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KIDSTOP INDOOR PLAY CENTER - ESTABLISHMENTS KIDSTOP INDOOR PLAY CENTER 400 Highland Avemie li �I II SP 4ioCommonwealth of Massachusetts City of Salem Tau Board of Health 120 Washington IGmberley Driscoll Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Kidstop Indoor Playcenter File Number:BHF-2004-000007 400 Highland Avenue#13 Salem MA 01970 LOCATED AT: 0400 HIGHLAND AVENUE#13 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-200&0024 Jan 3,2008 Dec 31,2008 $70.00 Total Fees: $70.00 PERMIT EXPIRES December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted 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 V of 28 I � QTY OF SALEM, MASSACHUSEM BOARD OF HEALTH 120 WASHINGTON STREET,4"`FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 r MAYOR TSOOTTna SALEM.COM " ---- -_ _ JOANNE SooTT, NOV 2 9 2001 HEALTH AGENT CITY OF:SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT K lw-ro Cf TEL# 978'-Zy0.3167 413 ADDRESS OF ESTABLISHMENTAf U�` FAX# MAILING ADDRESS (if different) EMAIL-Business': Website: KIdslill llcm • corn OWNER'S NAME Micf eJ1c, '8rode-r c-r- ,, y� TEL# gZ9-3LII r02�OZ ADDRESS 7 Har� fnrd S-6 • VitIeM It a Dl0J70-1033 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON ow nt HOME TEL# DAYS OF OPERATION I Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION Please example 11me o1day. 9A -V 90-IP 9A -9p �� 9A -9 P �,qlq �A-9n For example 11am-11 m alxImIA rn amourYC o ours We- coulpl open)� TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. _$70 1000-10,000sq.ft. more than 10,000sq.ft. =$420 - - - - - �-��---�- -------------------------- - - -----------------------------------------I-e-YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 sears =$280 more than 99 seats =$420 ---------------------------------------------------------------------------------------- BEDIBREAKFAST/ VIES----�NO $100 CHILDCARE SERVICES ...-- -�--�--� -... .-..------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES19 O $25 TOBACCO VENDOR YES $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 fled all state tax returns and paid all state taxes required under the law. 11JZloJO-7 02x-&49-2-123 Signature Dae ocial Secu Federal Identification Number - -- - - ------ --------- �� --------- -----------------—----- ------------------------ -------- 3� --- Revised 4/24/07 FOODAP2008.adm Check#&Date �J- 0400 Highland Avenue #13 Kidstop Indoor Playcenter City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 740-3187 Physical Facility FAIL BLUE Owner: Comment:There are water stained ceiling tiles in the party room. Find source of leak and repair.Replace damaged tiles. Michelle Broderick PIC: Scott Broderick Inspector: John Gehan Date Inspected:Correct By: 4/25/2007 Risk Level: Permit Number: BHP-2007-0098 Status: SIGNED OFF #of Critical Violations: 0 j Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 25,2007 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) C l 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. Apr 25,2007 ) Page 2 oft n H20range2 An environmentally preferred product CER�e�� HxOrangez Concentrate 117 is certified under Green Seal GS-37 Standard for Industrial and Institutional Cleaners. Ald # �• s '' In order to meet the GS-37 Environmental Standard,H2Orange2 Concentrate 117 s� a satisfies all of the following health&environmental criteria: gr 1, Concentrate is non-toxic to humans - P 2. Concentrate does not contain carcinogens or reproductive toxins 112OFar19e2pYOOM aP_W ical, 3. Concentrate is not corrosive to skin or eyes a ' 4. Concentrate is not a skin sensitizer sreduced-aoxrcity alternaitue to" �a, 5. Concentrate is not combustible contkmtional.jgnitoricil cleaning 6. Use solutions do not contribute to smog formation or poor indoor "" , ; - , air quality "sy terns,It is a arable new tool in a 7. Use solutions are not toxic to aquatic lifethe eforl to prptrtde it e�anjsafef 8. All individual ingredients are readily biodegradable `" 9. Use solutions do not contribute to eutrophication (no phosphates) -m ng and lunng enm"ment e" 10. Product is sold as a concentratey H2Ora gea reduces toad. by ? - 11. Product's primary packaging is recyclable 12. Product does not contain specified prohibited ingredients ellmina#ng chentkafa' k ,Ix ' A full reference detail of the health and environmental criteria may be found at common lytised innu �aorial www.b2orange2.com or www.gretnscal.org ' "j cleaners. 112Orange2 contains In addition to these technical reguiremew for GS-37 certification, there are additional - "_ tl r criteria for Organization,Regulatory Compliance, Training,Education and Labeling, no Acids, Alcobol, Amines, and Quality Control. ,a Ammonia,Caustic, Chlorine Hydrogen Peroxide modified, Citrus modified, Multi-purpose, 73leacb, Glycol Etbers, Reduced Toxicity, Sanifizer/Virucide, Cleaner/Degreaser Phosphates, Quaternary H2Orange,kills 99.99%of Staphylococcus aureus,Salmonella choleraesuis,Klebsiella Ammonium Compounds, Dyes, pneumoniae,Pseudomonas aeruginosa,Streptococcus faecalis and Escherichia coli,in or Fragrances. 5 minutes on hard surfaces. H2Orange,kills Herpes 2,Influenza A2/Japan and 111V-1. US FPA registered(>r692(a4-2) 1 IE P C E ARO A 0 '�� a -7 - 4• fay: 1.764 - • . • ill .14 www.lizurdflye- • IMOD0 0 1 . V L•+ CA1 . j PLENTY OF FREE PARKING a ADULTS ARF, ALWAYS. FREE! NNE • ! . , • CONQUER OUR MAZE *JUMP IN OUR.BALL PITS DRESS UP AND PRETEND LETS YOUR CHILD USE THEIR IMAGINATION * SNACKS AVAILABLE •ALL DAY. PLAY - LEAVE AND COMEBACK WITH;PASS • CHILDRENMUST BE.ACCOMPANIED BY,AN.ADULT 18 OR-OLDER pARTY SUND *.H aaa 9 1 �c-r^ IS ca 1YOUFts! WE OFFER SMALL PLAY GROUPS OF 3-9 KIDS - $6.0EACH OR BIG PLAY GROUPS OF 10+ KJDS �- $5.00 EACH BASIC BASIC+:PLUS. ULTIMATE •Pizza.(2 square pieces each) Add one to the BASIC,pkg.. *Pizza(2 squarei pieces each) OR •Cake with a theme •Cake with a-theme *Cake'with-a theme .*Goody bagswift a theme •Goody,bags` *Paper goods with balloon design *Paper goods with.a theme •Paper goods with;a theme 12.00 per child 15.00 per child 18.00 per child ' (minimum of 10 children) (minimum of 9 children) (minimum of 8 children) ALL`PARTIES INCLUDE: •2 hours in the private party room •unlimited play time •a party host/hostess to serve and' •a;balloonfor every.child +unlimited'juice for the kids:(apple or fruit`punch) t HILAN VE., SALE e = , 1 7 CITY OF SALEM, MASSACHUSETTS BEARD STREET, E RECEIVED 120 WASHINGTON STREETT,,4 4TH FLOOR SALEM, MAO 1970 TEL. 978-741-1800 DEC - 4 2006 FAx 978-745-0343 CITY OF SALEM Kimberley Driscoll www.SALEM.COM BOARD OF HEALTH Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 7�1idS!!2 1 r � _ -+ P/QL{(!ent�Y TEL 19 7S'7LIQ ,3 I 7 ADDRESS OF ESTABLISHMENTL460 M4 K I I P• 13 FAX# MAILING ADDRESS(if different) EMAIL--Business': AA � ,�!,�,, ,�J,, ,,` Owner's:Mt (.— C.'o-1771�.. s 1 ne—t OWNER'S NAME lyrl(,,,I f�J/,QJ L/Y�C1il( YIrCL.K� c . 1 TEL# 913— I`7J-02&2 ADDRESS 7 l'7(ar4-f0 01 , 1Z . �& I eM X1q 01'776-10 3 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) NO P6PEPPREb ON PREMISES (Required in an establishment where potentiallyhazardousfood is prepared)) / EMERGENCY RESPONSE PERSON !°ll+�Ile �YtL_�`e—rl',.,Ay HOME TEL# 9797`11 02& 2 OAVSOFOPEMEOR Monday Tuesday Wednesday Thursday friday Saturday Sunday ROU RS Of OPERATION Pleasewrneintimeatdav, 30_ SD 3D 34� ?3' 73a ifof examote nam-nnmt 9 9 �%313-�' • 9 30`�' 9,:3D- 7 -- �_ 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 =$200 _._.. ... - _. ----NO- .. .... ... ----- -- -------- - - --- --$, - ---------------- ----- --------- --- BED/BREAKFAST YES $104 ----------- - ---------- ------------ ---- --- ..... .. .. ... _.. . .... _. .... __.--..._.-.......... .... ...... 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, hay tiled alk state tax returns andaid all stat��taxes uired under the law. Signature Date Social Security or Federal Identification Number -------------------------I------------- ------------ -------------- --------- ------ ----- --------------------- ------------------------------ -------- --------------- Revised 11/13/06 FOODAP2007.adm C.heckti 8 Date/D,j�.,r „J 1r ( $ ,8d � t"-„ ,4,�a`Yah',�wv� y��". �•', , nor #�' ki �{tb.m` 'S ��•y C ,yk# "A. `s['Trek '�,� . a �'�R >W k.- }-Ctlk$ frr,Y> yy:µYft S .-. +.i.w M�q '`i• s 5 1 pM '� cyww i `il. , a, { Commonwealth of Massachusetts v ll - .�yS` ^'�?"` `, ,,`-,fir -se x *n^+'yy e ar. Axa J f � `at•v'. .�`^{ , ,�'V`° City of Salem j �,3d V xrt v�tg # '»*^. ¢ rA s. °- • _ • i E.w )r Board of Health V Vmd$Wv1"y"t( yp 4 +SY�Ys1x 't tf.+,'r2 'xka... '�P'�:i;i. '*��'S`'V pa.,:. >x 120 Washington Street,4th Floor, lalnl>ettey Unseoll, U SALEM,MA .01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: Vidstop Indoor Playcenter File Number:BHF-2004-000007 400 Highland Avenue#13 Salem MA 01970 LOCATED AT: 0400 HIGHLAND AVENUE #13 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0098 Dec 19,2006 Dec 31,2007 . $50.00 Total Fees: $50.00 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 1 of 2 IMPORTANT MESSAGE FOR :�sanvt DATE !�i �� LIL-TIME OF PHONE AREA CODE NUMBER EXTENSION O FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL ' WILL FAX TO YOU MESSAGE SIGNED III FORM O5 MADE I .S.A NOTES ---- - - - --- - i---- CITY OFSALEM BOARD OF HEALTH Establishment Name: 1 G \/_)� Date: i a1L2 Page: ` of t Item Code C-Critical item g DESCRIPTION OF VIOLATION/PLAN OF CORRECTION VDate erified No. Reference R—Red Item .., +PLEASE PRINT CLEARLY - ".- '�51r'C d u r rn 0 l 1111 n� ("U n 6,. a Ss a nj mcciectnt ,i M 11S XA-nhl ) h 1A4 IWS, 0,)(4e —Th-a I Ulna to viybiV #4 �h P IAM 60AJ 1tn l I 1 CQ r O C l 11�1�' I d 17 1 V' 0 � ( .. 60Onn000 bl hd /C�� _ PoA11 . 1 IM&0_1. si )��Q �� ,1e -mel , -I)O A6 rr -7-PV V` A 11 tdt�J) Qt (�b� I I Tl-i q tN T G E r n nd 4R- . v :f i iq � V) %i) haM S S) G rrn Q t 1 if Nm _' fitb 1° \h I Ce r(rro m Ai 1 K61 is \ mS . 5VJmc . In Ao s On -�--d OJT o G k NSXa,` ak Q CNAM l) - Discussion With Person in Charge: , Corrective Action Required: ''❑ No ❑ Yes Lhave read this report, have had the opportunity to ask q estions and agree to correct all L3 voluntary Compliance LJ Employee Restriction violations"before the next inspection, to observe all conditions as described, and to Exclusion P Ll Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that nor compliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo El Emergency Closure !+ your food permit. ( /f"� ❑ Voluntary Disposal 0 Other: 3-501.14(C) PHFs Received at Teitperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'F145'F Within 4 Hours. PROTECTION FROM CHEMICALS 3 501.15 Cwlin�Me hods forPHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives" 3-501.16(B) Cold MIN Maintained at or below 590.004(F) 41%45'F* 3-302.M Protection from Lina t proved Additives* 3-501.16(A) I lot PI1Fs Maintained at or above 15 Poisonous or Toxic Substances 1aa'F. 7-101.11 Identifying InlorntaYion-Original 3-501.16(A) Roasts Held at or above 130°'F, C.ontaiuers" 7-102.11 Common Name--Workoo,Containers` 20 Time as a Public Health Control or 7-201.11 Separation-Stage;, 3-501.19 Time as a Public Health Control* 7-202.1.1 Restriction-Presence and Use* 590.004('H) Variance Requirement 7-202.12 Toxic Containers i ers- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic C'ontaincrs-Prinhibitions"` 7-204.11 Sanitizers.Criterio-Chemicals* POPULATIONS(HSP) - 7-204J12 Chemicals forWashin Produce,Criteria* 2.l Beverages with Warning Labels* 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14Dr iu>� ants.Criteria* -��- 3-801.1 I(B) Ilse of Pasteuuzed E,e Use s* 7-205.11 Incidental FooUw Contact,Lubricants* 3-801.1.1(D) Raw or Partially Cooked Animal Foil and 7-206.11 Restricted Pesticides. Criteria* Raw Seed S trouts Not Served. :, 7-206.12 Rodent Bait'Stations" 3-801,11(0) Uno rened Food Package NoC Re-served. 7-206.13 Tracking Powders,Pest Control and Monitorial+=" CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Folds That are Raw.Undercooked or 16 Proper Cooking Temperatures for PHFs_ Not Otherwise Processed to Eliminate 3-401.LIA(1)(2) FiPathoge g, 'LS5�F15Su.. 21S.*EOecove m�oai E is Inmedt ttc,Service 145°P15sec* 3-302.13 1 Pasteurized Eggs Substinrte for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game E es* Animals- 155'F 15 sec. 3-401.11(13)(1)(7) Pork and Beef Roast- 130'F 121 ruin" SPECIAL REQUIREMENTS _ 3-A01.11(A)(2) Kntites,Injected Meats-155`13 15 590.0O9(A}(D) Violations of Section 590.009(A)-(D)in sec,', catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Staffed PHI's, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Po t ft;or Ratites-165°.F 15 sec.a: above if related to foodborne illness 3-001.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other - 145`13': 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under 1129- Microwave 765°F* Special Requirements. 3-401.11(A)(1)(h) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 1650F 15 sec. * (Items 23-30) 3-403.11(13) Microwave 165°F 2 Minute Standing Critical and non-critical violations, ndrich do not relate Io the Time* 'foodborne illness interventions and risk factors listed above, can he 3-403.1.1(C) ComanerciallqProcessed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F" 590.000. 3-40311(E) Remaining Unshced Portions of Beef Item Good Retail Practices FC 590.000 Roasts* 23. Manaement and PersonnelFC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC--3 004 25, ___ Equipment and Utensils FC 4 005 3-50't.la(A) Cooking Cooked PHI-'s from 140'13 to 26. Water,-PI and Waste FC 006____ r0"F Within 2 Hours and From 70'F 27. Physical FacilityFC--6 .007 Lo 41°F/457 Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Coo6n,PHFs Made From Ambient 29. Special Requirements - .009 Temperature Ingredients to 41°F/45°F 30,, _Other Within 4 Flours* i:sw)r .b,cer zd„, 'Derotas cr¢ical item in the fMeral 1999 Food Code or 105 CNIR 590.600. CITY OF SALEM i BOARD OF HEALTH Establishment Name: 7 I I�J/U� Date: ��'o�U�Q�O Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red item Verified . „��'... PLEASE PAINT CLEARLY ."'"t , - ` -h //o�ir�� GuP/ n -.l �Li/ lfi/�' fi Cid in ��ie is oza A::2,06-0- - t w r s 4 ' 6 Discussion With Person in Charge: Corrective Action Required:' ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure our food ermit. J y . {l+ E p 'C�C��a� 13 Voluntary Disposal ❑ Other: 3-50 1.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to taw Cooled to Factors(items 1-22) (Cont.] 41°F/45°F Within"Hours. PROTECTION FROM CHEMICALS 3-50 1�15 Cooling Method,for PHFs F PHF Hot and Cold Holding 14 Food or Color Additives Eq 3-501..16(B) I IFs Maintained red at or below-202 12 Additi%c3:' 590,004(F) 41°/45" F* 3-302.14Poisonous or Toxic Substances Protection from Unppfoved Additives'* _�,50 1.16(A) Hot PHFs Maintained at or above 1,5 14ff. * 7-101.11 Idevid'yolL Information-Original Cou'aillOrS, 3-501.1.6(A) Roasts Held at or above 130'F, 7-102.11 Common Name-Workin-Containers* 20 Time as a Public Health Control 7-201.11 ASe�Storage' 3-501.19 Time as a Public Health CControl*_ j 7-202.1.1 -Presence and Use* 590.004(ti) Variance Requirement_ 7-202.12 Conditions of Use- Toxic Containcre-Prohibitions'; 1-2031,11 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitize",Criteria-Chemicals ' POPULA IONS(HSP) 7-204,12 Chenacils for Washunz Produce,Criteria* 21 3-801..1 1(A) Unpasteurized Pre-packaged Juices and 7-204.14 _2aH�� _Lejeiaues with Warnme Labels* 7-205.11 Incidentai Food Contact, ,urticants* I I I(B) Use of Pasteurized 7-206.11 Restricted Use Pesticides,Criteria* 3-80 Ll I(D) Raw or Partially Cooked Animal Food and 7-200-12 Rodent Halt Statiorrs'4 - Raw Seed Sprouts Not Scned. * 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-served. Monitorilr-* CONSUMER ADVISORY TIMEirEMPERATURE CONTROLS3-603.1 I 22 Consumer Advisory Posted for Consumption of Proper Cooking Temperatures for Animal Foods'lliat are Raw. Undercooked or El: PHFs Not Otherwise Processed to Eliminate 3-401.1 IA(l)(2) Eggs- 1_55'F 15 Sec. PathogenO"""' E-s-burnediatc Service 145'1715secl 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish, Nicals&Gains Eggs* Arorrads, 155'F 13 sec. 3401.11(B)(1.)(2) Pork and Beef Roast- 13(PF 121 rain* SPECIAL REQUIREMENTS 3-461.11(A)(2)1.11-(A)(2) Raines,Injected Meats- 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D) in _ sec. * catering, mobile fixrd,temporary and 3 POUitTY Wild Game, Stuffed PHFs' -,-401.11(A)(3) residential kitchen operations should be Stuffing Containing Fish, Meat, debited wider the appropriate sections Poultry or Ratites-165°F 15 sec above if related to foodborne illness 3-401.I I�(C)(3) -Whole-muselt, hilact Beef Steaks interventions and risk factors. Other - 1450F* 590.009 violations relating to good retail 3-401.12 Raw Annual Foods Cooked in a practices should be debited under#29- __ Microwave 165'F* Special Requirements. 3 4 01 11'A)(1)(b) All Oflicr PHFs 145°F 15 sec. 17 Reheating for Hot Holding -WOLATIONS RELATED TO GOOD RETAIL PRACTICES 3 403.11(A)&(D) PHFs 165`'F 15 sec. * (Items 23-30) 3-403A I(B) Microwave- 165° F^ Minute Standing Critical and non-critical violations, which do not relate to'he Tfirrc4 foodborne illness interventions and riskfiictors listed above, can be 3-403.1.1(C) Commercially Processed RTE Food- found it;thefiollowing sections o the Food Code and 105 C14R 140'F* 590.000. 3-403.11(E) Remaining unsliced Portions of Beef Item Good Retail Practices FC 590 000 Roams* 23, ��srsonnel_ FG - 2 .003 F-18 - Proper Coating of PHFs 2-4-, Food and Food Protection FC-_3 .004 3-501-14(A} Cooling Cooked PRFs from 140°F to 25, E�� FC-4 .005 2& Water, jumbinP and Waste FC-5 .006 .q_ 70`17 Within 2 Hours and From 7WT 27. --Physical Facility ___ FC-6 .007 to 4 PF145'F Within 4 hours. 28. Poisonous or Toxic MaterialsFC-7 .008 -- - -- R9-7-7�p�ial Reqnirom_ents --- - -,009 _T50 1.�14(13) CookingP1IFs Made From Ambient Temperature Ingredients to il I'F/45'F 30 _other Within 4 Hours* Denotes critical itta,in flue IoJeral 1949 Food Code of 105 CKER 592000. 0400 Highland Avenue #13 Kidstop Indoor Playcenter City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 740-3187 Equipment and Utensils FAIL Non-Critical BLUE Owner: - Comment: Provide visible accurate thermometers in all freezers and refrigerators. Michelle Broderick Physical Facility FAIL Non-Critical BLUE PIC: 1 - Comment: There is water damage on the ceiling in the men's room. Investigate the source of the leak and repair. Repair ceiling. Inspector: GENERAL COMMENTS: David Greenbaum 654: Date Correct By: I6 6 Risk Level: Permit Number 6HP-2006-0361 Status SIGNED OFF { # of Critical Violations: 0 Time IN. TimeOUT 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 orwithin 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. Jun 16,2006 ) Page 1 oft v ." Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 16,2006 ) Page 2 oft RT.DOCIOET Na: CRAMON NO COU +�E�_ CITY OF SALEM O . NAM I VIOLATION NOTICE NAME(LAST.FIRST,.Ml&) O p STREETADDRESS l~j CITY/TOWN STATE �' m = LICENSE NO. LIC.EXP.BATE GATE OF BIRTH W _ O r L I OWNER'S NAME(LAST,FIRST,INITIAL) 07 EA ~ m=CDN j mEETADDRES5 ZIP .. � =r--0 mall,e-.. �j >5;m_ � REOISTRAT ON NO. Sra YEAR COLOR Q, 1 Z - 0 Op WZ ! >m D 0<00 DA/TE OF VIOLATION TIME DATE CITATION WRITTEN PEAeNn YES 0 1. 1 NO .mm 9 LOCATION OF VIOLATION ,?IMJ EN�FOBRCING D � m EPT. O g7�Cs {CJo f�i llfd/rcrGwF Yf�n1 �d CI Iut4 --0 C'I OFFENSE JJ d CHAP. SECT. FINES O 4 A hp/G!/oe * 0,V Cf/A� m --Nm r, o B etln'ole O '. m O C d9x7!/1! 7` IJ OFFICER /J yy I.D.NO. TOTAL NE 1L��y c I DUE VV . N OFFICER CERTIFIES COPY GIVEN TO VIOLATOR M ❑� anlo G X L/ . e, i.�- BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY O ORDER OR BY QTY CLERK PAYABLE TO: CITY HALL FA 93 WASHINGTON STREET ED SALEM,MA 01970 0 I TEL(508)745-9595 X 251 E 'Q I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON RR Irl REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE i i PAYMENT IN THE AMOUNT OF i n.3. g CASE#_. — � SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL II COURT DOCKET NO. Q& CITATION NO. CITY OF SALEM PD 0387 VIOLATION NOTICE ��++ NAME(LAST,FIRST,INITIAL) STREETADDRESSS ° CITY/TOWN STATE ZIp'.' ff r riffs fif�x Jt° r .4�rt�% P LICENSE NO. ✓ LIC.EXP.DATE DAT F BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) ,f,ode,vc 2ntrA,- STREETADDRESS CITY/TOWN STAT ZIP Q REGISTRATION NO. STATE EXP.`OA K PE AR COLOR DATE OF VIOLATION TIME ATE CITATIO / ITTEN PER NAL ❑PM `i 6 IWUVES -ONO LOCATION OF VIOLATION ENFORCING DEPT. / a.-sri- 7 OFFENSE B CHAP. SECT. FINES B o�OvG fZlDn�l)�p12 4/C' C s /�17T J OFFICER I.D.NO. TOTAL { o; DU OFFICER / OFFICCEEjR CERTIFIES COPY GIVEN TO VIOLATOR / X �I 1/ >Ll}K/ (, O BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE N SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL f CITY OF SALEM, MASSACHUSETTS • ; BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT January 26, 2006 Michelle Broderick Kidstop Indoor Playcenter 400 Highland Avenue Salem, MA 01970 Dear Michelle Broderick: You are currently operating your Food Establishment, Kidstop Indoor Playicenter located at 400 Highland Avenue, without a Food Permit. This is in violation of the State Food Code, 105 CMR 590.000, section 8-301.11. In order to receive a 2006 Food Permit, you must: • Pay outstanding tax bills, if any • Pay outstanding tickets from the Board of Health • Pay for your 2006 Permit • Submit a completed 2006 Food Permit Application You are hereby ordered to obtain a 2006 Food Establishment Permit forthwith. Failure to do so by Monday, February 6, 2006, will result in a Board of Health Order to cease all food operations at your establishment immediately. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. An attorney may represent you. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Si erely, anne Scot Health Agent Commonwealth of Massachusetts City of Salem ` KimberleyDriscoll Board of Health :. q,� 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 02/01/2006 WHO'S PLACE OF BUSINESS IS: Kidstop Indoor Playcenter File Number:BHF-2004-0007 400 Highland Avenue#13 Salem MA 01970 LOCATED AT: 0400 HIGHLAND AVENUE #13 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0361 Feb 1,2006 Dec 31,2006 $50.00 Total Fees: $50.00 PERMIT EXPIRES December 31, 2006 Board of Health �� This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 2 of 5 t CITY OF SALEM, MASSACHUSETTS „ a BOARD OF HEALTH . ( s 120 WASHINGTON STREET, 4TH FLOOR „ 1 SALEM, MA0 TEL. 978-741'181-1800j� STANLEY J. USOVICZ, JR. FAX 978-745-0343 JAN 3020 MAYOR WWW.SALEM.COM IN0/2-y 06' ,�.. JOANNE SCOTT, MPH, RS, CHO �,g9oC�/:S, HEALTH AGENT 0/C/�'y(FM 2006 APPLICATION FOR PERMIT ERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT K�� 0 �YYII�r PJdUf nfeCTEL# Nl� -7LIO '38 /r� ADDRESS OF ESTABLISHMENT #O Whh nd A-ye • #13 MAILING ADDRESS (if different) OWNER'S NAME AJI Ch6le, TEL# 978,7L//'0 2-6o2. ADDRESS 7 klod forcl Sfr,°e-t CITY QSerrs STATE ZIP 01g/70 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON QJ HOME TEL# HOURS OF OPERATION: Mon. ✓ Tue.AWed. ✓ Thu. t/ Fri.__k,,-Sat. ' Sun.J� TYPE OF ESTABLISHMENT 8 PM FEE (check only) RETAIL STORE YE NO s r less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 -------------- ------------ -------------------------------------------------- -------------------- ------------------------------------ RESTAUR,4NT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 - .........- - ----------------------------------------------------------------------------------------------$- - ......----------- BED/BREAKFAST YES NO 10- 0 ....--------------------------------------------------------------------------------.......------------------------------- 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. �.�.9/,�O�.Y,I'p� l� lIOJ� 0110 •/0(0'2/23 Sig ature Date Social Security or Federal Identification Number --------------------------------------------------------------------{--------------------- ---------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date +aY"7 fY "�w'mr ..iN. g�� i��y �i:'y' .,:5.i A a r+. yr.t „�Tf a. {t +yl �1` .x.r.• 3 t"m'"'L ,� f 4;4# a S. r �i,�.:a.._-.a ,.. s'^"'^.'''SR 'X•' "•.'�yly-.a,. Ylx'"R sw artP. x3�.✓.xs� +.s. p..,.....t, i,. ,.a�,.,�y,.�*Y•?++�m. s7 CITY OF SALEM MASSACHUSETTS r 'BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOORv +"`• 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: FOOD SERVICE Name of Establishment: Kidstop Indoor Playcenter Address of Establishment: 400 Highland Avenue #13 Owner's Name: Michelle Broderick Restrictions: Application Date: 12/6/2004 Permit for Food Establishment 185-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. 114 - HEALTH AGENT CITY OF SALEM, MASSACHUS L M b3 11 11 BOARD OF HEALTH IU� < 4' 120 WASHINGTON STREET, 4TH FLOOR DEC _ Z004 SALEM, MA 01970 .� TEL. 978-741-1800 CITY OF SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT K 1D5TOP I rdoor P) y Cwter TEL# 99b'7110'31B r/ ADDRESS OF ESTABLISHMENT40�)und Ave• Sui 1"e-#13 MAILING ADDRESS (if different) OWNER'SNAME MI( he)j2 Zrodent,)C TEL# ?90'7LI/'02(x2 ADDRESS 7 Harry prd St' CITY SQ /exn STATE A4A ZIP 01990 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSONSCOU "BYC)Cler-CJC HOME TEL# 999-70) '020Z HOURS OF OPERATION: Mon�13 Tueg3�U/Wed.��hu. '�pb Fri. '�? Sat. 3 Sun.13Z-li May stay open until 9PM any day -For a late pa1-ly. TYPE OF ESTABLISHMENT FEE check onlya= 5 RETAIL STORE YES � less than I000sq.ft. = 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES EO , I �j b� 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 ge�ef`, h-avg filed alate tax returns and paid all state taxes required under the law. t=PA 01 7 r 1�*Lo4 02&-&19 -2/23 Signature Date Social Security or Federal Identification Number -------------------------------------------------------------- --------- ---- Revised 11/03/03 FOODAP2.adm Check#& Date �� 1 /3V- INSPECTORS PLEASE NOTE: AS OF 2/26/003, PLEASE FORWARD COPIES OF ALL DAY CARE INSPECTION AND REINSPECTION REPORTS TO: M.J. BURNS, GROUP DAY CARE LICENSOR OFFICE FOR CHILDREN 66 CHERRY HILL DRIVE BEVERLY, MA OL915 FAX # 1-617-727-2533 0400 Highland Avenue #13 Kidstop Indoor Playcenter City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ r, Telephone: Item Status Violation Critical Urgency Nature of problem or correction :740-3187 Non-compliance with: Not Done Owner: Anti-Choking N/A ❑ Michelle Broderick Tobacco PASS ❑ :PIC IKiKlm Galeotd FOOD PROTECTION MANAGEMENT Not Done m tor' ` a - PIC Assigned/Knowledgeable/Duties PASS ❑Q RED David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: Correct By: - Reporting of Diseases by Food Employee and PIC PASSd❑ RED 8/24/2005 T ' Personnel with Infections Restricted/Excluded PASSd❑ RED Risk Level FOOD FROM APPROVED SOURCE Not Done Permit Number: % - Food and Water from Approved Source PASS RED BHP-2005-0280, „ = s-.. Receiving/Condition PASS ❑d RED Status: _ Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNED OFF #of Critical Violations: Conformance with Approved Procedures/HACCP PASS RED Plans PROTECTION FROM CONTAMINATION - Not Done Time IN: Time OUT' Separation/Segregation/Protection PASS ❑d RED Notes: - Food Contact Surfaces Cleaning and Sanitizing PASS RED 254: Proper Adequate Handwashing PASSd❑ RED Urgency Description(s): Good Hygienic Practices PASSd❑ RED BLUE: - Prevention of Contamination from Hands PASSd❑ RED Violations Related toGood Retail Practices (Critical Handwash Facilities PASSd❑ RED violations must be corrected immediately or within-10 ' days)(Non-critical violations GeoTMSO 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 24,2005 ) Paee I of 0400 Highland Avenue #13 Kidstop Indoor Playcenter must be corrected immediately PROTECTION FROM CHEMICALS Not Done or Within 90 days) ' P Approved Food or Color Additives PASSd❑ RED RED: Violations Related to x Toxic chemicals PASS ❑ RED Foodborne Illness InterventlonS TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors(Require Cooking Temperatures N/A ❑d RED immediate corrective action) Reheating N/A ❑d RED Cooling N/A ❑d RED Hot and Cold Holding N/A ❑./ RED Time As a Public Health Control N/A ❑d RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP N/A ❑Q RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A ❑Q RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils FAIL Non-Critical ❑ BLUE Provide visible, accurate thermometers in all cooling and freezer units. The back refrigerator needs a thorough cleaning. 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 GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 24,2005 ) Page 2 of 0400 Highland Avenue #13 Kidstop Indoor Playcenter GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 24,2005 ) Page 3 of 3 ++pp CITY OF SALEM, MASSACHUSETTS �1L BOARD OF HEALTH `� yf 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to:. Type of Establishment: FOOD SERVICE Name of Establishment: Kidstop Indoor Playcenter Address of Establishment: 400 Highland Avenue #13 wn , O er s Name: Michelle Broderick Restrictions: Application Date: 12/4/2003 Permit for Food Establishment 135-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT i u CITY OF SALEM, MASSACHUSETTS- BOARD OF HEALTH • 120 WASHINGTON STREET, 4TH FLOOR \ SALEM, MA 01970 lll��j DEC 1 -?003 TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALLIM STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT K jDSTDP 1r)CJD V- PICLI(CPPtfi21'TEL# �)7A' 7L)G '3j 87 ADDRESS OF ESTABLISHMENT '+00 Highland Ave-nue- MAILING V-enu2MAILING ADDRESS (if different) OWNER'S NAME M1(!,hdt4L TEL#978'��40'3i87 —7 ADDRESS / Par LL UY(!J St k4rn g78. 7'-II •02LO2 CITY j—r-n STATE ZIP OIL)-20 CERTIFIED FOOD MANAGER'S NAME(S). __________ (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# �'�O Tue. 30 3d " 0 e Sung 30 HOURS OF OPERATION: Mon9. � 6 Wed -Ip Thu "(O Fri 3'7 Sat 3 -� TYPE OF ESTABLISH FEE check only RETAIL STOREYES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 -4 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 $5 TOBACCO VENDOR YES $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 be t kn� ed e and belief, have filed all state tax returns and paid all state taxes required under the law. 11120703 O-Z& LO Fi —Z ja Signature Date Social Security or Federal Identification Number ------------------------------ - - ----------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#8 Date 1129&- //—'-2 x-63 1 Salem Board of Health Massachusetts Department of Public Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978)745-0343 i Name Dat Tie of Operation s T ' of Ins ection tFI (� Food Service Routine Address /L Risk 171 Retail [IRe-inspection r r t Level E]Risk' Kitchen Previous Inspection Telephone n _9/F7 (_ ❑ Mobile Dater`1)3'_ ,3 HAGCP YIN E] Temporary ❑Pre-operation Owner (' f ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) 9 Time ❑ Bed&Breakfast ❑General Complaint ❑ HACCP -{ In. Permit No. ❑Other Inspector a„ i j j , ,c fax/�t,� Out: - Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590,009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ; ,-. �,....- ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties _ ❑ 13. Handwash Facilities EMPLOYEE HEALTH { PROTECTION FROM CHEMICALS' ❑ 2. Reporting of Diseases by Food Employee and PIC 'A,'i, ❑ 14.Approved Food or Color Adddives ❑ 3. Personnel with infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM.APPROVED SOURCE, , TIMEMEMPERATURECONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18•Cooling PROTECTION FROM CONTAMINATION. "` ( ❑ 19•Hot and Cold Holding :i , •s C18. Separation/Segregation/Protection u ❑20.Time As a Public Health Control ❑ 9.Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY:SUSCEPTIBLE POPULATIONS(HSP). ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY .. .. ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions f immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105,CMR of Health. 590.000/federal Food Code.This report, when signed below C ' 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 4. Food and Food Protection (FC-3)(590.0044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 8. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days Of receipt of this order. 02130. Other DATE OF RE-INSPECTION: S:SM3lnspeclForm6-14,o In Qtor's ign e: i Print: IC's Signature: i Print: ' Page of Pages n 1C,11 Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(A) Assignment ofResponvbility` _ 3-302.11(An]) Raw Animal Foods Separated from 590.003(B) _ Demonstration of Knowledge"` Cooked and RTE Foods* 2-103.11 Person m charge-duties Contamination from Raw ingredients - 3-302A 1(A)(2) Raw Animal Foods Separated froth.Each EMPLOYEE HEALTH Other` 2 590.003(C) Responsibility of the person in charge to Contamination tram the Environment require repotting by foal employees and 3-302.11(A) F'oocl Protection* a flicants* 3-302.15 WBShtlt Fruits and Vegetables 5)O 003(F). Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char+e* Contamination from the Consumer 590.003(G) Re ortina b Person in Charge* 3-306.14(A)(;B) Returned Food and Reservice of Food* 3 590.003(13) Exclusions and Restrictions* Disposition otAdulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE I 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 Sanitization Tem eratures* 3-201.12 Food in a Hermetically Scaled Container* 3-201.1.3 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewastrinr Hot Water 3-202.13She(I E s* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* A-501-114 Chemical Sanitization-temp., pH, 3-202.16 ice Made From Potable Drinkinn Water* concenbation and hardness. 'k 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0"` Contact Surfaces and Utensils a Shellfish and Fish From an Approved Source 1.1 - 4-702.11. Frequency of Sanitization of Utensils and 3-204 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methals of Sanitization-Plot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 1 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-202.18 Shellstock Identification Present* 2-301.J2 Cleanim Procedure* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* I1 Good Hygienic Practices 3-201.17 Game Animals g Receiving/Condition 2-401.11 Eatin ,Ddnkin or Using Tobacco* 3-202.11 Ph1Fs Received at Proper Tem eratures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Inte it y* Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock L12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em)loges* 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 C:a tacities* 590,004(1) 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 Devices 3-502.11 S ecialized Processin Methods* 6-301.11 Handwashing Cleanser, Availability 3-502.1.2 Reduced os en packaging.criteria* 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand D �im Provision "Denotes Critiad item in the federal 1990 Food Code m 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: /.v 114 pla Date: (o` 0 Page: of Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified _. PLEASE PRINT CLEARLY ~ i d 7 r f O r f l// l , 6 S - 1 IV-t- A� _ 7` / v mrt e 7� --!2717,,rrte- o f I 'Y e 4ky Z 74- 40ry2 bG / (7 A01 o 1 Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ,Comply with all mandates of the Mass/Federal Food Code. I understand that Ll Re-inspection Scheduled ❑ Emergency Suspension I., noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. G Ws �� Livoluntary Disposal LIOther: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to Iaw Cooled it) Factors(teems 1-22) (Cont.) 411T/451F Within 4 Hours. '% PROTECTION FROM CHEMICALS 3501.15 Catlin Methods for PHFs Food or Color Additives I9 PHF Hot and Cold Holding F-14 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Addiuves'r 590.004(F) 41%45° F" 3-302.14 Protection from Una t roved Additives' 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 14o'F. 7-101.11 Identifying information-Original 3-501,16(A) Roasts Held at or above 130°F. " Containers* 20 Time as a Public Health Control 7-102.11 Common Mame Workingri Containers*axe* 3-501.19 Time as a Public Health Control* 7-201.11 Se Talion- e 7-20217 Restriction-Presence and Use* 5590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP} 7-204.t2 Clhenricals for W ashni¢Produce.Criteria* 21 3-801..11(,,) Unpasteurized Pre-packaged Juices and 7-204.1.1Drsin eats,Catena' _ Beverages with Warning Labels* 3-801.11(B) Use of PasteunaedP xa* 7-205.1.1 Incidental Food Contact. Lulincants* 3-301.71 7-206.11 Restricted Use Pesticides. Criteria=" (A) Raw or Partially Calked Annual Food and Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations* 3-8It.]I(C) Unopened Food Package Not Re-served 7-206.13 Tracking Powders.Pest Control and Monitoring* CONSUMER ADVISORY TIMETTEMFERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw-Undercooked or PRFs Not Otherwise Processed to Eliminate Pathogens.* r-vzooi 3-4oLUA(lx2) Fggs- 155-(15See. E>gs-TnnuedrateService 145"F'15sec* 3-302.13 Pasteurize d Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish, Meats&Game E s* - Animals- 155'F 15 sec. SPECIAL REQUIREMENTS 3-401.11(13)(1.)(2) Pork and Beet Roast- 13(fT 421 nein' 590.009(,,)-(D) Violations' of Section 590.009(,,)-(D)in 3-401.11(A)(2) Ratites, Injected Meats 155-F 15 sec *. catering, mobile food,temporary and 3-401..11(,,)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffmg Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'17 15 set. * above if related to foodborne illness 3-401.1.1(C)(3) Whole-muscle,Intact Beet Steaks interventions and tisk factors. Other 145'F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under 1(29- __ Microwave 165'F* Special Regtwremerrm 3-401.11(A)(I)tb) .All Other PHFs- 145'F 15 sec 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 1403.11(A)&([)) PHFs 165°F 15 sec. * (items 23-30) 3-403.11(B) Microwave- 165'F2 Minute Standinx Critical and non-critical violations, which do not relate to tire Times ,foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Fad- found in rhe followink sections of the Food Code and 103 CMR 140'F* 590.000. 3-40111(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC b80.000 Roasts* 23. Maria ement and Personnel_......_ FC--2 _.003 ig Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25 Suipment and Utensils FC 4 .005 3-501.14 A Coolin Cooked PHFs from 140`F to __......... -- -- -- --.006 10"F Within 2 Hours and From 70'F 27. Physical Facility FC-6 .007 _ to 4CF/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-50114(}3) Cooling PHFs Made From Ambient 29_ Special Requirements _ .009 Temperature Ingredients to 41'F/45'F 30. Other Within 4lloucs'x *Denotes critical item in Inc[metal,1999 Food Codc or t 65 CMR 590.000. CITY OF SALEM9 MASSACHUSETTS QM%�w BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner' s Name : Michelle Broderick Name of Establishment : Kidstop Address of Establishment : 400 Highland Avenue #13 Type of Establishment : FOOD SERVICE Application Date : 05/30/2003 Restrictions: Permit for Food Establishment 301-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT - a r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH m 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS. CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT [�-7 NAME OF ESTABLISHMENT ►dam t� TEL# 9287L-10 '31 f2 C}/ ADDRESS OF ESTABLISHMENT q00 14iqU u Avir �ZL /tel MAILING ADDRESS (if different) OWNER'S NAME Michbb 3rCxJer«�� TEL#'3`7B'7y1'U2 a2 ADDRESS ! 1&rb ZJYU CITY c) -VP--M STATE MA ZIP 01976 -/033 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# 930_ 7 ,30 PM — 7 ctaVS 0- HOURS HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun. TYPE OF RETAIL STORE ESTABLISH YES NO 301Ebg -0-3 FEE check onlso)less than 1000sq.ft.1000-10,000sq.ft. 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 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. 529 o 02-(o '[oG 3 Signature Date Social Security or Federal Identification Number — -- - -- -------------------------------------------------------------------------—-------- Revised11/25/02 FOODAP2.adm Check#&Date /0a .7 S-AZ-2---! 0`jd- j .- ... ..- v __..-..�•e..�•..�..-.-w�r_. .. .rr rpm .�.- ., w.w...„v='++"wti V'P•zgEid'Mi'tyi..-P'. ...+%Y+.i.vx•yts•py,i r._'r '+�.'cw w'--".-'1-...n•4 M*. • a THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name / Date Type of Operations) Tyne of Inspection S�/d p7 ❑ Food Service ❑ Routine Address �/`�y� //J ` Risk ❑ Retail ❑ Re-inspection Level / El Residential Kitchen Previous Inspection Telephone 9'l ! _ L ❑ Mobile Date: Owner // HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ caterer ❑ Suspect Illness Person in Charge(PIC) Time El Bed&Breakfast El General Complaint In: ❑ HACCP Inspector ` c- 1 C 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 (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS El2. Reporting of Diseases by Food Employee and PIC El 14. Approved Food or Color Additives El 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIMEJEMPERATURE CONTROLS(Potentially Hazardous Foods) E] 16. Cooking Temperatures El 5. Receiving/Condition ❑ 6. Tags/ Records/Accuracy of Ingredient Statements E] 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans E] 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/ Protection El 20. Time as a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) 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: Inspector's Signature: Print PIC's Signature: Print: PagezofPages FORM 734A HOBBS&WARREN - BOSTON Violations Related to Foodborne Illness ` Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1' 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 190.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2' 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) 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 Charge* 3-306.14(A)(B) Resumed Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 1"3'1590.003(D) IExclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9' Food Contact Surfaces 4<4 h. Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H, 3-202.14 Eggs and Milk Products, Pasteurized* P'p gg Concentration and Hardness 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703,11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes, Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* 'S'J Prevention of Contamination from Hands ,6' Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* F-13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* •Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH / d Establishment Name: �� i Date: ,� /'0/d 3 Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY IV 4 o c:0 ,c L ✓ 1- l -4-7 c < ? ztln I �/.C_ 'eO 2 r 1 l �c1 d 1 /A)7 ' G Discussion With Person in Charge: Corrective Action Required:: ❑ No ❑ Yes r I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.1,4(0) PHFs Received it'rentperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Coaled to Factors(Items 1-22) (Cont.) 41.'F/45^F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHR I4 Food or Color Additives 19 PHF Hot and Cold Holding 3-20112 Additives F 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 41`/45"F* _U302.14 Protection from i Una awed Additives* 3-501.16(A) Hat P11Fs Maintained at or above I S Poisonous or Toxic Substances 14U°F. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1.30°F. * Containers* 7-102.11 Common Narne-Working C:ontainers* 20 Time as a Public Health Control 7-201.1.1 Separation-Storap,c' 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use` 590.004(H) Variance Requirement 7-202.12 Conditions of Use' 7-203.11 'toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Saniti7. rS.Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.1.I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Diving Agents.Criteria* Beverages with Warning Labels* ',-601.11.(B) Use of Pasteurized Eggs* 7-205,11 Incidental Food Contact,'Lubricants* 3-801.1.1(0) Raw ni Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria'" 7-20612 Rodent Bsit Stations" Raw Seed Sprouts Not Served. * 3-801.11(0) Unopened Food Package Not Rn-served. 7-206.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY _ TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of I6 Proper Cooking Temperatures for Animal Foods That tire Raw. Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens 'e ","'2001F Eggs-Immediate 3-40LilA(1)(2) Eggs 155'F15 Servide 145`Fl. Pasteurized15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401,11(A)(2) Conminuted Fish.Meats&Come E9 rs" Animals- 155'F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast- 130`14 121 min* SPECIAL REQUIREMENTS _ 3-401..1 I(A)(2) Ratites, Injected Meats- 155'F 15 590.009(A)4D) Violations of Section 590.009(A)-(D)in Seq catering mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game. Stuffed PHFs, residential kitchen operations should be ::cNicd cadca the arn2 S�Jlrv:iS SmfungContainingFish,'Meat, ^^ pria rr r- Poultry or Ratites-165'F 15 sed. * above if related to foodborne illness 3-401.1l(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F" 590.009 violations relating to gaol retail 3-401.12 Raw Animal Fools Cooked in a practices should be debited tinder#29- Microwave 1.65'F* Special Requirements. 3-401.II(A)(1)(b) All Other PHFs-145'F'15sec. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165"F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk,faciors listed alcove, can be 3-403.1.1(C) Commercially Processed RTE Food- found in the following sections d/the food Code and 105 C:YIR I4VF' 590.000. 3-403.11(E) Remaining UnslicedPortionsofBeef Item Good Retail Practices FC 590.000 Roasts" 23. Management and Personnel FC--2 .003 I8 Proper Cooling of PHFs 24. -Food-and Food Protection FC-3 .004 25. Equipment and Utensils FC 4 .005 3-501.14(A) Cooling Corked PHFs from 140'F to - i- ---_..... g 26. Water,Plumbing and Waste FC 5 .006 7WF Within 2 Hours and Front 70`'F 27, Physical Facility FC 6 .007 to 4l"F/45°F Within 4 Hours. * _28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements _009 Temperature Ingredients to 41'F/450F 30. Other _---.--- ......_............ . _. Within 4 Hours* d- *Denotes critical item in the federal 1999 Food Cale or 10i CMI!590.000. CITY OF SALEM, MASSACHUSETTS < y BOARD OF HEALTH - 3 • 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner ' s Name : Christopher Ciampa Name of Establishment : Kidstop Indoor Playcenter, Inc . Address of Establishment : 400 Highland Avenue #13 Type of Establishment : FOOD SERVICE Application Date : 12/24/2002 Restrictions: Permit for Food Establishment 151-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT .q� ��T .y,..x�� fp•`l Sy,.+ l `" �, f� -thy ^e y .' 'i CITY OF SALEM, MASSACHUSETTS BOAKID OF HEALTH 120 WASHJNGf"ON- STRXE7, 4TH FLOOR SALEM. MA 0197C) ^0 OLL, 4. LZ,Z TFL. 978-74 1. ISOO 0 FAX 978-745-0343 Sl- ��LEY U10%1jC7_JR Gil M-N�'op JO,�NNE SCOTT, MPH, RS. CFJ0 BOARD OF HEALTH 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT_D KOk, 'JAS. P TEL ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME ( Lr' 3�1 TEL ADDRESS 3L14 <T-, vse CITY 4;Q-7 =— STATE ^!! ZIP CERTIFIED FOOD MANAGER'S NAME(S) (�G, �-AeC /14-kCERTIFIEKfE—#FSJ]n?-�76) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON ) 4 HOME TEL# -rcp 4-r 14!)& - HOURS OF OPERATION: Mon,—Tue.—Wed.--Thu.—Fri.—Sat.—Sun. TYPE OF ESTABLISUM� FEE check only RETAIL STORE N 0 less than 1000sq-ft, =$ 50 1000-10,000sq.ft. 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 ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 At L MON-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 Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best kno e an f, hays filedalI state to rerns and paid all state taxes required under the law. -2- C7 Signature A Dat6 Social Security or Federal Identification Number ------------------------------------------------------------ --------------------------------- Revised 11/25/02 FOODAP2.adm Check#&Date--