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JAHO COFFE & TEA - ESTABLISHMENTS JA ,n Ccs*fee Tc � L4(rl'p?jlA COM universal one,M www.myuniversalop.com phone: 1-800-756-4676 UNV16162 MADE IN USA - Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Jaho Coffee & Tea File Number:BHF-2005-000040 6 Harrington Court SALEM MA 01970 LOCATED AT: 0197 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0305 Jan 1, 2011 Dec 31,2011 $280.00 ESTABLISHMENT FROZEN DESSERTS BHP-2011-0306 Jan 1,2011 Dec 31,2011 $25.00 Total Fees: $305.00 PERMIT EXPIRES December 31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Paye 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HE-LTH A . 6 120 WASHINGTON STREET,4"FLOOR TEL. (978)741-1$00 is KIMBERLEY I�RISCOi ti _ " ' . .-. —(978) 741718 FAx(978),745-0343 IVLAYOR - DGUENBAUN1(c SALE 'i.COM DAVID GREENB AUN1,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Off,n�o (W� F7L- -Qf1�. TEL# ADDRESS CF ESTABLISHMENT 3- FAX# MAILING ADDRESS(if different) ` EMAIL- Business': `11 f� Website: tow(J 1 �A,5 .CtlL-1 OWNER'S NAME �t�/i t �1 h� TEL#IV C/��' sat2- I ADDRESS Ij F�0.TE`Iy1Q�j'1 �� ^'� 0 (11-lO STREET Q CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# TDAYSOF OPERATION t`TM { .. ;='Monday , duesday€ W_ednesday vl, °Thursdays t Fdtlayh S,atu day ,,v„`, t,`Suniia;, „: ; HOURS OF OPERATION eel �rA�A4 �t�( Please write in time of day. "�Aul- Vt'vl—II f'"' �'" '—f I ” For example 11 am-11 pm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 --------------------- - - -- ----- ----------------------------------------------- ----- RESTAURANT ES NO less than 25 seats 1 (Outdoor Stationary Food Cart$2 i I 25-99 seats -$2 ^ more than 99 seats =$420 BED/BREAKFAST/ YES N $100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE ® NO 25 TOBACCO VENDOR YES dfd $135 ALL NON-PROFIT(such as church kitchens) YES N $25 Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment, i 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 MGL Chapter 62C,Section 49A,I certify under the pains and penalties or perjury that I,to my best knowledge and belief,have filed all state tax returns ai II at taxes required under the law. 0 Z S--7 / A 3 SignaSigna u� Date Social Security or Federal Identification Number Revised 10/7/11 FOODAP2011.adm Check#&Date p I t�I I � $ �S•d� t Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE,PRINTED: 01/04/2010 ESTABLISHMENT NAME: Jaho Coffee&c Tea File Number:BHF-2005-000040 6 Harrington Court SALEM MA 01970 LOCATED AT: 0197 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0025 Jan 4,2010 Dec 31,2010 $140.00 ESTABLISHMENT Total Fees: $140.00 i PERMIT EXPIRES (Deeember 31, 2010 Board of Health i This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page t i • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR - DGREENBAUM/7U=.SAMM.COM DAVID GREENBALim, . ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT ' NAME OF ESTABLISHMENT ��O 1 1 ed� TEL# ADDRESS OF ESTABLISHMENT t' 7 Clea I I FAX# MAILING ADDRESS(if different) EMAIL- Business': it n-- o a, C At^n Website: WWW• Ado Cows OWNER'S NAME fttn5 / a�'.,( TEL# ADDRESS 6 W"MI 6 0 QlZ� A 0 L) STREET r CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) !'t to 01�-V OD.V 5 CERTIFICATE#(S) �i2S JIZ (Required in an establishment where potentially hazardous food is repared) EMERGENCY RESPONSE PERSON A\—i'1 HOME TEL#_k 1 11S-oKi 7 DA13S'OFO„PEIiA5710NMplv1 Z Bay iTuesday '. Wed_n`gs�ayThursdayi , .Fn�ay` Saturday ,p,, Sitnday ` HOURS OF OPERATIONf I Please write in lime of day. ! I M (`IAM-il 1 M ”—IAM--II0A1 IN 11 M ,?AM- IPPA !SArot_I,�(?M For example 11am-11 I i. TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -------------------------------------------- -------------------------------------- ----------- --------------- RESTAURANT ES NO less than 25 seats 4iAy (Outdoor Stationary Food Cart$21 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME - - - - ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to GL Chapter 62C,Section 49A, I certify under the pains and penalties of perjurythat I,to my best knowledge and belief,have filed all state tax returns 77id all st a taxes required under the law. Si e ' Date Social Security or Federal Identification Number. - -------------- ------,-7--r------ Revised 424/07 424/07 FOODAP2008.adm Check#&Date $rt10.0� Commonwealth of Massachusetts E City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2008 i ESTABLISHMENT NAME: Jaho Coffee & Tea File Number:BHF-200"00040 6 Harrington Court 4 SALEM MA 01970 LOCATED AT: 0197 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009.0241 Dec 29,2008 Dec 31,2009 $140.00 ESTABLISHMENT i FROZEN DESSERTS BHP-2009-0242 Dec 29,2008 Dec 31,2009 $25.00 Total Fees: $165.00 PERMIT EXPIRES December 31,,2009 i Board,of Health I i This Permit is not transferable and must be relssued 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 i i r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4w FLOOR TEL.(978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 N AYOR IDIQNNE mLEnt.Cofvf JANET DiONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Jaho Coffee & Tea TEL# 978-744-4300 ADDRESS OF ESTABLISHMENT 197 Derby Street FAX# 978-744-4300 MAILING ADDRESS(H different) EMAIL-Business: info@'j.,aho.com Website: www.jaho.com , OWNER'SNAME Anil Mezini TEL# 978-223-8982 ADDRESS 6 Harrington Court Salem MA 91970 STREET CITY STATE ZIP a CERTIFIED FOOD MANAGER'S NAME(S) Anil Mezini CERTIFICATE#(S) Ll U( _.) 15-L (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYS OF OPERATION I Monday_ ?u�day Wednesday I Thurs _;FdI Saturday I Sunday HOURS OF OPERATION 1 I Reese wide In fuse of day. 7AM-11PM 7AM-11 Ph11 7AM-11Pt 7A!4-11P 1 7AM-11PI� SAM-11PMI SAM-lOPM {Forezampellam-11pnI I f { � TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.1t. =$70 1000-10,000sq.fL =$280 more than10,OODsq.ft. =$420 --._........_...................... -- ----14 - "". - ----.---..............-.. .._..... ----..........-'---...,`•-'...,,-,,... .... RESTAURANT YES NO less#tan 25 seats 140 (Outdoor Stationary Food Cart$210) 2599 seats =$ 80 more than 99 seats =$420 BEDIBREAKFAST! XES NO $100 CHILDCARESERVICES............................••---••^....... ......------....................--.-•' ADDITIONAL PERMITS MAKE(not just serve)ICE CREAM,YOGURTISOFT SERVE (a NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 i `Reese pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Penult must be posted In a prominent location in the Establishment In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 82C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax return and aid all slate taxes required under the law. z "✓"_7 87-0745151 Signature Date Social Security or Federal Identification Number RevtsW4)24t07 FOODAP2008.adm ...Chink#&Date�`--6,,,,.1-- O�S S 00•-^ :�� . 't_ -.....,„y�;�M�`�„/'Citi}a$+�.,��':$...kq.yY.�W-ti+k`�'�P�`d A,"..�i�w'x'+� •,,.,... - w,yv-r., ..t.a�.�+,;, .1 1a'l,�,io1'P�•ir7.�ri!`''k �. Massachusetts Department of Public Health Salem Board of Health 120 Washington Sreet, Division of Food and Drugs Salem, MA 01970-t35234 1h 190-35234'"Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name + Date T e of 0 eration s Type of inspection �I'1() PO l y Food Service Routine Addressa / __ Q 0 Risk Retail Re-inspection SAV \ Level ❑ Residential Kitchen Previous Inspection Telephone Q--� C/ , i ( a ❑ Mobile Date: Owner �(,� `1 HACCP YIN ❑ Temporary ❑ Pre-operation Pf M ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑❑General HACCP Complaint f� q^�� //-- Inspector tr 7�J�� (-A pui I (LW Permit No.� c�V ❑ Other Each violation checked requires/an explanation on the narrative pages)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),Q 590.009(F),E' action as determined by the Board of Health. 'FOOD PROTECTION MANAGEMENTa.'„;'m` w-„:.,„."„,,.»,„„'„�-c f bjV12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties / fy J ❑ 13 Handwash Facilities EMPLOYEE HEALTH ` ;gym. £,„. VPROTECTION FROM CHEMICALS `°"i'"' ";` "' E] 2. Reporting of Diseases by,Food Employee and PIC .e _,�� _'••�'�u � ! � r'= ��'.nr dn,.L_• E] 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives a ❑ 15 Toxic Chemicals Ok �'FOOD FROM APPROVED SOURCE.„„„,*� ,;,{.,� ❑ 4. Food and Water from Approved Source a rTIMEITEMPERATURE CONTROLS(Potentlally Hazardous ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating OK ❑ 7. Conformance with Approved Procedures/HACCP Plank El 18.Cooling r PROTECTION FROM CONTAMINATIONS a , `��` `' ,f` ` Vii. El19. Hot and Cold Holding �] 8. Separation/Segregation/Protection r [120.� Time As a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing , j( /` !REQUIREMENTS FOR HIGHLY SUSClPTIBLEPOPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing 11. Good Hygienic Practices CONSUMER ADVISORY;tmivMJK7'MF s. A=4 ll ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below ' by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(5so.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.000) 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:59JlnspecfFomi6lC.tloc `-I Inspector's Signature*_6"j,,_;nom" U I Print: ( t _i An PIC's Signature: �I--'Cf�_X ` Print: 1�J �� Page of 2Reges l� ti Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 'I I 59f).003(.A) Amii meet of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTEFo(xls* 2-103.11 Person in charge--duties Contamination from Raw Ingredients 3-302A I(A)(2) Raw Annual Foals Separated frorn Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Prosection* a nccants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact.with Equipment and Applicant To Report To'rhe Person In Utensils* Charge' Contamination from the Consumer 590.(H)3(G) Re ortiM,by Person in Charge* 3-306.14(0)(B) Returned Foal and Reserviee of Food* 3 590O03(D) Exclusionsand Restrictions* Dispos@ion of Adulterated or Contaminated - 590.(03(E) Removal of Exclusions and Restr et ons Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food` 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.1.11. Manual Warewashing-Hot Water 3-201.12 Foal in a Hermetically Sealed Container* Sanitivition Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.14 Fg=s and Milk Products,Pasteurized* 4-501.114 Chemical Sarritization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5401.11 Drinking Water from an Approved System* 4-601. I(A) Equipment Foal Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4-602.1 L Cleaning Frequency of Equipment Nood- 590.006(B) Water Meets Standards in 310 CMR 22.0* * Contact Surfaces and Utensils Shellfish and Fish From an Approved Source 4-702.I 1 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authorft 2-301.11 Clean Condition-Hands and Arms* 3-20218 Shellstock.Identification Present* 2-301.12 Cleaning*Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices g Receiving/Condition 2-401.11 Eating.Drinking or Using Tobacco* 3-202.11 PRFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package kite it y* Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained' Em to ees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible - 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5204.11 Location and Placement* q Conformance with Approved Procedures 5-205.1 J Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 S ecialized Processin Methods* Devices 3-502.12 Reduced ox gen packaging,criteria* 5-301.11 Handwashin Cleanser,Availabilit 8-103.12 Conformance with Approved Procedures' 6-301.12 Hand Drvin Provision Denotes critical item in the Weral 1999 Food Cate or 105 CMR 590.000. CITY OF SALEM � n BOARD OF HEALTH Establishment Name:,GAkn ,,l A—torl Date: Pager of c Item Code C •Critical Item V - DESCRIPTION OF VIOLATION/PLAN OF CORRECTION T, Date .No Reference R,',Red Item *, " f t- 'r Verified �A.✓xd'. stJ,Fn. = ", `.. ,;r'8= /,m .v •z nUen(.�..ra rs '�. ry PLEASE PRINT CLEARLY'*' - 'r = - 1 111 A Yn ��tn•�1 i,l Jllrm �I lnl1� 1 Onn_n� 1K .1� l�YOf-:, C \ F) (�J anr. -"�A n .,c'��r n C_,0 — '!;l i .!„ a�� -17_1/.'0 _11'-'A ilii JV a\O 1 :0 A A /7/� f/ _q --Ir- d'..Y �(A'� 'V !0/1A r.{�,�Ain . �A� ) //1/1 n 'A / / V �/If1 �/�n P� /P A PAdA 1'P�� I/L_)44A 'O ,i � AAIK /U -tom!/, /r A,) AI -, + A10 (/AI LPO J C. / /Y 40 010A1 l;ah c(, \Q P, J-0 �'Y� n A"'h/,IAAA nrinA C'94.�.a - - - I Discussion With Person in Charge: Correct' a Action Required: ❑ No Yes { oluntary Compliance ❑ Employee Restriction/ l4 I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: tares —5ulA4(0 PJTFs Received aT pera Toro Violations Related to Foodborne fitness Interventions and Risk Accrording to Iaw Coated ti Factors(Iterna 1-22) (Cont) I I T145°F Wirtfin 4 Hours. PROTECTION FROM CHEMICALS TT-- CtK3111111 kl(Aho&far PHN L!-9 �2(- 1 T--fAfidTt ! PHF Hot and Gold"ding 1=4 Food or Color Additives + 1501.l6f B) Cold PUN Maintifined at or below7, - - 590,0014F) 41�45' F� T5ii 14 Protection from], od I 3-501,16(A) Hot pl-IFs'Kentaille'd at or above Poisonous or Toxic Substances �40'1`. I -s a-f�1w,"Z f,f t f on "—L Rfiigir field at or aiz-s I—,0h Containers' 1 2(L Time as a Public Health Control r-102.11 CommonNarac Workii) L �l-I 7-20 L I i 'i9 T i in e,as a P a b I i, I I e a I t It C ii. o — -S�pa, V�r ?-20111 Rest,icion-Ffescifoe and Use 7-202.12 colldiflm�of Use (5 f F,,i -- REOUIREMENTS FOR HIGHLY SUSCEPTIBLE conadrim -- Proldbi,�orf�'� POPULATIONS(HS 7-2(4.11 Saratizes,Crneri�i -Oiviaiols* [-FI7--, x n, 1-11-A)- Unpmlcurizcd Ne-rad:aged Juices and 7-204.12 Chemicals for Nvasbl�E lievemses with Walai 7 4IG4,14 Dr�ul, Aiierac.Criteria" I I Incite -2(f'i,111 Incidental Fox]Contaij.lairwicants' —1.71—(D) Raw of Ptfn61ly Cis)k,d Amin d Fotyj and 206.t it L Pe nude Crits;i)* ervc.d. OG.In R�tIefll Beisuhwm" 1711(C 1 Unomned rkxxi PaL,k Tracking Powders,Pest Control and CONSUMER ADVISORY 7 22 3-00', 11 Panted fix Consomption of TIMEITEMPERATURE CONTROLS lI OThat are Raw, Undemfolicei or 36 Proper Cooking Temperatures fW- 1,et Qtlwrwiso ffrccessed to' Iiafimtw PHFs 3 QL 1110 10(z} I-, jP,Ltho,�ens �ggf,- 155'F 1.5 S,�C. 145'1`15secl --43-t,2,1-3 Eag.�Su6nnav for[taw Shell Comminuted fish,Meats& Game Anti ds- Li,e'F 15 svC. � — SPECIAL REQUIREMENTS _75iA l(if)t I f12) Puck and Beef kozim 1-70-Fi il minx — q9i) 3-401.11(,%)(2) #9tt13 s17} violwiows of Section 590.009(A)-(D) in catornip v c. mobile fwd,temporai v and resident at kitchen offeiations should be Fish; Mea stuffin Cofamain Fish; debited under the appropriate,sections a � l, _IL)ultr,v or Ratitc165"Tifiscc. above if related it)foodborne illness whole-malole IZ—act Beef—Sicaks-- inter vemions and risk faclon, Other t45"F* —. 1 590.009 violations relining to gcxid retail 3-40L 12 Raw Aniatai Food,,,Cook in a practices, should be debited under#29 - Microwave 165,F special -, -lY1- - - ---L -- I iV[Other ffl*'�- 145'F 15 sec, —1 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES -14— 011]iA)&fl)) Ilf-lbs 165)F 15 sec, (Items 23.30) 3-443.23(;$) microv,avc- 165,F 2 Milan'!skandin." Cravwlajed nori-cilical violafwffj: n4fich do nia elan,in life little, foodborne iltness iMervencivias and risl,jairors hited above. can be, 3-403.11(C) Cominfacially Pitxe�&ed RTE KKK- found fit thefsflotong sections of the Food Code effid 10-5 CATH 590.000, 3-463.1.I'E) Rcinamial, Un"i�i�ed Poctium(if flc-,cf -77� -6-6T lloam'0 and Persoinel -L�..... I MnallemnntLnd- - - I-,-- 24, 1 Ry:fdand Food Protecti i8 '-- Proper Caoilnfj of—PRFs 2 1 5, ------ I Equipalsint and Utensils F0 -4 005 7 01—1141%) -C(Kflii)2 Cwk(Af PHFs fi-orn IUff if) �� . -1 water- ------ ii6 I watel, F ,-5 006 70017 Within 2}fours and From 701' 1 27 -0-07- to 4J^T,,14` F Within 4 Him 26, Paisonousor-toxii:k/lateNals FC, -7 4008 b 29 Spmtal Rearemeni0091. . ) r ,m FromArnmen �T'fafLaaircIngredientslo41"F145°F other ------ ....... Wi tl fin 4 flmrO iiem in tov r Itq,tl iYN FoMGAf-T R15(-MR 5900% 0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (978) 744-4300 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑i RED Owner: mment:Cutting board stained and scored.Flip over and use other side,or resurface or replace cutting board. Anil Mezini Violations Related to Good Retail Practices (Blue Items) PIC. Food and Food Protection FAIL Critical BLUE _Anil Mezini Inspector: iedomment: Inside panel of ice machine has accumulation of grime.Thoroughly clean and sanitize the panel. Elizabeth Salandrea Equipment nd Utensils FAIL Non-Critical BLUE Date Inspected:Correct By: mment:Victory freezer needs general cleaning. 3/28/2008 - ---- - - - Risk Level: �rmer under oven needs general cleaning. 0/0"ur bin not labelled.All dry ingredients not in original packaging must be labelled-flour bin labelled at time of inspection. Permit Number: Victory fridge needs general cleaning. BHP-20.0.8-0269 status: toaster has build-up of food debris inside.Thoroughly clean the toaster. _VIO_LATION _ Vro s used at toaster must be stored in a dedicated container or hung up,and not left on surface in front of toaster. _WW Critical Critical Violations: 2 oor tracks of desert case need general cleaning. Time IN: Time OUT: GENERAL COMMENTS: Urgency Description(s): Reinspection in one week, all violations to be corrected. BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 02,2008 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 02,2008 ) Page 2 oft ° CITY OF SALEM PUBLIC PROPERTY DEPARTMENT M\„ns 120\\'psi uu:ION Srei;i-r . It 1-1 o i 97u 'ri-i;978-745-9595 * F:\s:978-7-Iii 9846 VIOLATION NOTICE PROPERTY ADDRES DERBY STREET July 2, 2008 RECEIVED Mr. Anil Mezini RECEIVED �( 197 Derby Street 'JUL 2"2009 Salem, MA 01970 CITY OF SALEM BOARD OF HEALTH Dear Mr. Mezini: This letter is to notify you that placing tables and chairs outside of[ Jaho Coffee Shop the Derby Street sidewalk is a violation of Salem City Ordinance 38-7. ou are ereby ordered to remove said obstructions immediately.. While there is in Salem a procedure for permitting an Outdoor Cafd, that procedure only applies to the Salem Redevelopment District. 197 Derby Street is outside that District. Si e y, omas E. McGrath, AIA Assistant Building Inspector/Local Inspector CC: file ealt , Fire Prevention, Mayor's Office, Councilor Pinto s. Commonwealth of Massachusetts City of Salem Board of Health . Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 FoodMetail Establishment Permit DATE PRINTED: 01/07/2008 ESTABLISHMENT NAME: Jaho Coffee & Tea File Number:BHF-2005-000040 6 Harrington Court SALEM MA 01970 LOCATED AT: 0197 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0154 Dec 20,2006 Dec 31,2007 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 4 of 6 CITY OF SALEM, AWSACHUSEM c BOARD OF HEALTH 120 WASHINGTON STREET,4T FLOOR TSL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR ISCOTTna SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION/F'OR PERMIT TO OPERATE A FOOD ESTABLISHMENT q NAME OF ESTABLISHMENT � �j W rPS 140\, TEL# ADDRESS OF ESTABLISHMENT ` /L S A2k4 FAX# MAILING ADDRESS(if different) 9 EMAIL-Business': �'At l 1 No rC it • Website: WWW �U�Io ca& OWNER'S NAME tri/ m�o^ t TEL# �2 ADDRESS b G1Wrl "cQ � C AuJC Q 70 STREET //�� CITY STATE / / ? ZIP CERTIFIED FOOD MANAGER'S NAME(S) F�tJ XU_ -; CERTIFICATE#(S) (Required in an establishment where potentially hazardous food its prepared) EMERGENCY RESPONSE PERSON r ; I }t'� t HOME TEL# DAYS OF OPERATION 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION Please write in time of day I _7iQ-t/1 IIfM 7AM-u QM "1,n M_II�M; `lAM-IIPN! �/�M-IIP SAM- IIPM a/fA'1- IJ�M For example Ilam-11 m TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 .......--- - --- ------------- .. ....s'----- -- -' RESTAURANT ES NO less than 25. eats---------- (Outdoor Stationary Food Cart$.210) 25-99 seats =$280 more than 99 seats =$420 -------' ------------ S------------------------- ------------------------------$06------` BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES ------------------ ---------------------------------- - .............--- -- . AITI DDONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE ESQ NO TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax return , d pai all s ,,l//taxes required under the law. nature ate Social Security or Federal Identification Number --------------------------------------------------------- I� ✓ '-- --------$— -------------- --------'------- Revised 4/24/07 FOODAP2008.adm Check#&Date - 0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (978) 744-4300 Food Contact Surfaces Cleaning and Sanitizing PASS Critical RED Owner: Comments: Knife fond in knife rack with accumulation of food debris. Thoroughly clean and sanitize knives after each use. Anil Mezini PIC: Handwash Facilities PASS Critical [j RED Anil Mezini Comments: Back hand wash sink obstructed. Hand wash sink to be free and accessible at all times. Inspector: John Gehan Violations Related to Good Retail Practices (Blue Items) Date Inspected:Correct By: Equipment and Utensils PASS BLUE 8/13/2007 Comments: Front Beverage unit requires general cleaning. Risk Level: coke unit has no visible thermometer. Provide visible and accurate thermometer. Permit Number: Sandwich True unit requires general cleaning. BHP-2007-0154 Status: True unit beneath coffee station requires general cleaning. SIGNED OFF Cadco hot plate requires thorough cleaning. #of Critical Violations: 0 Belshaw unit requires general cleaning. Time IN: Time OUT: Shelf left of ice machine requires general cleaning. Urgency Description(s): Victory freezer requires thorough cleaning of bottom. BLUE: Victory refrigerator next to desk requires general cleaning. Violations Related to Good Retail Practices (Critical GENERAL COMMENTS: violations must be corrected All violations from August 6 have been corrected. immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 13,2007 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 13,2007 ) Page 2 oft I ~ 0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (978) 744-4300 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical 0 RED Owner: t:Knife fond in knife rack with accumulation of food debris. Thoroughly clean and sanitize knives after each use. Anil Mezini � PIC: Hand hB Facilities FAIL Critical v/j RED Anil Mezini Comment: Back hand wash sink obstructed. Hand wash sink to be free and accessible at all times. Inspector: John Gehan Violations Related to Good Retail Practices (Blue Items) Date Inspected:Correct By: Equipment and U ens'ils FAIL BLUE 8/6/2007 mment: Front Beverage unit requires general cleaning. Risk Level: __S-qkeunit has no visible thermometer. Provide visible and accurate thermometer. Permit.Number: andwich True unit requires general cleaning. BHP-2007-0154 Status: Tr�ue unit beneath coffee station requires general cleaning. Open c hot plate requires thorough cleaning. #of Critical Violations: lsha 2 ew unit requires general cleaning. Time IN: . Time OUT: ! -,Shelf lett of -machine requires general cleaning. Urgency Description(s): eezer requires thorough cleaning of bottom. BLUE: 7V,f_Ct00yryr(frigerator next to desk requires general cleaning. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 06,2007 ) Page ! of Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 06,2007 ) Page 2 of `0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (978) 744-4300 1 Handwash Facilities _ FAIL ❑d RED Owner: Comment:Employee restroom has"out of order"sign on it. Repair restroom to proper working order. Anil Mezini PIC: . Public restrooms are missing employees must wash hands sign. Provide signs. Anil Mezlnl _ "'C The sink on the right of the coffee bar has no working hot water. Repair sink to proper working order. Inspector: Violations Related to Good Retail Practices (Blue Items) John Gehan Food and Food Protection FAIL BLUE Date Inspected:Correct By: Comment:There are dry goods and food products stored directly on the floor in the back and in the storage areas. All items must 2/6/2007 _ be 6-8 inches off of the Boor. Risk Level: Equipment and Utensils FAIL BLUE Permit Number: L_Com'ment: Sandwich true unit requires general cleaning. BHP-2007-0154 Status: rue unit left.of juicer requires general cleaning. i Openeke refrigeration unit requires general cleaning. #of Critical Violations: 1 /Unit beneat offee barvrequires general cleaning. Time IN: Time OUT: eneath coffee condiments area requires general cleaning. Physical Facility FAIL BLUE Urgency Description(s): BLUE: Comment:;The entire establishment requires organization of storage areas. Violations Related to Good -� Retail Practices (Critical GENERAL COMMENTS: violations must be corrected immediately or within 10 ner to have extermination reports readily available at re-inspection. days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 06,2007 ) Page I oft < Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 06,2007 ) Page 2 oft �f 7 O O QOD COD D ° <e O O a' D ] 1�_l 00D CoD O O I _ - � N � =o N COD COD DOD I1r^✓) l r d CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH + s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL, 978-741-1800 FAX 978-745-0343 Kimberley Driscoll %VwW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATtI;ON FORPERMITTO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT (1lVt7� � } C��O� TEL# �� -1 — tC, O ADDRESS OF ESTABLISHMENT Pl \1 * FAX# MAILING ADDRESS(if different)f ( ! EMAIL--Business':A" I *O.ikta d-COLI" _ Owner's: At$'t l VA a t ,fGtn t OWNER'S NAME 4 0'J I I/1 it — TEL# Ok'7t9 -2 "8't c ADDRESS {j H4JPi"e6In if4 . <dte t #1 00.70 STREET 14 /A� / CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) oto i� NIQ-2-i to { CERTIFICATE#(S) (Required in an establishment where potentially/�haz1ardousdf000d is prepared) �} EMERGENCY RESPONSE PERSON 1 Mil I�E`�tyl + HOME TEL# 'i7I OAYSOFOPERATiON Monday Tuesday wednesdaY Thursday Friday Saturday Sunday Pieasew RouxsoFeIntimIox 1/#-11 70,11PM JAN-liPM ` AM-t14il? tr7*t I(fm "VA-110 S -(Of n[eindmeeiday. lFer example Ilam-him) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 _- -- - RESTAURANT ES NO �Ipcc t�75 seats =$100 25-99 seats more than 99 seats =$200 _._.. - _............. .. - - ----... .... .$"1_0_0_ .10_0------ ---.-... ... . ---.. .... -.. ---. . - BED/BREAKFAST YES NO ------ ----- ---..__... -------...... ....._..._-.... ....._..... ......---- ...... ........ ........_..... - __ ------- .---- .. ADDITIONAL PERMITS MAKE (riot just serve) ICE CREAM, YOGURT, SOFT SERVE ES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant toMG Chap er 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fil d all to to et s and paid all state y taxes required under the law.. DIS 0 06 SRat Dae Social Security or Federal Identification Number __.. ____.____..__ _.._.-----.._____-___-------- _—_.J_________________.___...._____..-____.._ -----------..____. -..-_______________...____.._____..____...______._ Revised 11/13/06 FOODAP2007.arm Checkq 8 Dale/_667 UI/j (�5.QQ !l kk M'°�3, •rC cr � ; ¢ '•',a"� . 1 monweal Comth ofM- r ter ,C YZ 1 1 ''�' ��, i ` 2& +t.-«+4'`.2 'kS', ^'' ' s41,''.frs•evl:3{ A�3•;�:*4'xa,.jy�t t '«§*'x 3 f'+ir'2'xa^i':Pl"' y` ,f+ S,COf Salem ity 3} .� t • §i' -,� Fj Ty }r t r� Board Of Health a� ') rlumbelie D �1 -E k 120 Was Street,4th Floor1 MByoYf nscoU SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Jaho Coffee & Tea File Number:BHF-2005-000040 6 Harrington Court SALEM MA 01970 LOCATED AT: 0197 DERBY STREET SALEM, MA 01970 `Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0154 Dec 20,2006 Dec 31,2007 $100.00 ESTABLISHMENT Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 8 of 16 0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone ,r � § A` {'_r Violations Related to Good Retail Practices (Blue Items) (978)744-4300 Food and Food Protection FAIL BLUE Owner: Comment:Various items stored on meat slicer. Remove item and clean and sanitize slicer. Anil Mezim �t PIC. "4 Accumulation of grime on inside panel of ice machine. Thoroughly clean and sanitize panel. Anil Mezim )AI,- Small true unit by front handwash sink has uncovered foods. All foods in storage must be covered. Inspector:u, `+x Equipment and Utensils FAIL BLUE John Gehan En Comment: Mo stored incorrect) Mo to be stored so that it is allowed to air d Date "'" Correct By: p y' p dry. h .. Belshaw oven requires general cleaning. Risk Level: True unit beneath coffee area missing thermometer. Provide visible and accurate thermometer. Permit Number'x Coffee area requires general cleaning. ;BHP-2006-0116 Small sandwich unit requires general cleaning. Status: , ° �' Ice cream unit missing thermometer. Provide thermometer. Open #of Critical Violations Front Beverage unit requires general cleaning. Time IN „�-? Time OUT: Sanitizing log missing feom September. Log to be maintained daily. ! v Urgency Description(s): GENERAL COMMENTS: BLUE:- 816: Violations Related to Good' Retail Practices (Critical violations must be corrected immediatelyor,within 10 days)(NonI-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 14,2006 ) Page 1 oft Item Status Violation Critical Urgency RED: '# ; r Violations Related to Foodborne Illness Interventions` and Risk Factors (Require, irrimediate corrective action) '' City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 14,2006) Page 2 oft CITY OF SALEM BOARD OF HEALTH / Establishment Name: �Jt t ` V l�/� Date: 51 )610/t) Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION nate r No. Reference R—Red ItemVerified PLEASE PRINT CLEARLY. 11 f �f r /44A, Vwhtab;;,�<2' L f. U1 W. r a d s l� r t Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct all 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 9ode. I understand that is noncompliance may result in daily finesoftwenty-fi e dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �/lJ ❑ Voluntary Disposal LlOther: 3-501 11, PHFs Received at Temperatures Violations Related to Foodborne Iciness Interventions and Risk According to Lanw Cooled to Factors(Items 1-22) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHP, 14 Food or Color Additives Iy PHF Hot and Cold Holding 3-50t.16(B) Cold PFiFs Maintained at or below 3-202.12 Ad 'x 590.004{B) 41`145°F* 3-302.14 Protection Ufon from Unapproved Additives* 1g Poisonous or Toxic Substances 3-501.16(A) Hof PHFs'Maintained at or,,have 140°F. 7-101.11 Identifying information-Original 3-501.1.6(A) Roasts Held at or above 130°F. Ctimtainers" 7-1021 1 Common Name-Working Containers* Time as a Public Health Control 7-201.1 l Separation-Storage` 3-501.19 Time as a Public Health Control* 7-202.1.1 Restriction-Presence and Use* 590.004(1-1) Variance Re. uiremenC 7-202.12 Conditions of Use"`- _ 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chenacrls* POPULATIONS(HSP) 7-204.12 Chemicals for Washin Produce,Cr{retia* 21 3-801,11(A) Unposteucized Pre-packaged Juices and 7-204.14 Dr'in guts,Criteria" Beverages with Warvin;Iahets* 7-205.11 Incidental Food Contact.Lubricants* 3-801.11(13) Use of Pasteurized Eggs* 3-801A 1(D) Raw or Partially Coked Animal Food and 7-206.1 1 Restricted Use Pesticides.Criteria* Raw Seed S xouts Noe Solved. 'x 7-206.12 Rodent Bait Stations* 3-801.11{C) Unu ened Pool Packa Not Re-served. " 7-206.7 3 'Cracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods"Chat are Raw, Undercooked or PHFs Not Otherwise Processed to Eliminate , . a u• rr^ooi 3-401.1]All)(") Eggs- 155"F 15 Sec. Pathot•fIlS F qe-hunnedtatc Service (.45`P15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Cormarnuted Fish,Meats&Game E gs* Animals- 155°F 15 see * 3-401.11(13)(1)(2) Pork and Beef Roast- 13WF 121 min* SPECIAL REQUIREMENTS " Ratites,Injected Meats- 15SF t5 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 PRFs, residential kitchen operations should be Stuffing Contain ng Fish,Meat, debited under the appropriate sections Pouitry or Ratites-165".F 15 sec. *` above if relatedto foodborne illness 3-401.11(C)(3) Rfiole-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 PHFs-1.45°F'15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(.A)&-(D) PHFs 165°F 13 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing C iticai and non-critical violations, which do not relate to the 3Tune, .foodborne, illness interventions and risk factors listed above., can be -403.11(C) Commercially Processed RTE Food- .found in the following sections of the Food Code and 105 CMt2 140°F'* 590.000. 3-f03.].1(F) Remaining Uusliced Portions of Beef ttom Good Retail Practices FC 596.000 Roasts" 23. Maga ement and Personnel_ FC-2 .003 Ig Proper Cooling of PHFs 24. Food and Foe Protection FC--3 A04 _ . _ 1-501.14(A) CoolignCooked PHFs from t40°F to 25 Equipment and Utensils FC 4 00526 Water. Piumbing and Waste FC 5 .006 _ 70°F Within 2 Hours and From 70°P 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) Coolim,PHFs Made Prom Ambient ?9- S ectal Re uirements mg Temperature Ingredients to 41'1,-/45'F 30. Other Within 4 llours:` ssnro,,:ma*e-zaw *Denote,crstical item in the federal 1999 Food Code or 105 CMR 590000. I od CpIt ci uT a ;`\ ,. � ` \ � �i �� i � �� A _ t! '� � ,\ � � , � �' � �� i �� \� � � �� \ +` \ 1 i �, `� � t � � 1 � �� i A � �� ', 1 � � �� V �� \ � � ' � \`�, , , ; � �- � � C��' , � : n6r- -c� - .�,�� -- �, ��-� � �v� �- �,� l ��n�v 4;1=�� - ll..��/fin lJl !t- -b� 4 i i i it i i I i i I i K-oJ i a-utc?-ee. �� A - - j ' �, � \ `,, � ' r ` � � � � �{ � � 1 � � t ` � � 1 � � �'� �i i LTb6� 0 -9 f)-o'- - c _l I , s I } C Is/ — I --- V"�I� __- -- -- --- - �- I.. ._._- - - - - ---_ -- - .. -_- � -----I i CITY OF SALEM ?.. BOARD OF HEALTH f C Establishment Name: �r tv �P� 1 it P Date: Page: of ;t Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date r No. Reference R—Red Item Verified PLEASE PRINT CLEARLY YZAD z 1 't .IS ( -pCIA Q A43 d ctrl ti � c J � INP c C21 rCA I A i �� - aon, vi -� aid lno 1 C\ 1 44 - dalI n V f)ryi . _ DI: 2 2 1 }� IP5 , Eyve ' L Y k e5t7_ _ ' crn_ _ 1 J re C� n� 1 bU - � p Y 3 24A n0 } Discussion With Person in Charge: 'G'A"2te ?foer 1W w 0 S.'ph I Y1 Corrective Action Req ire dc ❑ No ❑ Yes I have read this report, have had the opportunity to ask ques ions an�daa e f'o correct all ❑ voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Emersion =� P C3 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 twer�lfy�doollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. // t ` ❑ Voluntary Disposal ❑ Other: v V ,-50114(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont) 41"F/451F Within 4 Hours." PROTECTION FROM CHEMICALS 3-501.15 Coolies Methods for PIFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-'oL16(B) Cold PHFs'Maintained at or below _ 3-202.12 Additives* -7 41V45° F* 3-302.14 Protection from I7nar.wved Additives* 3-501.16(A) Hot FIIPs Maintained at or above is Poisonous or Toxic Substances 40°F. 7-101.1l Identifying information-Original 3-5p1 J.6(A) Roasts Held at or above I30°F. Containers* - 7-102.11 Common'Name-Workinu Containers* F20Time as a Pubhe Health Control 7-20LU Searaiion-Storaee' 3-501.19 'Time asa Public Health Cuntrot* 7-202.'(1 Restriction-Presence and Use'' a90.004(H) Variance Ra-uirement 7-202.12 Conditions of Use, 7-203.11 'Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP) 7-204.12 Chemicals for W hihine Produce,Criteria` 21 3-SO 1, Unpasteurized Pre-packaged Juices and Beverages with Wamine Labels* 7-204.14 Drying ends,Criteria` - 7-205.1.1 Incidental Foot)Contact,Lubricants* 3-501.11(B) Use of Pasteurized Fees* 7-206.1 I Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Foot and Raw Seed S coats Not Served. .F 7-20G.12 FrackingRodent Powders,att Pe 3-5(11.11fC) UnopenedFood Package Not Re-served. " 7-206.13 'Tracking Powders,Pest Control and i4onrtorin<* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consmner Advisory Posted for Consumption of Annual Foods'lbat are Raw,Undercooked or 16 Proper Cooking Temperatures for PHFs NNotOtherwise Processed to Elirmnate 3-40 1.t 14(1)(2) Eggs- 155°F 15 Sec. Path cns 'r°`""`'�"roar E >s-Immediate Service 145°FlSsec* 3-102.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Came Eggs* Animals-155°F 15 sec. * 3-401.1l(B)(1)(2) Pork and Beef Roast-130"F 121 nun* 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 sea * entering. mobile food,temporary and 3-40L l I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish, Meat, debited under the appropriate sections Poultry or Ratites-165"F 15 sec. *= above if related to foodborne Illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Anitnal Foods Cooked in a practiees should be debited under 7129- Microwave 165"1- * Special Requirements. 3-40 L1I(A)(1)(b) All Other PIFs- 145'F 15 sec. I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(x)&(D) PHFs 165°F 15 sec. " (Items 23-30) _r403.11(B) Microwave-165°F 2 Minnie Standina Ci-tical mut non-critical violapoin,which do not relate to the Timesfoodborne.War. s interventions and tisk-j actors listed abore, can be I 3-403.11(C) Commercially Processed RTE Food- found in theft)/towing seclions of the Food Code and 105 CMR '140"F* 590.0©U. 3-403.11(E) Remaining Unsficed Portions of Beef ' Item Good Retati Practices_ FC 590.000 ...] Roasts* 23. Manu ement and.Personnel__.__._ FC-2 .003 Ig Proper Cooling of PHFs 24 Food and Food Protection FC-3 x04 20. ,Equipment and Utensils FC 4 .0_05 3-501..1=1-(A) Cooling Cooked PHFs from 140°F to -26,- Water,Plumbin and Waste FG 5008 _ 70°F Within 2 Hours and From 70°F 27. Ph sisal Facility FC-6 007 to 41°F/45°F Within 4 Hours. * 28. Poisonous or Toxic MaterialsFC-7 .008 3-501.14(13) Cooling PHFs Made Front Ambient 29. S ecial Re uirements __ __ .009 Temperature Ingredients to4l"F/45°F 30. Other Within 4I-Iours" e s e,M7 - 'Denotes critical item 171 46e federal 1999 Food Code or 105 CNIR 590-000. CITY OF SALEM BOARD OF HEALTH J, / Establishment Name: ) ( Ol QJ Date: JV� 1-2d o(O Page: 1 of Item Code C-Critical Item c DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified `.M PLEASE PRINT CLEARLY -` - -- t to im1 A 4 F4 = srAqAr I r -ZL G i 1 UfjWCAV t c °_ �� will-) a ) / r4 N P I S 1i _('/ t o r 0. 11f1 F 1_ n kn t K o vio f I a - V I I - art 7 1 TI h C t S:hP — 1 I Q r 44 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension E comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily finesof ft ty-fide dollarsfor suspension/revocation of ❑ Embargo Ll Emergency Closure your food permit. 7� �� YYY `7`'( ❑ Voluntary Disposal ❑ Other: r. 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to Factors(items 1-22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cowling Methods for 1114Fs 14 Food or Color Additives 14 PHP Hot and Cold Holding 3-202.12 Additives'" 3-501.16(B) Cold PHFi,Maintained at or below 590.004(F) 41V45'F* Poisonous P 3-302.14 Protection hs or Toxic Substances from Unapproved Additives* 3-501 16(A) Hot PHFs Maintained at or above 40"F. * 7-101.11 Identifying Information-Original 3-501.1.6(A) Roasts Held at or above 130'F-* Containers'° 7-102.11 Common Name--Working(:ontuiners* 20 Time as a Public Health Control 7-201-I1 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 ItesCric[ian-Presence and Use* 590.004(H) Variance Req aremem 7-202.12 Conditions of lJse* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washine Produce,Criteria* 21 3-90'1.11(A) Unpasteurized Pre-packaged Juices and _ Beverages with Warning labels* 7-204.14 Dt t cots,Criteria* 3-601 11(B) Use of Pasteurized Eggs* 7-205.11 Incidental ntal Food Contact-Lubricants* 3-801A 1(D) Raw or Partially Corked Animal Food and 7-206.11 Restricted Use Pesticides.Criteria Raw Seed S rronts Not Served. :z 7-206.12 Relent Bait Stations* 7-206.13 Tracking Powders,Pest Control and 3-801.1](C) Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-003.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undorcooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.I IA(l)(2) Pegs- 1-55'F 15 Sec. Pathogens.* 1i gs-hhmhedtate Service 145°Fi Ssec* 3-302.73 Pasteurized Eggs Substitute for Raw She)] 3-401.11(A)(2) Comminuted Fish,Meats<&Game E s: Animals- 155'F 15 sec. 3-401.1l(B)(1)(2) Pork,Lord Beef Roast- I'U'F 121 min* SPECIAL REQUIREMENTS 3-401.1 I(A)(2) Ratites,Injected Meats 155".F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in see,* catering, mobile food,temporary and 3-401..1.1(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr,or Ratites-165'F I S s'w`. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beet 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 f{29- Microwave 165'F* Special Requirements. 3-40L11(A)(1)(b) All Other PHFs-145'F15see. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec. "` (Stems 23-30) 3-403.11(B) Microwave- 165"F 2 Minute Standing Citical and non-critical vfohnions, which do not relare to the Time` ,foodborne Wnes.s interventions and ristcfactors listed above„ can be 3-403.11(C) Commercially Processed RTE Food- ,found in rhe following sections of the Food Code and 105 CMR 't40'F* 590.000. 7403.11(F) Remaining Unshced Portions of Beef -Item Good Retail Practices_ FC 580.000 Roasts" 23. Mane ement and Personnel FC-2 .003 24Food anoodrotectio . Fd d FProtection—Ig Proper Cooling of PHFs FC 3 ' .004 25 Equipment and Utensils FC 4 J .005 3-501.14(A) Coobng Cooked P11Fs from 140'F to 26. Water. Plumbing and Waste -76--5 .006 70"F Within 2 Hours and From 70'F 27 7 Physical Facility FC-6 .007 to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials .008 _ FC-7_ 3-501.14{B) Crwliny PHFs Made From Ambient 29. _ S ©tial R uirements .009 "Pemperatnre IngredienCs to 41OF 30;_-__,__Other _ Withtn 4 IlourSs -.woro,,�en,-z,i�o "Denotes critical iter?)in Lhc foicral 1999 Food Code or 105 CNIR 590.000. �Y € CITY OF SALEM BOARD OF HEALTH / 2 Establishment Name:)\A� (�0?XP(2- Date: � l) to Page: J of ,T Item Code C-Critical Item 'DESCRIPTION.OF VIOLATION/PLAN OF CORRECTION Date F No. Reference R—Red Item Verified ". PLEASE POINT CLEARLY - YYI q \Argil fl C l I S n 2 - 1 ns:.pv -4- X) O 0G T r r ALU 1w o 4 F Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes F I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ i 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-fivAollars or suspension/rer v�ocatiio-n_ of ❑ Embargo, L3 Emergency Closure your food permit. �� ❑ Voluntary Disposal ❑ Other: 3-501.14(C`) PHFs Received at Temperatures Violations Related to Foodborne illness interventions and Risk Accoolife,to Iaw Cooled to Factors(items 1.22) (Cont) 41'.F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Conim,Methods for PHFs P,9 PHF Hot and Cold Holding 14 - Food or Color Additives 3-501,16(B) Cold PHFs Mairrained at or below .-203.12 Additives'K 590.004(F) 41°/45° 3-302.14 Protection from Unapproved Additives- -_ o�isonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 15 15 14WF, * 1 7-101.11 Identifying Information-Original =3-501,16(A) Roasts Held at or kibove 130'171 Containers* -5 Time as a Public Health Control 7-1.02.11 Common Narne-Working Cmtarners- F-2o V 3-501 19 Time as a Public Health Control* 7-201.11 Separ don-Storage'" _ 0 7-202.11 Restriction-Presence and Use 5190,004(11) Variance Reautrentent 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 toxic Containers-Prohibitions"` POPULATIONS(HSP) 7-204.11 Sanidizers,Criteria-Chcuricah,* a-- -Ti-Mot I(A) Unpastein ized Pre-packaged Juices and 7-204.12 Chemicals tLaWashinit Produce,Criteria* 7-20414 _pDarrL.Afents Craeita' I Beverages with Warnine I,abcls* 7-1105.11 Incidental Food Contact, Lubricants* 3-801,11(B) Use ol"Pasteurized Eg-s* 7-206.11 Restricted Use Pesticides.Criteria* 3-801.1I(D) Raw or Partially Cooked Animal Food and Raw Seed S gouts:VoC Served. 'n 7-206.12 1 Rodent Bait Stations, 3.801.11(C) 7-200.13 "Tracking Powders,Pest Control and - Monitoring, CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS3-603.11 22 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Amnnai Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A1,1)(2) E,,gs- 1.55'F 15 Sec. Pathoggens.* -10213 Pasteurised Eggs Substitute for Raw Shell 3-40IJ I(A)(2) Comminuted Fish,Meat,&Game Fggs* Animals- 155°F 15 sec. 3 401.11(B)(1)(2) Pork and Beef Roast- 130"15 121 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(:1)(3) Poultry,Wild Came, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish, Meat, debited Linder the appropriate sections Poultry or Ratites-165`F 15 see. above if related to foodborne illness 3-401.1 1(C)(3) IntactBeefSteaks Interventions and risk factors. Other 1450E 1: 590.009 violations relatin,,,to good retail 3401.12 Raw Animal Funds Cooked in a practices should be debited under /129- Microwave 165"F* - Special Requirements. 3-401,11(A)(1)(b) All Other PHFs 145'F 15 see. L17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES -3-403.11(A)&(I)) PHF,, 165'F 15 sec. * (Iten-iii 23-30) 3-403.11(B)B) Microwave- 165'F 2 Minute Standing Critical al and non-critical violations, ivinch do nut relate to the Time* ,foodborne illness interventions acrd riskjnctorx listed above, can be 3-4011 UC) Commercially Processed RTE Food- found in the fallowing sections of the Food Code and 10.5 CAIR 140"F* 590.000. 3-403.11(F) Reniainin,,,Unsficed Portions of Beef Item Good R00-Practices FC 590.000 Retail a '9 00 cane Roasts* 23. ment and Personnel-_. FC-2 .003 -protection FC;_3 00 a d Utensils 4 C)L) Ste �Ln - C 5 a � _Ma� ...onnel ------ 24� Food and Food Protection FC-3 .004 L_!o- Proper Cooling of PHFs .........t.. 25. Equipment FC-4 005 3-501 14(A) Cooling Cooked PHFs from 1,10'F to 26, Water,Plumbinq and Waste FC-5 '006 Ifty C_6 70'F Within 2 Hours and From 70'F 27. Physi- F -6 007 fhjs cal Facility _ to141'F/45'FWithin 4Hours. 28. Poisonous or Toxic Materials 3-501.14(B) Cooling PHFs Made From Ambient - Temperature ingredients to 41 017/450F -30, Other Within 4 FlOuri,* I Denotes critical item in the federal 1999 Food Cock or 105 CMR 590 000, Page 1 of 1 Joanne Scott From: SHuntgero@aol.com Sent: Friday, April 28, 2006 4:20 PM To: jscott@salem.com Subject: Became III after eating in Salem On Tuesday, April 25, a colleague and I split a chicken salad sandwich at a small coffee cafe near the Waterfront Hotel in Salem.The coffee shop cafe was on the same side of the street as the hotel and was just beyond the Maritime Visitors Center and the pier where the old sailing ship is docked. Afterwards, we took a cab to the Boston airport and boarded separate flights. I returned to Michigan, my colleague was en route to Louisiana. After I returned home Tuesday evening, I became ill, vomiting, chills, and soreness. After a few hours, I quit vomiting but was very tired and ate little for the next 32 hours. Lost night I learned that my colleague, Linda Sadden, began vomiting en route to Dallas, TX. She was so ill that a wheelchair was provided for her to use getting off the plane. A physician was called to see her before she could leave the airport terminal. She was taken via ambulance to a hospital because she was so weak. She was vomiting, had chills, was shaking, and had diarrhea. She was seen in the emergency room and admitted for observation due to heart irregularities and for rehydration. Her return home was delayed another day before she was discharged and strong enough to fly. I wanted you to know about this in case health clinics or hospitals in Salem have had an increase in people with these symptoms this week. I believe our illnesses resulted from the chicken salad sandwich we split. I ate very little after that. My colleague had nothing else to eat. We attended a conference but no one else was sick with this type of illness. I am thankful that we each had only one/half of the sandwich! I do not have the name of the coffee shop/cafe. It was past the Derby Restaurant and well before the House of the Seven Gables. Sara, Sara S. Hunt 2007 Trail Wood Circle Midland MI 48642 (989) 631-3817 shuntgero@aol.com 5/2/2006 l. ,adac4`:"b,"F,..p rt,-$5i�, t a a >r Y«• r e.:'+ '§ ^+tqY �a � °4:!c� '.'.. P+. w. i ,.. }�p�}t'�y. F:P'rPLT'P ' a. .... a +i'ti - r • ..�,jy. .0 4 - s TY rJY.'Sk q"Ay^4!.., x+{.Y.S o�w v i .R v v-"tly, Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor r'Uh SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Jaho Coffee & Tea File Number:BHF-2005-0040 6 Harrington Court - SALEM MA 01970 LOCATED AT: 0197 DERBY STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0116 Jan 3,2006 Dec 31,2006 $100.00 ESTABLISHMENT FROZEN DESSERTS BHP-2006-0117 Jan 3,2006 Dec 31,2006 $5.00 Total Fees: $105.00 PERMIT EXPIRES IDecember3l, 2006 Board of Health 49 This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 9 of 9 ag CITY OF SALEM9 MASSACHUSETTS ,. BOARD OF HEALTH T 1 _ s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. UsOylcz, JR. FAx 978-745-0343 (Yy C)F SALEM MAYOR WWW.SALEM.COM k'A f'dlrrt JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR 1IPERMIT QTO OPERATE A FOOD ESTABLISHMENT j / NAME OF ESTABLISHMENT r M �-�7o o 14 r�� TEL# ADDRESS OF ESTABLISHMENT 1 L/?/16l/ 4ny- MAILING ADDRESS (if different) OWNER'S NAME V\ il t1Al TEL# Q\lS-ZZ�-M Z ADDRESS b H W FIr ✓ACo c om CITYG&K h SATE ZIP ollk ( 0 CERTIFIED FOOD MANAGER'S NAME(S) r t CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) A EMERGENCY RESPONSE PERSON ANt /�Q'r HOME TEL HOURS OF OPERATION: Mon.(xuA�IQMTu Wed. ( Thu.�Fri. 6-1( Sat. 11 Sun. -I TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES 6 JO less than 1000sq.ft. _$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ---- -----------a---....--- ----- ----------------- . RESTAURANT YE NO less than 25 seats 120 /511 u "7 more seats =$150 7 v more than 99 seats =$200 - .............. . . ...........-- --------------------------------- ----- BED/BREAKFAST YES NO $100 --------------------------------------------------------------------------------------------------� ...... ... ADDITIONAL PERMITS (MAKE (not just serve) ICE CREAM;YOGURT, SOFT SERVE, Y N $5 TOBACCOVENOOR �~ YES $50 ALL NON-PROFIT(such as church kitchens) YES $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 knowl a and ef, ha filed all state tax returns and paid all state taxes required under the law. 7 12 a D2-S--7,g--4G_3Q S_1'9nhtdfe ate Social Security or Federal Identification Number --------------------------------------------------------------------------- --------------------------- Revisedll/03/05 FOODAP2.adm Check#&Date 361 9 QVC eel ,y 0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT (978) 744-4300 PIC Assigned/Knowledgeable/Duties PASS RED Owner: • Non-compliance with: Anil Mezini Anti-Choking PASS PIC. ` Anil Mezini - Tobacco PASS Inspector: John Gehan V EMPLOYEE HEALTH Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 2/27/2006 Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level: .. FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2006-0116 - - — Receiving/Condition PASS RED Status: Open Tags/Records/Accuracy of Ingredient Statements PASS RED #Of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS 0 RED 1 Time IN: .: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 28,2006 ) Page I of Item Status Violation Critical Urgency RED: - PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS ❑ RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS ❑ RED immediate corrective action) Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS (] RED Prevention of Contamination from Hands PASS RED HandwashhFFacilities FAIL Critical d❑ RED ✓Comments: Back bathroom missing paper towels in dispenser. Provide paper towels. -�aandwash sink next to ice machine missing"hand wash only sign". Provide sign in visible area. >/F(andwash sink in front area missing"handwash only"sign. Provide sign. ✓Front handwash sink had accumulation of food on bottom. Sink must be used for handwashing only. PROTECTION FROM CHEMICALS Approved Food or Color Additives PASSd❑ RED Toxic Chemicals PASSd❑ RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASSd❑ RED Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS ❑d RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 28,2006 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL BLUE Comments: Personal items stored on shelves in back area. All personal items must be stored in designated areas away from food items. Equipment and Utensils FAIL Non-Critical BLUE Comments: Hussman freezer in bac storage area missing thermometer. Provide visible and accurate thermometer. ✓Microwave in back area requires general cleaning. elshaw unit requires general cleaning. oaster oven in front area requires general cleaning. VMop stored incorrectly. Mop must be stored hanging up to air dry. Water, Plumbing and Waste PASS BLUE Physical Facility FAIL BLUE Comments: Backdoor has air gap. Provide weather tight seal or sweep. Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: 500: �I City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 28,2006 ) Page 3 of 0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION (978) 744-4300 Handwash Facilities PASS RED Owner: Comments: Anil Mezlnl Violations Related to Good Retail Practices (Blue Items) PIC:_ Food and Food Protection PASS BLUE u Anil Mezini z, Inspector: Comments: John Gehan Equipment and Utensils PASS BLUE Date Inspected: COrreCt By: -,_ Physical Facility PASS BLUE 2/27/2006 Risk Level: - GENERAL COMMENTS: 512:all violations noted on 2/27/06 inspection have been corrected. Permit Number: BHP-2006-0116 - Status: Open` #of Critical Violations: 0 Time IN: Time OUT. - Urgency Description(s): ` BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 , days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 06,2006 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 06,2006 ) Page 2 oft 0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone' = -- Item Status Violation Critical Urgency Nature of problem or correction (978) 744-4300 = Non-compliance with: Not Done Owner: Anti-Choking PASS ❑ Anil Mezini Tobacco PASS ❑ PIC._ _ ..y FOOD PROTECTION MANAGEMENT Not Done Anil Mezini X PIC Assigned/Knowledgeable/Duties PASS ❑J RED Inspector: _ David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: Correct BY: .y. =_=i Reporting of Diseases by Food Employee and PIC PASS ❑d RED 8/15/2005 Personnel with Infections Restricted/Excluded PASS RED Risk Level: - FOOD FROM APPROVED SOURCE Not Done Permit Number: - Food and Water from Approved Source PASS d❑ RED ;_BHP-2005-0500 Receiving/Condition PASS ❑ RED Status: _ Tags/Records/Accuracy of Ingredient Statements PASSd❑ RED iSIGNED OFF Conformance with Approved Procedures/HACCP PASS Q RED #of Critical Violations Plans * PROTECTION FROM CONTAMINATION Not Done Time IN: _.,. Time OUT Separation/Segregation/Protection PASS ❑� RED Notes:j,., Food Contact Surfaces Cleaning and Sanitizing PASS RED 244: Proper Adequate Handwashing PASS ❑d RED Urgency Description(s): Good Hygienic Practices PASS RED BLUE: = ".` % Prevention of Contamination from Hands PASS RED Violations Related to Good Retail Practices (Critical - Handwash Facilities PASS RED violations must be corrected immediately or within 10` days)(Non-critical violations GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 15,2005 ) Page ! of 0197 DERBY STREET Jaho Coffee & Tea must be Corrected Immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) Approved Food or Color Additives PASS ❑Q RED RED = '' Toxic Chemicals PASS Q RED Violations Related to m Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require ! Cooking Temperatures PASS ❑d RED immediate corrective action) Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS ❑J RED Hussman cooling unit to be fixed on 8/15/05. Hussman technician on site. Time As a Public Health Control PASS ❑J RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASSd❑ RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE The menu consists of specialty coffees and teas and cold sandwiches. Any changes to the menu must be approved by the Health Agent. In accordance with the Federal Food Code and the State Sanitary Code this establishment has met all requirements to operate a food establishment. GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 15,2005 ) Page 2 of 3 1 0197 DERBY STREET Jaho Coffee & Tea GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 15,2005 ) Page 3 of CITY OF SALEM, MASSACHUSETTS ~ BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Jaho Coffee & Tea Address of Establishment: 197 Derby Street Owner's Name: Anil Mezini Restrictions: Application Date: 8(15105 Permit for Food Establishment 317-05 Frozen Desserts/lce Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. 'x� U HEALTH AGENT CITY OF SALEM MASSACHUSETTS - BOARD OF HEALTH 9I 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FORT PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TA Ho 09FFEt 9-T� A TEL# -1 ee_78-T44 -43 c2o ADDRESS OF ESTABLISHMENT , 1 De�l6�� Sd�z� SAlet�/ ,/V OW70 t MAILING ADDRESS (if different) 6 APP- y1,Q 6%.n t . Ujtt j OWNER'S NAMEAv11 1 'aI t TEL# a7� ADDRESS 4&rrl o P q�_n c4. Ap) .a CITY Se_Uyw 13STATE M� ZIP 0142 0 CERTIFIED FOOD MANAGER'S NAME(S) ;I A iln 1 CERTIFICATE#(s) Su� (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON N,I\oUAy, �X&�An HOME TEL# a_7� -�( 1 -,_j V41. HOURS OF OPERATION: Mon.� Tue. 6-tI Wed. 6-II Thu. (-il Fri.�Sat. 6—II Sun. 6 II TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NOless than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 00 more than 10,000sq.ft. =$250 RESTAURANT NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE ES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL hapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best �� nd b f, ave filed all state tax returns and paid all state taxes required under the law. J2K 7e vOS �->— E7� 5 I eider Signature Uate / Social Security or Federal Identification Number -------- -------- - ------ -- ----- ----- -- - ----- -- ------- Revised 11/03/03 FOODAP2.adm Check#&Date l)� 's _`6 s- CITY OF SALEM BOARD OF HEALTH. Establishment Name: Date: g ) J oS Page: of s Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified � . PLEASE POINT CLEARLY r.\ n kA, si tokLS - r E i1 U t V he k Q v (N? 071 \ r\0 Discussion With Person in Charge: Corrective Action Required: ❑ No- ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or pension/revocation of ❑ Embargo ❑ Emergency closure your food permit. ❑ Voluntary Disposal ❑ Other. i i 3-501.14(0:} PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 122) (Cont.) 41"F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-*501,15 Tooding,Methods for PHFs - 14 Food or Color Additives E19 - PHF Hot and Cold Holding 3-501,16(B) Cold PHFs Maintained at or below 3-20212 Additives* 590,004(F) 41°/45°F* 3-302,14 Protection from Unappmeed Additives* 3-501,16(A) Hot PHFs Maintained at or above 1=5 Poisonous or Toxic Substances140°F. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. - Containers" Time as a Public Health Control _T102,11 CommonName-Working Containers* 20 7-201.11 Separation- 3-501.19 Time as a Public Health Control* uiretnent 7-202.11 Restriction-Presence and Use" 590.004(H) Varianc - 7-202.12 Conditions of Use" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic containers-Prohibitions" POPULATIONS(HSP) 7-204.J 1, Saunizers.Criteria-Chemicals* 7-204.12 _ ChemicalsI for Washnuz Produce,Criteria"'_ 3-80'1.11(A) Unpasteurized Pre-packaged Juices and 7-2404.14 DIVing tVCMS.Croei ta" I Beverages with Warning I abcls* - 3-801,11(B) Use of Pasteurized Eg-s* 7-205.11 Incidental Food Contact,Lubricants* 1 7-206.7 1 Restricted Cie Pesticides.Criteria* 3-801A 1(D) Raw or Partially Cooked Animal Food and 7-206.12 Podcrut Bail Station,0 Raw Seed Sprains Set Served. 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-served. Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3 603.11Consumer Advisory Posted for Consumption of Ib Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401A]A(1)(2) E" 155'17 15 Sec. Pathogcn0 " �""'" '011 Fags- - 1-302 13 Pasteurized Eggs Substitute for Raw Shell 3-401A7(A)(2) Comminuted Fish,idtais&Came Eg'2s* Animals- 155'T 15 see. 11 3-401.1 l(B)(1)(2) Pork and Beef Road - 130°FF 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,WildGame,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'4 15 sec, above if related to foodborne illness 401.11((-)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors, Other 145°F 590.009 violations relatingto good retail 3-401.12 Raw Annual Fotxls Cooked in a practices should be debited under ff29- Microwave 165°F* Special Requirements. 3-401,11(A)(1)(b) All Other PHFs-- 145'F 15 see. F17 -Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403AJ(A)&(D PHFs 165'F 15 sec. ": (Iteirts 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing Ctitical and non-(rilicul violations, which do not relate to the Timcl foodborne illness interventions and risk fie tors listed above, can be 3-401 II(C) Cornmercialtv Processed RTE Food- foand in the following sections of the Food Code and 105 Ci4R 140OFT 590.000 .____ 3-403.11(E) Remaining Unsficed Portions of Beef Item Good Retail Practices FC 590.000 Roasts` 23. Mena anent and Personnel FG-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 004 -2-5. - Equi FC--4 _ 005 3-501.14(A) Cooling Cooked PHFs from 140OF it) 26. Water, Plumbing and Waste FC-5 .006_____ 70`F Within 2 Hours and From Aff T.7 _2 - Physical Facility FC-6 .007 to 411°F/45'F Within 4 Hours. 28. Poisonous or Toxic Materials FC-7 .008 -501.14(13) Cooling PHFs Made From Ambient 29. S eciai Re uirements .000 Temperature Ingredients to 41 J-/45'17 Other --- --------__...... Within 4 lJour';k Denotes critical item m tho Wend 1999 Food Code or 105 CNIR 590 000. Espresso Bar(Hot or Iced) Sm. Reg. Lg. Cappuccino 2.65 3.20 3.50 Caffe Latte 2.65 3.20 3.50 Vanilla Latte 2.95 3.50 3.80 Caffe Mocha 2.95 3.50 3.80 Marshmallow Mocha 3.25 3.85 4.15 White Chocolate Mocha 3.25 3.85 4.15 Grand Mocha Orange 3.25 3.85 4.15 Caramel Mocha 3.25 3.85 4.15 Caramel Macchiato 3.00 3.60 3.85 Americano 1.85 2.15 2.50 Single Double Espresso 1.45 1.75 Espresso Macchiato 1.50 1.85 Espresso Con Panna 1.50 1.85 Custom Bar Syrup (add .30) Milk French Vanilla Pumpkin Spice Nutmeg Whole milk Caramel Peppermint Walnut 1%/2% Milk Hazelnut Coconut Gingerbread Nonfat Milk Almond Macadamia Butterscotch Soy Milk(add .40) Orange Irish Cream Dulce de Leche Organic Milk(add .40) Cinnamon Pistachio Tiramisu Espresso Raspberry Amaretto Kahlua Add shot(add.55) Coffee Bar(Regular or decal) Sm. Reg. Lg. Hot Coffee 1.40 1.70 1.80 Iced Coffee 1.80 2.10 2.30 Cafe Au Lait 1.85 2.20 2.50 Turkish Coffee 1.45 Teas Sm. Reg. Lg. Chai Tea Latte 2.90 3.30 3.55 Green Tea Matcha Latte 2.90 3.30 3.55 Black Iced Tea 1.50 1.90 2.15 Mango Iced Tea 1.50 1.90 2.15 Lemon Iced Tea 1.50 1.90 2.15 Raspberry Iced Tea 1.50 1.90 2.15 Peach Iced Tea 1.50 1.90 2.15 Passion Fruit Iced Tea 1.50 1.90 2.15 Hot Tea 1.35 1.75 1.75 Black Assam Black, Earl Grey, Kashmiri Chai, Darjeeling Green Orange Sencha, Jiangxi China Green, Moroccan Mint Red Tea Red Bush Blend, Lemon Rooibos Bubble Teas(Extra Boba.30) Sm. Reg. Lg. Green Tea Honeydew 2.90 3.30 3.55 Green Tea Mango 2.90 3.30 3.55 Green Tea Honey 2.90 3.30 3.55 Thai Tea 2,90 3.30 3.55 Coconut 2.90 3.30 3.55 Zodiac Tea(Served in Tea Press) 3.15 Aries A fine, energetic blend of Apricot Brandy,perfect for the courageous Aries. Taurus Heavenly combination of tea and lemon for the traditional Taurus. Gemini A clever blend of Mango and tea, sure to impress even the most discerning Gemini. Cancer Inspiration. Sensitivity. Evasiveness. This is what a Cancer experiences upon tasting this tropical blend. Leo This special blend of the finest Masala Chai is a perfect match for the powerful Leo. Virgo A logical combination of tea and Vanilla will the delight the always logical Virgo. Libra The Libra will enjoy this harmonious blend of Ginger, fruit and tea. Scorpio A mysterious blend of oranges, teas and spice to satisfy the thirst of the Scorpio. Sagittarius Strong and flavorful, this blend of Passion Fruit should do justice to the Sagittarius. Capricorn Even the most stubborn Capricorn can not resist this unique blend of Coconut tea. Aquarius A spiritual blend of wild berries, strawberries and blueberries that only an Aquarius could handle. Frosticcino (blended ice drink) Blended Coffee(Regular or Sugar-Free) Sm. Rg. Lg. Coffee 2.75 3.25 3.75 Caramel 3.25 3.75 4.25 Mocha 3.25 3.75 4.25 Mocha Chip 3.25 3.75 4.25 Peanut Butter Mocha 3.25 3.75 4.25 S'More 3.25 3.75 4.25 Non-coffee Blended(Regular or Light) Vanilla Bean 2.65 3.15 3.65 Frozen Cocoa 2.65 3.15 3.65 Strawberry 3.15 3.65 4.15 L Banana 3.15 3.65 4.15 Mango 3.15 3.65 4.15 Green Tea Matcha Mist 3.15 3.65 4.15 Sipping Chocolates(8oz) 2.75 Triple Chocolate Ultinjjte Dark W�tp P{ ocolate pulc� de Leche ie� �� EXAMINATION FORM NO : 4227 CERTIFICATION NO : 4437547 ServSaAw Certificeltionleft To ANIL MEf INI for successfully completing the standards set forth by the National Restaurant Association Educational Foundation for the ServSafe® Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSA-Conference for Food Protection (CFP). Presented by the National Restaurant Association Educational Foundation I 6/22/2005 DATE OF EXAMINATION 6/22/2010 DATE OF EXPIRATION Local laws apply. Check with your local regulatory agency for recertification requirements. Mary M.Adolf President and Chief Operating Officer National Restaurant Association) Educational Foundation n National Restaurant Association F EDUCATIONAL FOUNDATION L 0 2004 National Restaurant Assaciadon Educational Foundation www.nraef.org i CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR o SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. UISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL# ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME TEL# ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-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 Date Social Security or Federal Identification Number ----- ---------------------------------------------------------- -------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date r -- CITY OF SALEM BOARD OF HEALTH Name of Establishment: Jaho Coffee Address: 197 Derby Street Owner(s): Anil Mezini Phone: 978-223-5909 The Owner of this proposed establishment presented a preliminary Floor Plan for review in accordance with the State Food Code. FLOOR PLAN A Hand Sink must be located in each food prep and service area. Therefore there must be a hand sink in the prep area and front counter,used exclusively for hand washing. Hand sinks must have wall hung soap and paper towel dispensers. These must be stocked at all times. If the hand sink is located close to a food prep area, a splashguard may be necessary to prevent cross contamination. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. EQUIPMENT All food service equipment must be NSF (National Sanitation Foundation) approved. The dishwasher must wash, rinse and sanitize all dishes, utensils and food equipment. Sanitizing in the dishwasher may be by 180 degree water in the final rinse or by an automatically fed chemical sanitizer in the final rinse. There must be an alarm with the chemical sanitizer to indicate when it is running low. MENU/FOOD PREP Any pre-made items must be purchased from a wholesaler licensed by the State. Fruits and vegetables must be washed prior to preparation. This may be done in a bay of the sink. This bay must be sanitized before and after washing. All food must be held at 41'F or lower, or 140°F or higher, at all times. Therefore, soup should be brought to boiling before being held hot. There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used when handling such food. I There must be sufficient room to place necessary equipment and to prepare food safely. CERTIFICATION There must be a Certified Food Manager working at this establishment full time. The owner has enrolled in a June Zth class. When a CFM is not onsite there must be a Person-in-Charge (PIC) who is fully trained in sanitation techniques and has a thorough understanding of the operation. 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 3`d 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. Outside area of premises, including the dumpster area, must be kept clean and sanitary. Please submit a final drawing of the planned renovations prior to construction. 6- �2 - os` ,panne Scott Date Health Agent 6- -2 -05 caner Date q y a F �7�J/ re- qtr+ pT7yq fSv /vy SAU4 l Comer sv 4,.O� I n I ._ _I U41T 48'(BELOW) PREP TABLED CREAM DIPPING O FAEMA S _ ECUIFM_NI SCHEUULE F PALMA jUBILE n2 tl D MU300ESPRESSO GR INJEF O C U H0bAA UNDER CDUNiER REFR GERF fCR UH 4n8 C^' E HDDF VREP LE P12Jo F 1C IA SINGLE CREPE GRIDDLE G ICE CPIAM DIPPING f Fr NCI H DVC" SCRCEN CF7:1 REGISTER WITH AUTO CASH DRAWER C J - 11101E BE. DPINDER H - CrCIL CBS-R052 EERIERANCA L - ICEO TEF DISPENSER M - C_CA T ON CRCG TEP P 'PIED UGER [NG MFCHI7 O N - BLEARY UNBLENDER REFPILER TDR UHi2J D - ICED C F BLENDER �¢ - ICED COFFEE DISPENSER Dole eeFM ERo Ies125, OF ENuou O JAHO COFFEE PRELIMINARY EQUIPMENT LAYOUT 6-17-05 SCALE: '/d" = 1'-0" Massachusetts Department of Public Health Salem Board of Health < 120 Washington Street,0 Floor Division of Food and Drugs .y Salem, MA 01970-3523 FOOD ESTABLISHMENT.INSPECTION REPORT { Tel. (978) 741-1800 Fax(978) 745-0343 Namet' Date Tvoe of Ooeration(sl T of Inspection o 4 ��r 0-A I 0 Food Service Routine Address p Risk Retail ❑ Re-inspection (I _' err /, " Level Residential Kitchen Previous Inspection Telephone /': ❑ Mobile Date: Owner /1 �� } HACCP YM ❑❑ Caterer ❑ Pre-operation A A � ❑ Suspect Illness Person In Charge(PIC) Time ��y�h'� El Bed&Breakfast El General Complaint In:L_r" 4 ElHACCP Inspector ami 0 y 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) p� action as determined by the Board of Health. G XO'!„ e.. JUu�I FOOD PROTECTION MANAGEMENTml 12. Prevention of Contamination from Hands El1. PIC Assigned/Knowledgeable/Duties v'� 13. Handwash Facilities , EMPLOYEE HEALTH --- El ` PROTECTION F ' "' ` 2. Reporting of Diseases by Food Employee and PIC *-\,-.DM CHEMICALS _ ❑ 3. Personnel with Infections Restricted/Excluded ❑ 14.Approved Food or Color Additives ❑ 15.Toxic Chemicals FOOD FROM_APPROVED SOURCE El4. FOOd and Water from ApprOVed SOUrCe TIMEREMPERATURE CONTROLS(PoteMlslly Hazardous Foods) __.__ ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling ..PROTECTION FROM CONTAMINATION .. ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REOUIRENIENTS FOR.HIGHLY SUSCEPTIBLE POPULATIONS.(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11.Good Hygienic Practices CONSUMER ADVISORY' - _ - • A/ f[ 2_i 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 CeaNh. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils cited in this report may result in suspension or revocation of (Fc-a)(Sso.00s) the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.000) 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. Ot/h�er� DATEOF RE-INSPECTION.)"J 'I S.590In5peclFam 14< ( P/ I//1 I '\ !11 0ArV14Y 0(k 't/�,e A, Inspector's Signature: Print:h6o h 1 V PIC's Signature: Z / /c / I - ^ A Print: 28/-- /-- OL H, Page 1 of ZFages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(]) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility" Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11. Person in charge--duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.1 I(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer 3-306.14(A)(,B) Returned Food and Reservice of Food'* 590.003 G) Re ortin b Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning 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* 4-501111. Manual Warewashing-Hot Water - 3-201.12 Food in a Hermeticall •Seated 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.l4 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, Equipment 3-202.16 Ice Made From Potable Drinking Water* quip tr too and hardness. 4-(i0t. 5-101.11 DrinkingWater from an Approved System* 1'1(A) EEment Food Contact Surfaces and- 590.006(A) Bottled DrinkingWater* Utensils Clean* 590.006(13) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food Contact Surfaces and Utensils'" Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 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 Aufhorft 2-301.1.1 - 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* 3-201.19 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401..11 Eating,Drinking or Using Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2.401.1.2 Discharges from the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 1 Preventing Contamination When Tasting* 6 Togs/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstoek Identification' 590.004(F.) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction° Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11. Numbers and Capacifies* 590.004(J) Labeling of Ingredients' 5-204.1.1 Location and Placement* Conformance with Approved Procedures 5-205.11 -Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.17. Specialized Processing McOtcxis* Devices 3-502.1.2 Reduced oxygen packagmg,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision "Denotes critical item in the federd 1999 Fond Code or 105 CMR 590A00. 'a `7a�!>�vti'\ _ BOARD OF HEALTH :x Establishment Name: 5'n Date:�� _ c�y� _ Date:'- I I Page: Of 7 Hem " Code C-Critical Item •t ' : DESCRIPTION OFVIOLATION ! PLAN OF CORRECTION Date No. Reference R—Red Item- ) i zl, s PLEASE PRINT CLEARLY V72/y�,.t'> Verified 1 .y� r p • p A ' A 41 OA /10�.—Mo ry (E41(k 0 4 �k- 0 ,,..I_ kr,r iv�, �_ �,r. - rA, ,,P_,' o." I�.��-�. �_rc�„/0 ,� I� )J I I , �P" ( J , nI A n - /—I an< r.) '19voJar? GPC C eC_3t c- 'LC ;! IV 4t � . t ., .nn� ), C � n —7"'h�� 14 ItC . 0)4 IAA T\4 Ai) G n0 f + Discussion With Person in Charge: I1 C Corrective Action Required: ❑No ❑Yes f ❑ Voluntary Compliance ❑ Employee Restriction/ t P Q'CO 1 _ P Nv) — � iV— Exclusion t j ❑ Re-inspection Scheduled ❑ Emergency Suspension aA ❑ Embargo ❑ Emergency Closure 9 3(3 1 ❑ Voluntary Disposal ❑ Other �r FISRM 7348 (REV. 7/2000) HOBBS &WARREN, - BOSTON This Form Approved by the Department of Public Health y ^Y Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) Received at Temperatures Acco Factors(Red Items 1-22) (Cont) - According to Law Cooled to 41'F/45'F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs `14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(6) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 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* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic-Containers-Prohibitions* POPULATIONS (HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* 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 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Effective 71112001 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145°F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(5)in 3-401.11(6)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering,mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(6) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F*, Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 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. S ecial Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. Commonwealth of Massachusetts c o City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Jaho Coffee Roasters File Number:B14F-2009-000001 60 Wharf Street SALEM MA 01970 LOCATED AT: 0060 WHARF STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0291 Jan 1,2011 Dee 31,2011 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4T`'FLOOR -M-. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGCEENnAUN1@SALEN1 CONI DAVID GREENBAUM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT CPt NAME OF ESTABLISHMENT �v p .ARTS TEL# ��100 ADDRESS OF ESTABLISHMENT 60 FAX# MAILING ADDRESS(if different) EMAIL- Business': Ih� 0 AN^__� ^ Ct7y Website: WWW (\ono W� OWNER'S NAME Ay\y\ (VD'\ DtVr TEL ADDRESS 6 KtdS! i 1n�� C� • S��QU l /Uv, OW-7 y STREETq �f CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) 43-yO�c7 (tom r CERTIFICATE#(S) (Required in an establishment where potentially// n hazardous food is prepared) EMERGENCY RESPONSE PERSON 4\/\A / k-t I v� i HOME DAY$i:OFORERATION ,,,r, .. :'-:Monday Tuesday '• : .Wednesday zl x.:Thursdayw.'- FridayI , iSatuNay 1 ;Sunda;;, HOURS OF OPERATION Please write in time of day. M �I'M x --1(1M `�M—� NIM---�P�.t SAM pM a��- P For exam le 1lam-11 m / TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ------------------ ................................................... RESTAURANTNO less than 25 seats =$140 (Outdoor Stationary Food Cart$210 25-99 seats =$280 more than 99 seats =$420 -------------------------------------------------------- -----�----�--------------------------------------------------------------------------------------------- BED/BREAKFAST/ YES (N� $100 CHILDCARE SERVICES/NURSING HOME(9 -------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES O $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership:The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have fled all state tax returns and p lis Oat axes required under the law. /11 �1�1�6�I0 cyz -71-440Q Signature TDate Social Security or Federal Identification Number -------- -----'--------)rte— ---------------------------------- Revised lonli I FOODAP201 Ladm Check#&Date_L6 0, ��J($/� S l y(2 .,a�..-. ,.,�w'. ,.Ni.1 ..�s.ii�h;.+w.,.{F�a',t0..'`:trbf..t`�f. �;vA^V-nwh.sr+' a,,er..w1 f^,•et4wl;..�+r„y�.. y ;v� ( � Yl'. 9+.°N')F�ai.'. Massachusetts Department of Public Health Salem Board of Health 10 Division Of Food and Drugs 120 Washington Street,4"Floor g Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name //1V p Date Type of Operation(s) T e of inspection i -Ij Food Service Routine Address )�� `` ,Ian^'�n ISL y Risk Retail Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephonevh (n �� ElMobile Date: Owner - /; l� , Dn HACCP Y/N LlTemporary ❑ Pre-operation 4 1 c� P ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) /1)� P Ti e ❑ Bed&Breakfast ❑ General Complaint HACCP Inspector 11 � I� - v Out: ❑Other j" �l-�t�/ �`�.c Out: Permit No. El Other Each violation checked requires ab explanation on the narrative page(s) and a citation of specific provision(s)violated. M 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) ❑ s9o.00g(F) i action as determined by the Board of Health. x FOOD PROTECTION El12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH m - o w,_ 3.....a a.....»:.:.. .,., -J , PFtOTECTION FROM CHEMICALS r', , , a-�r •€- - ❑ 2. Reporting of Diseases by Food Employee and PIC • • „ »4» w=� m� .' h., �, , �• m .w E] 14.Approved Food or Color Additives El 3., Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals 'FOOD FROM APPROVED SOURCE 'r77MfJTEMPERATURECGNTROLS(Potentially Hazardous Foods ,".�" ❑ 4. Food and Water from Approved Source „ „M „ ( Y rd ) _11.1,j ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling f PROTECTION FROM CONTAMINATION"" "`°-"( ❑ 19. Hot and Cold Holding ❑ 8 Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing f%REQUIREMENTS FOR HIGHLY SU1SCEP TIS LE POPULATIONS(HSP)"T ❑21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practicesi:CONSUMEH ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an in immediately or within 90 days as determined by the Board 105 Con of Health. today, the items checked indicate violations of 105 CMR C. N 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (Fc-5)(550.005) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC:6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION:I `V}pL/).C/ 5:5901nspectFam614.Joc 1 Inspector's Signature: U ` Print: !� -7 I PIC's Signature: (\ Print: ' (0�_ , Page of/Pages i v \" Violations Related to Foodborne Illness p Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contaminatton 1 590.003(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 in charge-duties Contamination from Raw Ingredients 3-302.1,1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other- 590.003(C)590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A Fond Protection* a ilicants* 3-302.15 Washing Fruits and Veeetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report'Po The Person In Utensils* Char*e* Contamination from the Consumer 590.003(6) Reporting by Person in Charee* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 1 590.003(D) Exclusions and Restr cions* Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions Food -i-/01A I Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Temperatures* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Ilot Water 3-202.13 Shell Es* Sanitization Temperatures* 3-202.1.4 Eggs and Milk Products.Pasteurized* 4-50IA 14 Chemical Sanifiz2tion-temp-,pH, 3-202.16 Ice Made From Potable Drinking Water* Equipment F and hardness. 5-101.11 DrinkingWater from an Approved S .tem* 4-601.1 I{A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.04 Shellfish and Fish From an Approved SourContact Surfaces and Utensils*ce 4-702.1 i. Frequency of Sanitization of Utensils and 3-20114 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulato Authority 2301.11 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..17 Game Animals* II Good Hygienic Practices g Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301..12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-20118 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* - Employees* Tags/Records:Fish Products 13 1 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible - 3-402.12 1 Records,Creation and Retention* 5-203.11 Numbers and Capacifies* 590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced ox en Packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6301.12 Hand Drvin�Provision 'Denotes critical item in the Weral 1999 Foal Cale or 105 CMR 590.000. I CITY OF SALEM BOARD OF HEALTH Establishment Name: 11�CJnO l .ar- 2n_ d �P�t� Date: 1 A_ — 1: Page:_ of nem Code C-criticalitem �!u DESCRIPTION OF VIOLATION/PLAN OF CORRECTION, - a Fete No. Reference R-Red Item - r rerMier!3a PLEASE PRINT CLEARLY I e -n 6Y'Y1P, (� I n/\ t%/Ar\ , �7 ijr-4 -\nAC 2 11AAA 41 2.J -V/) A-Pn2 (lrll01 _ ( Q /e A"Y `krAA 0,. - \OA A _ � � 'K -ri c "'rCA oe x _t� O i- �Y Ili ,OA 1(\le A) (1 5�\ /iv�/1 �lV\ �1-�1� ��r 1-�i�n.� C1\0 � r'IrICi^ �A. 1 CA PA C An �� La I ' no P OAa- /1JIuro 1-V S ri I Y SC_. .o I I_a Xn .0� YA n_ fti f A C — ( o)rA n n n ( SVA `n /le nn _A n oP /J i i # Discussion With Person in Charge: Corrective Action Required: ❑ No , 5_ Yes '} I have read this report, have had the opportunity to ask questions and agree to correct all a oluntary Compliance ❑ Employee Restriction 4 violations before the next inspection, to observe all conditions as described, and to Emersion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Fo dsCod . I understand that noncompliance may result in daily fines of twe ive •Ilars o suspension/revocation of ED Embargo El Emergency Closure ''yeer food permit. ❑ voluntary Disposal ❑ Other: i 3-50IA4(C) PRFs Received at'1'empetatures_ -� Violations Related to Foodborne Illness Interventions and Risk According to Lav Cooled to - Factors(itehts 1.22) {Cont) 41TF/45`F Within 4 Howl. 3-5(11.15 Coolint,Methods for F's PROTECTION FROM CHEMICALS __� 19 PHF Hot and Cold Holding 14 Food or Color Additives 3501.16(B) Cold PHFs WMaintaineci at or below 3-202.12 Additives" ---111 590.01 11"/45°F' 3-302.14 Protection hour Unapproved Additives`^� 3-50i KA) llot PHFi bi:imtained atorabove 1.5 Poisonous or Toxic Substances '-MI'll klernn}wr inti. m,tion-On mal �� 40-F`.e. I z-50 I 16ed) I R< kits Held a[or shoe-e 1300F. + 7-102,11 ' C_otnmon\an+e Ro ki =Cern +in rs' i 2k) Trme as a Puhlrc Heatth Control -t- — --j _ a Pnbhe Elam,(onoolr 7-201.11 Sim+non Sirna' _ _ "SU 00"i ff Vs;rt Ti< w mini 2-202A i i Fe,t-+u cn Pr unu and (, c _ _{ _ �______._ �J �7-202J2 Corefiuo of Ilse -- —_ 7-203,11 Toxic C I mainerf REQUIREMENTS FOR HIGHLY SUSCEPTIBLE �i 04.11 Ssnnvet. C titins Chu+ic k _� _ POPULATIONS{HSS— _ —}— j 2(� 8tH 1 ii 1i Unp i tenriud Pr Face "ed tuices aid ( 9 04.12 Chemicals for th +,h+� t r u u f t ti r r"� } Rel et a cs with Rat nn i,alF As, 7104.14 L3rntr, A, uts tnu i; g{;�iiQ;, Fn f" PuPcni7edt _ i 1- 05,11 hFcta nt ii l xx t eniac+ Lutinctrofi, —J ' 801 i ItOt t<au or Pvtisll C(x,k tnal I,,sJ and f ° 206.11 '7 (2r;kn t Se Pr +ude C.� r n, t 7;� 06.12 lRaao{int Ht +i4_^F_oo , 1-7-1 -1 .... tf—l t h{i {L-Uri, d- F_ e \,)I 06 12 ti.ic, rIrFrlr 1 ------- --------- ---- ________ I, _ CONSUMER ADVISORY Tlit#EtTEMPERA7URE CONTROLS S 7 31 i1, 1+ t'f rp ke A >€on Pfnr 1 :,r C oli.ammon o; olwr Cooking r emperatt, ex for ani ,,i I a>d Mar art Raw U++tete r 1ved16 .c l _ PHFs i i ! �ctpth r �Fe t'rc*e�srd F it ut rr F.ltltl.l All it ; I r l�5r s v,S IbeiF ut + _Raw Six-1I 47) h,� C�mri+taLdl+.hrilea,e .. uwnt __— _ lnit oris 1 '" ` t fkc". r 11 t irH f i¢JF i trfi} I f,.�f Roik,t I} t i t-)i pori` I ,-.- SPECIAL REOU'RE fENTa _F _- e _ s __._' 1 11`'s$,n(r1j- i7r ! ia3zit t't 0 soe tior ?t).ERf�i �, IYJ M ie_jce_a lento F f, l ti I e atert irr 'not tt^f ,t 1 lC- .rat and " + ;gQt_li(A).:+t I Prtd r . Sl"ild Cr i ,-S-1`,-fl,-rt,(! t_atcfi>.n of c.F...,x;i s f1twidd #?e j C it nfamilig i i-h I i c'chited ti i-� ft ar IFrF„ arc r-,ions 7 Pr�l_4.li( � ,tr ,«-1, ..t��ti l� t,5 an.,. � i k#='_s- ,hn. jk i 'spec t .:G a•e i9 ___ ... i. peherktil,q for Hot tlotding .. _. VIOLA TiONS PFLATED TO GOOD RET.AiL FRACTIC Ei Nkk D) i fill I [("S"} i Wf 21 301 �. dO°.111 H� AItcu st ti�li ! Iii ni Stdud.n; I r r f �r n d ra rr al < rt ,+: xin i flo ,ioi :eow i,k f-e I _ 403.I ItC`) 1CFa}ILF_ialh Pstx .� fe 11 l�.+tl- � , rue h fift 1r, ne it >cc ;.rte rr<ric >de aetl , f1;It F 111 n o0, i item Good Retail Practices FC 590'000 34(i.;.i10::} lira*+ ui3+n't.na�:fe.,i Portxt.i o4 Hee l _ __ _ .._ _.-__ i mana0 no-it aria perfronfd _ PJ > 00' L1g Proper Cooling of PHFs— r?" ” F^na hd Fordi Prote. r c r _ i PC- 9 W4 + —.�–. — -- ---- x_253ui nr�Ft and Ute*totis f 501.1,4(A F+xFlmt;Cain d PH}s iiryn I dt F to - — - - - -, viatCt Pt nniigq 'd v i,te l F –5 ", 7()�1 Wuhin2 irow,ia!xllnm 1:)T i--2r F2 !tom F P-C_-C .fi97 tF 111F& tlm i Hui j ,--- l ' sroReaor is xrnravt die da , 501114l3i (+"ht FiF ht d Fr«n 'rrhtent 9 SFc i f"ripe sutra hi-r.0 int,to 41 1-M5:p ' i_30 7tlic _ CITY OF SALEM BOARD OF HEALTH Establishment Name: Smi ��e� �" �� - Date: I r7. -09 Pago:_C2, of Item Code c-Critical Itdm J L) DESCRIPTION OF VIOLATION/PLAN OF CORRECTION $ ue Die No. Reference R-Red Item - -, s:rr VerlTled-. PLEASE PRINT CLEARLY �Piv '.h"Y� - (I- A,) - ;4C3k !� ICA I`�A�n . I{'�' � rtrnD,2 n ` C"�Invl-�lIIC!:JNI D,11f .-. �� 1 ik.1 i. )).Ad1V_U,,t,a,. —q U U' ' Un/�JAn,e3�i1, l) \0--' Ci ()o / l �A iJ�n ODS to n Qo Jt l I P/ I 0 CVR/� pp- I \r # d/ � Q 51� ISRd .e—ll.Alet� �v A2 ( l_�-l< O4An 10 rllA., — F_ I0A.,.( .Y.! 9IA _ n., nn .)nJ0 pp pp (� , r .Nva- I,tX AA/Yl tl _ -/ne/, qA Aw, >-XAA Y� —( Y.QQ 0 , A 9 ,14 4) <,1A) OA-R-'1P r A �CJ7, � X" ( ti - - . . A „r, `.ate - D_ �AeA-r ..� , � Discussion With Person in Charge: U Corrective Action Required: ❑ No sd(. Ye§ I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Cod . I understand that noncompliance may result in daily fines of tw n'ty-ftv�ollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure i ,,ycV food permit. r ❑ Voluntary Disposal ❑ Other: i r ?S01 J4(C) PHF�Received at Temperatures 4 Violations Related to Foodborne illness Interventions and Risk According to Law Cooled to Factors(ffetrts 1-22) (Cont) -41"F/45`17 Within 4 Hours. PROTECTION FROM CHEMICALS 9-501.15 Coolio�Methods for PHFs 14 Food or Color Additives 19 PHF Hot and fluid Holding -- 9-501.16(B) Cold PHFs Maintainer!at or below- 3-202 12 Add nvcs`" 590.041(1-) 41'145'F- 3-302.14 Protection from Una>Prowed Additives'" - - 1 - ----) 3-591 WA) 33iu PH1-`,Maintainedat or above 15 : Poisonous or Toxic Substances '-I01.11 . ldeatd to i lnfr3rination-Oti<iinui1 v Y t r' i 5tH 16: a) -LRua.tn Held at or above 13011-. + _ _ l'ontia en I --I-= -� L20 Time as a Public Health Control i i iJ21f i..oamnnnti7m� 1\ >r(. i�ua nrr 1 -=�--. � -----� 11 Se a ruia St iia - -� 1> _ fin ss lublicHealthControl' 27)2.1 t �Pept a on- Pn_r s e and[, t .._ t4tl,aFla,73) ---�t aree R ui_n,ient 7-2()2.i2 f.andit on. of lyse REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 03.11 '', ToxicC( itamer. P�ohsbi:it,nc" FFFFFF�� i--= - F - POPULATIONS(HSP)I 2i� "-S01 i 1(A) Unpo teu lied Pr pact abed knees and -I 204.1' Chrnni kfot \Nash❑,. t x6144 Cutr a - .- - � i � t3erct s e,. yitb Warning 1 7204,14 Driing A, nm C ria i i _ t --- of Pa tc.+aired Egg:, _ 205 1 t Lund at tl t xxl i ,rrut 1 dt i ani - r-- �--- 1 r 4u=1 11{lit K,rE , P-itEdl C,�)kvd Aanril r,", srd 7-206.11 Re'i t i c4.Pe"Icides, Oiteu i -- - — I 1 4 ci Sproat,'vi 1 r ' 06 12 Sod,t li n + R,Staion —' --'— -� L, .�-- — t-ara nits a�Nui R. served_ " ._.__ _ CONSUMER ADVISORY TIMEfTEMPERATU_RECONTROLS 2 3 U' I' r uesuirxr }t 1aiF 'av 11 rtou etnptlonof Z —. 'aiuiiiali } v~d tha t 6 w Undee ,Eked to i 16� i�Proper Cooking ZempsratOrEnfor ) i I PHFs 3 i i i t Oi't 14� i'ry w5 A it,Eliminate its - > ;OLfi1Ei7(1ti r iSS015s pi,iirrruld (t , sldlswu - fus 6,." shell -Fl.11(02) t 2i n ofl,d f ,n Mei t Azii , . fit ` 1 � ._ uit , ` >r,it ii li ki} ~t 1 ,1 i 1' min _SPECIALREOINREMEN S 0L1 ,Br _ W>ajrzt vJeUu ?{t1k�d 1., )�s-r )1.11 t,1}FR 4tC �.lriim,t `4tc ids i =r h IS i . catem ni i c ttyolci. .einpora,l-and 4(t1.11(At :'t; ! P n t1- �iiN C itu �tari +} ht... i nsid 6 al kltcG4n olr r-a,a: stx,!tid be i i.ebit,d ll ildcr tiro appr.,i>r iatt! toads i' �tki'li t �'.iP'e. J k'li'gg'E klik'$F ii. - ..,.. Da.c Sa3 . i - z~re..e t.. re, . 1 , i t i_i it 3a t 7 ( tach-ahrg for riot Holding VIOLATION4._.RELATED TO GOO1D RET X t*RAt ;fCES (,itevN 23.301 -a{'-'!.1d(b) ( Urri Heave- ii [ 2 h9rrtu. Stun,ainp 'moi -r< rr < t i:ai r< v _.;,r t1- 'i r+ot r iic i riUt"f 1, ./} 5 Li bCrtt zon, z,n;lrik?LM ei i?:+ xd (zJ5'/ CL'Jt(JC i3-4=r3.il(Cj Com:nareua k Pi ch RTI }.axi-� 1, u<,in!h, I >x, Z.r T,s:' Io' l c ,a.-av,11^ :iWR I_ ! 4li F` 1 (; i lit) I Rvmaiuing{ s it ra r.'or.tc i;of Leet i_tient Gn_oo Rcreif Fr7rircec _ FC 640.(TOJ f 2,, i 10anaqerncirf and PPI -,-� 5 ;------_ '" --- 1 2i io^lc rd axf Pcotc tc Ft i - QCT L(gPruper Cooling of PHFs - - - t .. ._ { -.--�'---------.--- ---- .- ---a ; 26 iu, ry nni and Ulens,s ' F r -M (L 11(A) f ex)tit ;xik d PH}'s f, n tG Pte ( i 2i, ilvat4r �f,_ _ a 1 ' Within' tToc+ <.:tsd born :fi'f' Fa inr _ FC, t 067 1 1 i 4 J k35^F t4-.thin 4 fi,ut. �' !_ n -' No a„or T")3( h ,a:, Ft, 7 op➢ r ._v.__.....__. - �. _._ _ __ C s-501.l4(B'i roll a PHF Nfiijv From Arch ant ( 4 Spm i�C Lrr=.Nti 6C3 -i 1 mi uaunc hu,rzdiewti toil', t'i45`t' X30 O1l_f _ ._ til � (ri Ctll:C:i11 c IN's.[Irl n,,.=( c rinS L.lfiS fO..j)il(;, . 0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency -_ -_.__........---.__..._....�.�_.,. Telephone: - PROTECTION FROM CONTAMINATION (978) 744-4300 - Separation/Segregation/Protection FAIL Critical ❑ RED Owner: Vcmment:Victory fridge had meat stored above vegetables and other items.Organize fridge to properly separate potentially s Nikoleta Jaho hazardous foods from ready to eat foods. tPIC: Handwasshh Facilities ✓ FAIL� Critical ❑d RED Nikoleta Jaho /comment: Paper towel dispensers at sink in employee bathroom and at front h'Sndwash sink were filled,but not able to dispense - towels.Repair and ensure all paper towel dispensers are working to facilitate proper handwashing. Inspector: towels. EITEM PERATURE CONTROLS(Potentially Hazardous Foods) Elizabeth Salandrea Hot and C Id Holding FAIL Critical ❑� RED Date Inspected:Correct By: 2/25/2009 omment: Desert fridge at front counter had a temperature of 43°F.Turn down to ensure fridge maintains temperature of 41°F or below. Risk Level: Violations Related to Good Retail Practices (Blue Items) Equipment and Utensils FAIL Non-Critical BLUE Permit Number: VyC/omment: Hussman freezer missing thermometer.Provide visible,accurate internal thermometer for this freezer. BHP-2009-0241 � Status: {IVictory freezer needs general cleaning. VIOLATION Ven and warmers below it need general cleaning. #of Critical Violations: 13 r4inse sink at front counter must be labelled. Time IN: _ Time OUT: Urgency Description(s): j BLUE: Reinspection in one week, all violations to be corrected. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 04,2009 ) Page 1 oft ,w Item Status Violation Critical Urgency RED: Violations Related to 71 Foodborne Illness Interventions, and Risk Factors (Require immediate corrective action) i City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 04,2009 ) Page 2 oft 0197 DERBY STREET Jaho Coffee & Tea City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: (978)744-4300 Owner: Nikoleta Jaho PIC: Nikoleta Jaho Inspector: Elizabeth Salandrea Date Inspected:Correct By: 3/4/2009 Risk Level: Permit Number: BHP-2009-0241 Status: SIGNED OFF #of Critical Violations: 0 ,Time IN: Time OUT: Urgency Description(s): BLUE: All violations noted in the 2/25/09 inspection report have been corrected. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 05,2009 ) Page 1 oft r i Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions' and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GboTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 05,2009 ) Page 2 oft Commonwealth of Massachusetts f ` ` City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: Jaho Coffee Roasters File Number:BHF-2009-000001 60 Wharf Street SALEM MA 01970 LOCATED AT: 0060 WHARF STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0026 Jan 4,2010 Dee 31,2010 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES �December 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS Y BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERM(I�T-TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT � //./ / 10 C,4� � 1+40,, TEL#41 ADDRESS OF ESTABLISHMENT FAX# MAILING ADDRESS(if different) 1 1 EMAIL- Business': ✓�` :\C&D tM Website: C1•`A ID Cpl OWNER'S NAIVE �,� ice; TEL# ADDRESS �A.AA) V)!i 6n 0• S�,41AJ AAA N -70 STREET pp CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) A17V Ju 91QA 111, CERTIFICATE#(S) (Required in an establishment where potentially hazardous food I i__s prepared) EMERGENCY RESPONSE PERSON (-q L ^,,� !Qq�t\t HOME TEL# b9Y$"OF'OPERATION} , Ir";. ,Mondays r Tuesd`a.: Wetl esday I• Shy stlayy „ ,E,"Ni S turday� Sunda HOURS OF OPERATION Please write in time of day. 04- l�QM Q (1 p//� I M M j ` / 41 For example 11am-11pm I 1AN1- 0 N j /i"�" f qpm- O �/1/1._I��/� . I�P ; cY�/V� - ISP TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO Tess than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000s .ft. =$420 - lf§ - ... -------------- -- -- RESTAURANT NO less than 25 seats =$140 (Outdoor Stationary Food Cart$21 25-99 seats = 280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME ------------------ --------- - ------------------------- - ------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to M L 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 an p ' a state ted under the law. yC I SignatVc Date ^--� Social Security or Federal Identification Number_ Revised 424/07 FOODAP2008.adm Check#&Date KSZ� I L/�� $ ��0•D i7 CITY OF SALEM f BOARD OF HEALTH Establishment Name: �l`11�o �J � t C $ Date: 5'l S/C R Pager_ of Item code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified .'�. PLEASE POINT CLEAflLY S . v 11 rGl1 'lam(71A O - I)C, 1 Jwywr i li M zt I a I-. cuu � < a 1 C`�C�a m Ct 5 t t I f 11C-fl . C( uA 7n r I S t t Uj b , T'n SsC'111'v u e Ila i 6iv& fl p cto E i r I cR _ O e t � r f Ice c7 c f O � S r'ce 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 c 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 twertly-five dollars or,suspe Sion/revocation of El Embargo ❑ Emergency Closure { your food permit. �� ❑ Voluntary Disposal ❑ Other: ' L v 3-501.1.4(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Liw Cooled to Factors(items 1-22) (Cont) 41 )F/45' Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Conlin11 - Methods forPHFs I4 Food or Color Additives l9 PHF Hot and Cold Holding 3-20 3-50'116(B) Cold PHFs Maintained at or below Additives" 590.004(F) 41`145°F* 3-302112 14 Protection from Ona roved Additives* 3-501.16(A) Ilot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F. ' 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11 Common Name-Working*Containers` 20 Time as a Public Health Contra) 7-201.1 1 Separation-Stora e°' 3-501.19 Time as a Public Health Control" 7-202.11 Restriction-Presence and User 590,004(H) Variance Re uirentent 7-202.12 Conditions of Urex REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.1.1 Toxic Containers-Prohibitions"` POPULATIONS(HSP) _ 7-204.11. Santtizers,Criteria-Chemicals* 7-20412 Chemicals for Washine Produce,Criteria* 21 3-807_11(.4) Unpasteurized Pre-Packaged Juices and 7-204.14 Drying Agents.Criteria' Beruaees with Karrunghtbels* 3-801.11(B) Cse of Pasteurized E ��s* 7-205.11 Incidental Food Contact.Lubricants* 3-801.T 1 7-206.11 Restricted Use Pesticides.Criteria` (D) Raw or Partially Cooked Animal Foal and Kaw Seed S trouts Not Served. 'x 7-206.12 Rodent Bait Stations" 3$01.11(C) Uno nerved Ftxxi Packa e Not Re-served. *' 7-206.13 Tracking Powders,Pest Control and Monitori i-* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS ;[1Consumer61) ConsumerArivjsory Posted for Consumption ofProper Cooking Temperratures Par ooataAnimal Fds That are Raw,Undercooked or PRFs Not Otherwise Processed to Eliminate 3-40LLSA(1)(2) Fggs- 155"F 15 Sec. I'athoensB=ss-hnmedtate Service 145°F15sec* 2.13 Pasteurized F ggs St&utute For Raw Shell 3 40111(A)(2) Comminuted Fish,Meals &Game fi ss�r Animals- 155'F 15 sec. SPECIAL REQUIREMENTS 3-401.11(13)(1)(2) Pork and Beef Roast- 140°F 121 mini` i 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(-)(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-nmscle,Intact Beef Steaks interventions and risk tactors. Other 145°F a- 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 see. I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1](A)&(1)) PHFs 165'F 15 see. '= (Items 23-30) 3-403.11(B) Microwave-165'F 2 Minnie Standinn G itical and non-critical violations, which do not relate to the Time" foodborne illness interventions and riskfac-tars listed above, can be 3-403.11(C) Commercially Processed RTE Food- ,found in the following seenions of the Food Code and 105 CMR '14WPI 590.000. 3-103.11(G) Remaining Unsliecd Portions of Beef Item Good Retail Practices FC 690.000 1 Roasts* 23. Manafterrent and PersonnelFC-2 .003 Ig Proper Cooling of PHFs -24 Food and Food Protection _ - FC-3 ,004 25 ____ Equipment and lJ ensils FC 4 _.005 - 3-501.14(A) Cooling Cooked PHFs from 140`F to 26. Water,Plambin and W rite FC 5 } .006 70"F Within 21-tours and From 70'F 27. Ph sical FacilityFC-6 I .007 --- to 41.°F145'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 1 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial Re uirements .009 Temperature m eratH e Ingredients to 41°F I'lt 30 -Other Within __ l �r s-eax.a« Denotes critical item in rhe teafeal 1999 Food Code,ori 05 CNn2 590.000. IMPORTANT MESSAGE FOR Li z DATE 2' O TIME r D ' P.M. M Za,r r �/� L, �f l-Ie-r/� OF v`�ar'Cd�.Yrbn�' �faIl',oholaS. PHONE AREA ODE NUMBER EXTENSION ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL p� CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAXTTO YOU MESSA E AX- /4'u-e a�/'/P 8oklf, j dip t -/ A D gA XP tca4AS-D 10 fn A" SIGNED CL, o(WOf FORM 400 mim. MADE IN U.S.A.9 �/ NOTES Ca_.II_ee� Ia:.To�M S//_��nbu�k�k�-Fi�ll IMPORTAMT MESSAGE FOR 2' DATE J I , TIME '39 M ar OF PHONE AREA CODE NUMBER EXTENSION U FAX U MOBILE AREA CODE ` NUMBER TIME TO CALL TELEPHONED y PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE:YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE - SIGNED FORM 4009 MADE IN U.S.A. Nfum"'ll-Es Commonwealth of MAssachusetts ` r City of Salem Board of Health lGmberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/22/2009 ESTABLISHMENT NAME: Jaho Coffee Roasters File Number:BHF-2009-000001 60 Wharf Street SALEM MA 01970 LOCATED AT: 0060 WHARF STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0351 Jan 6,2009 . Dec 31,2009 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 L CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4""FLOOR TEL. (978) 741-1800 KINIBERLEY DRISCOLL FAx(978) 745-0343 MAYOR IDI0NNI3<7SALEN1.COM JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT _1&\An IAYS LX �Odl !\S TEL# '"'do--Iq S- S X22 ADDRESS OF ESTABLISHMENT �Q �VI �V FAX# $66 qH1 "5663 MAILING ADDRESS(if different) 1 _1, EMAIL- Business': t� Q` to.C o�^ Website: k)liJci \A A 0 �� OWNER'S NAME_ P i a { TEL# ADDRESS ( 4Ft-i tAQ 6y) SQ• Sdt, w1 STREET 14 I j�^ CITY STATE IZIP CERTIFIED FOOD MANAGER'SNAME(S) t \�V\0 \� v\L �� CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# sDAYS OF OPERATION '-Monday-., "1 --Tuesda •.-Wedn6sda '; Thursda <Fdda Saturda Sunda HOURS OF OPERATION 1 n�n Please write in time of day. ,�M-11 I"'v 1 `��-) I"'� �'�-1 I rlI/1 I -1AM 1 P/r✓( i "-1 AM- 7_�,b1 (Forexamplellam-11pm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ---- ----- - -- RESTAURANT NO less than 25 seats $�1AD� (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES k6bif(644L PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax retu�7 and aid 11 st taxes required under the law. ll,. � rL&I/0-� p2S- 7-b — cebas Si atur� Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date l The CommonboeaCtb of A&M5arbitzette; DEPARTMENT OF PUBLIC HEALTH, DNI9ION OF FOOD AND DRUG$ 305 SOUTH STREET,JAMAICA PLAIN,MA 02730 LICENSE 5 5 In Accordance with Massachusetts General Laws Chapter 94 Section 305C yr NUMBER ISSUED EXPIRES TYPE S MA-7138 0312512449 03/2512410 Process or Distribute Food for Sale at Wholesale 5 ISSUED TO JAHO INC. JAHO COFFEE ROASTERS&TEA MERCHANTS 60 WHARF STREET SALEM,MA 0197 1 %. COMMISSIONER OF PUBLIC HEALTH 5 POST IN A CONSPICUOUS PLACE S RECIPIENT'S COPY 477961 Cd nc,�nrn�r ri'+ ' .. ren ;rumr u'un ';.nnnruanuarc �r•,' ,�-rum - �,ter' i CITY OF SALEM _JS -VnBOARD OF HEALTH / Establishment Name: Q C Oj t C r�C `}��S Date: I as lcp Page: of { Item Code 5C-Critical Itervii DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date ! - _ <, „ Verified No Reference R—Red Item r ; - ' - °' q `^ z I PLEASE PRINT CLEARLY I �� Ptd-Jn7 � Vlln� l i 1 pec �t �n wGt� c -)f1C U C__ffC( C'f rlc�l t¢ At bvd initis( Inklton aa log (a) Irbo�-L ") V-NOA wdf4� d c� V�J� iY eerv',l�l 11�� cx/� �1� nc �L�ict� �1 �JVI 5 . tQ.CY'✓T i� <<its Cf '.mak_t,' �uY�ct � X517 2�YlSPi�• (/ v 4 0-'GC+OfI L4;30p � . tQ ct b�Ye �iolcxfi )ns (7ac> ivy _h4Q �v�U/� • \ Jrc )IAG.( W1v�( cov , _c f lUM5• DpYoL4t c" o-i' (mot (L kQ_ E Ct h�i �YiwtBvi� Cl t� (S pew ri Wr( 45 upon k > .)A ISNcx=ehdj� CC Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes 'i I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee RestrExclusion iction/ ? violations before the next inspection, to observe all conditions as described, and to 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 C3 Embargo ❑ Emergency Closure I your food permit. �.�� j / f ❑ Voluntary Disposal ❑ Other: 5 i 53314{C} PFiEtsRr„civcdatTeenfSeraturls�—j Violations Related to Foodborne fitness ftittsvenrlrrns and Risk Accordiro,to Lae Cooltil to Factors(Ifeew 1-22) (Cont.) 41°1445',F Within,' Hows, PROTECTION FROM CHEMICALS3-<:}1.75Gxlliu�,Mclbods for PHF, PHF Hot and Cold"ding I]C4 Food or Color Additives F!C-99 -- -TJ -72(7212 'ditive, 1 16(13” Cold PHFli Maintained at(w belvo, - )tection from 90,0l 4i"t45°F ---4; 3-501.16(A) I IN IsHFs i4aimlinned at or above Ii c5 — Poisonous or Toxic Substances �2t4 Pii 446114L11 E '. T ConoullcrS� 1.16(A) 1 Roasts Held at of (ommon'Namc, - workill aulens=- 20 Time as a Public Health Control 1 �-50 .1 7-201.1 t ---— tl�ia Publie I lotildi Control'- ��7 90,004�14) Variance R��rc nl�nt -202.11 Rcltricdon-Pri'scrice and tete* 7-20112 Conditions of ikv. ---- - ' -203 t I ii7o Comion Prol;i1ni ions, REGUIREMENTS FOR HIGHLY SUSCEPTIBLE 7 -- 'F ioldc�lls* 7-204AT Sarl rdria-6-,- POPULA IONS(HSP -7-2(4.12 Chemicals for W�e 1, F-2f 1-801.11 lA4 Uninosicurizod Pre-paidaged Juices and 4 Di — 7-204,1 Rewralles Avah Warni — 11(B) Use of f"U'learized bcjn� ;_265,I—I feasiricied[.Tw pv�dcidci;,Criteria, '3-801.1 1(Di 1-11-IIr Pau i it I J Gaited An i ma I F-(-X-j 711 T- 7-206.12 Rodem Bail Stiaion�' fole,St.ed Sprout. Not StrveeL -——--- ------------- - - tl-lsol !(�L- L106,11 Tracking Poeders. Pest Coatrol and L ) -j --V"-- CONSUMER ADVISORY TIMFITEMPERATURE CONTROLS 22 3-601-11 ('�)rqaaeraaji;s0ry P(i�aed l(ir F�M-Itlutptuln of 'sann'll 1-old�-fluitarc Raw� Under"li Iti Proper Cooking Temperatures for mcd C-1 PHFs Not Othdm ise Piulcessed to 1-lin flaw i'gg.,- 155'F 15 Su- h ot Micias&Unix: og 7401 11(A)(,,, Comminuted fish, ., itirmodiacc qer,,icc I'll T l51,cc I,�;)2 13 Fog:;Substitute fol Raw sh Animals 155"F15sec. " SPECIAL REQUIREMENTS 3 4F)l 71 Polk and Beef lialast - 1301, 121 amq* 3-401.1 IlAg ) Raines,bijeoii iiAt is - 155 F 15 s40ection J904)9(A) (D)in se, cawrine, niolule tood. ternporary and kitchen operations should be 340lJl(A)f3,t lloulnn,Wild Gaille, Sniffed 11141", re'side'lltal 1� Sluff ng CowaiwnL-,FishMeat 4 jobiled under the ripproprlinC ieCl-lolls sec. above if related to frKAborric iiiacsg 3-401.1102)9) 6hvle mus tc finso Roof Steaks interventions aad risk factors. Odder 14501, 4* 590.009 violations relating to 000d retail 3-4t)I.12 Raw Arl Fo(Kis Coiilkod ma I praclilcc;tiould be debited under#29 Special Requirentarits. -40l,lliA)(l)(b) All Odun PlIFq 1451: 15 sec, C E7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACUCES (Iterni 23-30) 1403.11(5) Nficlowave 165'r 2?VlimuStanding air tall wrli, wbichdow); elate u,file., ince' frro fbvrna IZtue rc mut c:cn&r tri ups'ri+A jrrcs¢rr limit at oir. can Fir. commerciaT, tioand in fia,jolh nwn, sec urnis of the Food Code and 10,5 (.,,VR 140'fir 03 1 I(Fi I Run umn�t pati ed Portioas oP llecf (?fens f Good Retact Practices _ -t F_ �530.00t1 1 Roast,* Moangurnept and Percorinpl ,,4 Propel Cooling of PHIPs 24,.- Fc;r�d and rood"Pr-o-1 ---tlo'n- FC 9 OLA - FG - 4 3-5o1.14(A) cocling Cooked PI-11-s froin --------- ------- 26-,- 'eldoreste F 70'F Within 2 ffours and Foni'll)"I -o------------I 2T Phyr,rd Facilllj� a 007 to 4 1 1`145e F Wifiti n 4 Hour, ile, Poisarious or Toxic Materials FC-7 008 ------------- ---------- ------------ ---- --- 1,i(B) Cooling PHF,,Made filoal Adniicut ------ 009 T mporawite ingredients to 41�F/45 01hef ---------- -------- Within 4 fioursO Denote, mialien in lh,iollllritl 19,99 Fotxl CeAle,r 105 CMR 590 EXAM FORM NO. 4402 % Serrw9a � CERTIFICATE NO. 6259683 •� xyy t�b� t ., Berw5afe ® Y•yi�.4#. }% O ®S japes—_ ®on i � a 1#s m� to A ,N, A 1. EZ.IaN I " for successfully completing the standards set forth by the National Restaurant Association Educational Foundation for the ServSafe'e Food Protection Manager Certification Examination,which is accredited.by the American National Standards Institute (ANSI—Conference for Food Protection (CFP). 1/8/2009 DATE OF EXAMINATION 1/8/2014 2lu DATE OF EXPIRATION. mellum Local laws apply.Check with your local regulatory agency for recertification requirements. r t •t t/ #0655 ® NATIONAL l RESTAURANT National Restaurant Association David Gilbert ASSOCIATION Executive Vice President.Products and Services Group EDUCATIONAL FOUNDATION f National Restaurant Association Solutions S 0 L O T 1 0 N S TM ©M National Restaurant Aasocietian Educational rvundation.All mine reserved.ServSaW and the SeorSsfa logo are registered trademarks of the Ne conal Restaurant Association Educational Foundation, and used under license by National Restaurant Association Solutions,LLC,a vol oxned subsidiary of the National Restaurant Association. This document cannot be reproduced or altered. W1211W v.0812 Student Detail 1/20/09 11:46 AM SEARCH �� Goi HOME CHECK EXAMINATION RESULTS TAKE ONLINE COURSE/EXAM PURCHASE MATERIALS ACCESS MY ACCOUNT CUSTOMER CARE/HELP Certification Support IFind a Class or Instructor/Proctor a Class or Instructor/ProctorI Regulatory Requirements Regulatory Requirements Hello ARNOLD MEZINI Examinee Score Analysis Report - Detail This report is meant for online viewing only. Printing a hard copy of this report may not be considered appropriate documentation to meet regulatory requirements. If you passed this course, you will receive a Certificate of Completion from the individual your proctor designated as responsible for exam results. If, for any reason, you need to obtain a duplicate of the original certificate issued to you click here. Course Name:ServSafe Food Protection Manager Certification Examination Student:ARNOLD MEZINI Class Tracking Report Class Information Class Number Organization Instructor Name i' Exam Location Exam Date Hold Code Cert. Number ' /Fail 720202 Pilgrim Hosp Richard Doyon MA 1/8/2009 6259683 Passed Form Information Test Pass Your Form Percent Percent Score Score 4402 75% 92 % Domain Summary Domain % Score I. Foods 89% II. Clean/Sanitize/Maint. 100% III. Facilities 67% IV. Monitoring Food Personnel 100% I V. Temp. Measuring Devices 100% VI. Allergens 100% VII. High-Risk Populations 100% VIII. Legal/Regulatory Issues 100% i IX. Facility Layout/Design 100% X. Training Employees 100% http://�.sewsafe.com/irc/classes/Student Detaii.aspx Page 1 of My Exams ^ 1/20/0911:45 AM • SEARCH GD HOME CHECK EXAMINATION RESULTS TAKE ONLINE COURSE/EXAM PURCHASE MATERIALS Jct ACCESS MY ACCOUNT CUSTOMER CARE/HELP I Certification Support 1 Find a Gass or Instructor/Proctor I Regulatory Requirements Hello ARNOLD MEZINI My Exams Note: If your exam does not appear here it may be because is still in progress or being processed.To check the status of the class click here. Class �� Course Date Score Pass I. Expiration I' Class .I % Date I, Tracking 720202 09-ServSafe Food Protection Manager Certification Examination 1/16/2009 92 Passed 01/08/2014 Tracking Don't see your score OW If you do not see the score % for your class, please click the class number to view your results. Don't see your class? 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I Class Number : �— Certificate Number Exam Date i Zip Code Last 4 digits of your SSN Find RecoM WrlSians Secured YI bPPr aeour BSL O:RTIrtUlES About Us I FAQs I News&Media I Contact Us I Legal and Privacy I Site Map Copyright 2009 @ The National Restaurant Association Educational Foundation http://w .seNsafe.com/irc/classes/myexams.aspx Page 1 of 1 Class Tracking Reports 1/20/09 11:48 AM q11 Ro SEARCH HOME CHECK EXAMINATION RESULTS TAKE ONLINE COURSE/EXAM PURCHASE MATERIALS l;j ACCESS MY ACCOUNT CUSTOMER CARE/HELP I Certification Support I Find a Class or Instructor/Proctor I Regulatory Requirements Hello ARNOLD MEZINI Instructor Resource Center Class Tracking Report mm ServSafe l0 Food Safety Training and Exam Go Back Solutions For Instructors/Proctors For Student/Examinees '+Class Tracking Information F ® Purchase Materials Class Number 720202 ' State Regulations Course Name 09-ServSafe Food Protection Manager Certification ® In The News Examination Resource Center ' Current Status Print Certificates-January 16 2009 ® Food Safety FAQs 4 Exam Date 1/8/2009 _ Exam Location MA ® ServSafe Alcohol Instructor Name Richard Doyon 1 ® Training and Exam Organization Pilgrim Hosp Solutions Exams Sent 12/19/2008 3:42:54 PM - ® For Instructors/Proctors Instructor Received Exams - ® For Students/Examinees Exams Received for 1/13/2009 12:58:00 PM - ® Purchase Materials Grading ® State Regulations . Checked in 1/15/2009 11:31:19 AM - ' ® In The News Scanned/Verified 1/16/2009 - Resource /16/2009 -Resource Center ; Grades Faxed/Emailed - ® Responsible Alcohol FAQs Certification Printed 1/16/2009 - Other Educational . Certification Sent - Products Certification Received Class on Hold ® Industry Resource Links PRestaurant.org ~� NRAEF.org Find a State Restaurant Association p Intemational Food Safety L� Council •m National Food Safety L�j Education Month -O Foodservice Workforce Solutions ^3 Restaurant Hotel-Motel d Show V:r81an rEeuaw VERirr• Heart WL omnRuM About Us I FAQs I News&Media I Contact Us I Legal and Privacy I Site Map Copyright 2009©The National Restaurant Association Educational Foundation http://www.semsafe.com/irc/classes/Submit_ClassTracking.aspx Page I of 1 /Pest Control Service Agreement B & B PEST CONTROL 271 Westem Avenue, Suite 203 8885 LYNN, MASSACHUSETTS 01904 (781) 599.4317 CUSTOMER SERVICE LOCATION J�/lMo J c STREET �vd wNARr CITY,STATE and ZIP PERSON TO BE CONTACTED SERVICE PHONE S�lCe.r, w PHONE TYPE OF PROPERry TO BE SERVICED DATE SERVICE BEGINS EXPIRATION DATE RENEWAL SERVICE TO BE PERFORMED I'26-Z4V7 -�pNc¢. ❑ El MONTHLY [I QUARTERLY ❑OTHER PESTS TO BE CONTROLLED: --------- --- --... ___.._ -.._.___. __ _. __ _-__ - ______ _ ___ _.___ -_-__ _____- ._ ____ _- ..._ - ---- Jr_�o - +vices ---------Se---- d°r�ioi,.,z0__ SPECIAL INSTRUCTIONS: -------------------------- --___--_-_- -- -_------------------------------------------------ ----,--- . , of , ------------------ - Xlee�Z /6-.71 o / ,f TERMS AND CORDITIO SERVICE GUARANTEE:We agree to apply chemicals to control above-named pests in accordance with terms and conditions of this Service Agreement. All labor and materials will be furnished to provide the most efficient pest control and maximum safety required by federal, state and city regulations. SERVICE RENEWAL:This agreement shall be for an initial period of one year, and will renew itself annually unless either party cancels _ this agreement by giving thirty days written notice before any expiration date. ANNUAL AGREEMENTCHARGE $ BY /-2 -2-"f J R H INITIAL SERVICE CHARGE $ COMANY (AUT DATE MONTHLY/QUARTERLY PAYMENTS $ FOR CUSTOMER DATE (AUTHORIZED SIGNATURE) CITY OF SALEM BOARD OF HEALTH Name of Establishment: Jaho Coffee Roasters & Tea Merchants Address: 60 Wharf Street (58 Union Street) Owner(s): Anil Mezini Phone: 978-223-8982 The Owner of this proposed establishment presented a Floor Plan for review in accordance with the State Food Code. FLOOR PLAN The Floor Plan is approved with the condition that the one bay sink and the hand sink switch locations so that the hand sink is closer to the sandwich unit. Hand sinks must have wall hung soap and paper towel dispensers. These must be stocked at all times. If the hand sink is located close to a food prep area, a splashguard may be necessary to prevent cross contamination. All floors, walls, and ceilings where food, utensils, paper products, etc, are stored, prepared or served must be intact, impervious, and easily cleanable. EQUIPMENT All food service equipment must be NSF (National Sanitation Foundation) approved. The dishwasher must wash, rinse and sanitize all dishes, utensils and food equipment. The dishwasher will sanitize using high temperature rinse of at least 180°F. There will be a small and larger coffee roaster in this store. The smaller unit states that it is a "smoke-free device that eliminates smoke as well as odor." The literature for the larger unit states that, "The self-contained drum and chaff filter virtually eliminates odors and emissions for an environmentally friendly roaster." The owner understands that the roasters may not create an odor nuisance and that he will be required to stop their use if an odor nuisance is observed by the Board of Health. MENU/FOOD PREP Any pre-made items must be purchased from a wholesaler licensed by the State or prepared in Jaho Coffee on Derby Street All food must be held at 41°F or lower, or 140°F or higher, at all times. A thermometer must be used to check temperatures in the sandwich unit. There may be no bare hand contact of ready-to-eat foods. Gloves, tongs, or tissues must be used when handling such food. CERTIFICATION There must be a Certified Food Manager working at this establishment full time. When a CFM is not onsite there must be a Person-in-Charge (PIC) who is fully trained in sanitation techniques and has a thorough understanding of the operation. 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. 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. Outside area of premises, including the dumpster area, must be kept clean and sanitary. If any products prepared at this establishment are sold to other stores, the owner must apply and receive a wholesale permit from the Massachusetts Department of Public Health at 617-983-6712. If there are 25 or more seats in this establishment, there must be an employee, on site at all timesnhe establishment is open, who is choke-saver trained. oanne Scott' Date Health Agent h. niNMezirii Date Jaho Menu Beverages Hot Coffee Ice Coffee Cappuccino Latte Espresso Machiatto Cafe Mocha Loose Leaf Teas Iced Teas Sipping Chocolates Orange Juice Foo"nacks Desserts (Cheesecakes, Carrot Cake etc) - wh°�tsa� Pastry (Croissants, Breads, Scones) Sandwiches CITY OF SALEM r e PUBLIC PROPERTY U DEPARTMENT BRI.EY DRISCOL L MAYOR 1k20 WASHINGTON STREET 1 SALEM,MASSACHUSE"ITS 01970 / '1$L:978-745-9595 ♦ FI-X:978-740-9846 REQUIRED INSPECTION PROPERTY ADDRESS 60 Wharf Street June 9, 2008 RECEIVED Mr. Anil Mezini 197 Derby Street 'JUN 10 2008 Salem, MA 01970 CITY OF SALEM BOARD OF HEALTH Dear Mr. Mezini We have been notified by the Health Department that you have submitted plans for their approval for a restaurant and coffee roasting business at 60 Wharf Street. The plans submitted indicate an amount of work.that requires a building permit. No plans or permit applications have been filed at this office. You are hereby ordered to halt all construction activity until a permit application is submitted and reviewed by us and the property inspected by us. The project , as described in the plans submitted to the Health Department will require plans prepared by a registered Architect and must comply with the State Building and Plumbing Codes as well as the regulations of the Massachusetts Architectural Access Board. Our inspection must be completed on or before June 20, 2008; failure to respond to this notification will be construed as non- compliance, and as such an Administrative Search Warrant will be sought, so as to allow the lawful inspection of this property. If you have any further questions regarding this letter, please call this office at (978) 745- 9595, extensio 644. Sinc e , Th cGrath, AIA Assistant Building Inspector/Local Inspector CC: file, Dep 1 Fire Prevention, Mayor's Office, Councilor McCarthy P'ROBAT PROBNONE Solid Drum Coffee Roasters Formerly the L series All four Probatone coffee roasters utilize the classic drum technology with special enhancements designed to ensure gentle, uniform roasting in a range of capacities. The self contained drum and chaff filter virtually eliminate odors and emissions for an environmentally friendly roaster. The result is a roast of premium color, rich aroma and exceptional flavor. Additional features include: _ • � � • Modular design for easy maintenance • Simplified controls for ease of use • Solid roasting drum and special paddle mixer to ensure optimal blending and an excellent roast • Continuous monitoring technologies to ensure roast quality • Environmentally friendly designs virtually eliminate emissions • Rapid cooling to retain the desired aroma and flavor of the beans • Energy-saving designs to minimize costs • Low noise, designed for in-store roasting Probatone 5 5 - 11 up to 44 Probatone 12 10 - 21 up to 104 Probatone 25 55 up to 220 Probatone 50 100 up to 400 For more information about the Probatone coffee roaster, contact ns http:/Mrww.probatcomindex.php?id=t&L=0 Major Features and Functions NEW— D New Features 1.Speedy power roasting at the rate of up to 6kg an hour. 2.Continuous automatic roasting program can run during cooling of roasted beans. 3. 'Maintenance Free'concept is achieved by the simple design. A.8 hours continuous usage is achieved by upgraded hardware. J 5.6 stage smoke free device eliminates smoke as well as odour.(l.Okw)(5 Stage fort 2OV) 6.Aroma roasting and gourmet coffee taste is achieved by using the auxiliary heater. (400w) 7.Consistent roasting even under irregular voltage is ensured by cutornaticaly adjusting the temperature of roosting beans. 8.Precise preheating function ensures accurate and economic roasting. 9.Accurate problem analysis program permits simple DIY maintenance. 10.Steam deoning function after every 5 roast cycles enwres cleanliness of the drum and reduces odours. D Previous specifications continue in the following areas. 1. Fully oubmatic digital operating and manual mode for ease of operation. 2.The roaster can be used by lust plugging it in to a regular power outlet without needing arty additional,high paver wiring. 3. Roasting heat is aeated by use of hologen lamps. A. Built in electronic sale automatically calculates roasting temperature from the input weight of the green beans. 5.Factory created roasting program can be changed to your personal roasting program. 6.Self diagnosis program allows simple maintewnce. 7. Built in fire extinguishing and water quenching programs are available in case of a coffee bean fire. 8.Easy to install compact and lightweight roaster for a professional coffee roosting service or coffee shop. 9. En ironmentally friendly,smoke five device. 10. Elegant styling and easy to use design. 11.+/-1 IC temperature variation is maintained by the computer. 12.Two temperature sensors ensure safe roasting. 13.Astonishing coffee bean expansion ratio(more than 85%on average)can increase coffee flavour. 14.Optimum taste and flavour is produced by water quenching to rapidly cool the coffee beans. —3— s„ t OyVN�E''j'S'' ty �' s r P f x YA �� a'zk'-t't�'"��"y'�✓ € � +„4` �� tR � i� — �' �} A�.='"� it t y ��1�'�- �"`*•:� d^rte i tts�S'� `��+'. Y�..r t n fA >ti A tf! ''k tt s 1 -^�s y•� J n u fi- n��l��k fi