizer". Outside area of premises, including the dumpster area must be kept clean and sanitary. TRASH Trash will be held in an outside dumpster. A grease barrel will be located in the same area. The dumpster must remain closed when not in use and the area must be kept clean. ODOR Exhaust air must be filtered in such a manner to prevent the release of food odors to the outside of the premises. A change of ownership inspection is scheduled for Thursday, October 21, 2010 @ 10:OOAM. An pplicatio d check have been received. r o- 1 \o David Greenbaum Date Acting Health A e t , Wang Shi Date Andrea or Date On" OF SALEM, MASSACHUSETTS � C .- BoARD OF HFAISH 120 WASHINGTON SnzFL i 4°• FLOOR TEi.. (978) 741-1800 ILIMI3F,IZI'_EY 17RISCOI,1� FAN (978) 745-0343 1.1AYOR lramchn@salem.com LARRY RANIDN,RS/RI iI IS,CI I(),(P-I;S Hi:,Aj xI I A(;I;.N"I' his i orin will be Co{recled during youij i,ext Board of Health inspection. QUESTIONAIRE -GREASE TRAPS 2009 1. NAME OF ESTABLISHMENT: zlat kl�cn_ - Cham ti1a„r� �c 2. ADDRESS OF ESTABLISHMENT: 3A I k '�112t}�y� , S o, Pal . 14 o 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? Yes 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 54nd6,4_",0 D �/Z/7 S 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? OnLE 2 maw irrLk'/rfZ�4'nCv 6�, a[�7`siL� Go.>JrlC�� 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? �Jn®o a mon 0/i 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? Bz"P/TCk n 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? l m CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4 "FLOOR PilblicHCAlt]1 r.c.rne.rammc.rmroc. TEL. (978) 741-1800 Fax(978) 745-0343 KIMBERLEY DRISCOLL liamdinng,salem.com ' LrViI2Y IL-\D113IN,RS/I2E1-1S,CHOP CP-I'S MAYOR . . . - HL.Aun t AGEN'I' This Form will be collected during your next Board of Health inspection. QUESTIONAIRE -fG�R�EASE TRAPS 2012' , a 1. NAME OF ESTABLISHMENT: C RAW&— W ANG, 7A a(Lg 74ber 14OvSE 2. ADDRESS OF ESTABLISHMENT: 33I L A FAY&T-CE ST 5xtPti Nlw o [q 7o 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? *6 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE?. CAPACITY IN GALLONS S''I"Q1 dnl j 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 1 L 6A0 a. m l vWaZldonak�Q hu 01 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? at 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?