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KNIGHTS OF COLUMBUS - ESTABLISHMENTS �n�y�gS of C01uM6J gu w4t,�Inyfa� lark} ftNIVERSAL® UNV-12110 MADE IN USA SUSTAINABLE MN pEEyam T E CDNIB7f 10% IMMA ® FORESTRY OTIAPV U ified Mer Soerdey POSTCMMER - nww.efiproprem.mp Commonwealth of Massachusetts ` t City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2011 ESTABLISHMENT NAME: Knights of Columbus File Number:BHF2004-000002 94 Washington Square East Salem MA 01970 LOCATED AT: 0094 WASHINGTON SQUARE EA SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0126 Jan 1,2011 Dec 31,2011 $25.00 ESTABLISHMENT Total Fees: $25.00 PERMIT EXPIRES December 31, 2011 Board of Health 14 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 r CITY OF SALEM, MASSACHUSETTS J a BOARD OF HEALTH 120 WASHINGTON STREET,4`FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGacr:NBAUNI SAla;na.CONI DAVID GREENBAUM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL# Rlk-7 y5- � yo8 ADDRESS OF ESTABLISHMENT q4 = 'Soo t=est- FAX# MAILING ADDRESS(if different) �. ©. (3nx 3-L Sam,, /YI R 01970 EMAIL- Business': r-\ erne Website: u� e S-at4,w. o RG OWNER'S NAME La lumnNun. 9-1R -7 YS- UFs ADDRESS 94 U)2 Anr h -1 0 e Gast- ' te^ IT P, OI 97o STREET _ CITY STATE ZIP ,101nn 1'"12.1 o^-k-F -1/ N�`JO CERTIFIED FOOD MANAGER'SNAME(S) CERTIFICATE#(S) < fl -/`l77_ (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON [\a.tiv e S M Izto e-N HOME TEL# a o F� SYS 1 19 DAYS'OFOPERATION , Monday,.:': =Tuesday:' i'sWednesda ,«;tI`'44^Thursday ". °. ,Friday ;»;.. ;.Saturday >s !t p Sunday;' ; HOURS OF OPERATION Spm {0 3Pm y Spm : 39M • Fo 3 am 4-0 A)oro-n ucryn Please write in time of day For example 11 am-11 pm 1 rim 1 Flm 1 Pf11 I I Ti� 1 Phrr\ TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 RESTAURANT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ---------------------------------------------------------- --- BED/BREAKFAST/ YES O $100 - CHILDCARE SERVICES/NURSING HOME - - - ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO 5 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 returnsanndd'paid all state taxes required under the law. �YTI� / l- ;L9-Io Gy- 255-7 &91 Signature (/ Date Social Security or Federal Identification Number Revised I Onli I FOODAP201 Ladm Check#&Date $ - I . k[ l 1 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'"Fioor Division of Food and Drugs Salem, MA 01970-3523 4 FOOD ESTABLISHMENT INSPECTION REPORT L Tel. (978) 741-1800 Faxi(978) 745-0343 Name L / Date Type of Operation(s) T e f inspection J > Food Service Routine Address Risk Retailc Re-inspection Level F1 Residential Kitchen Previous Insppec' n _ Telephone El Mobile Date: /3/v/j Owner HACCP YM El Temporary ❑ Pre-operation �d J ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time, / ❑ Bed& Breakfast ❑General Complaint Inspector In: `-J4 El P Out: Permit No.- ❑Other Each violation checked r qui s 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 PROTEQTION MANAOEMENT __ _ El 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EI-13. EMPLOYEE HEALTH �- _ - _ _ Handwash Facilities _ PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3.. Personnel with Infections Restricted/Excluded El15.Toxic Chemicals LFOOO FROM APPROVED SOURCE • - - _ _ _ _ _ - - TIME/7EMPERA7URE CONTROLS(potentially Hazardous Foods_) El 4. Food and Water from Approved Source �g ❑ 5.. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6:'Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Coi,formance 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 __ El 9. Food Contact Surfaces Cleaning and Sanitizing FiE0U1REMEN75 FOR HIGHLY SUSCEPTIBLE-POPULATIONS(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY - -� ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of c Health. , C 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 9 ( )( ) order of the Board of Health. Failure to correct violations 24. Food and Food,Protection (FC-3)(590.004) 25. Equipment and Utensils (FC-4)(590.005) cited this report may result in suspension or revocation of the food establishment permit and cessation of food 6. 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 ,,,,:f'28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: -Print: ) PIC's Signature: , Print: Page-4 of ZPages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(]) Raw Animal Foods Separated frum L 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 3302.11(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) I 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 Fotxl Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(1)(B) Returned Food and Reset-vice of Food* 590.003(G) Reporting 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 For& FOOD FROM APPROVED SOURCE 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 Foci in a Hermeticall •Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.,13 Shell Eggs* Sanitization Tem eratures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH; 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-I01A I Drinking Water from an Approved System*tem* 4-601.,11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food ShelHContact Surfaces laid Utensils*ish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreagonaily 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 Authorit 2-301.11 Clean Condition-Hands and Anns* 3-202.18 Sbellstock Identification PrescnO 2-301..12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11. Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges.From the Eyes,Nose and 3-202.1.5 Package Integrity* Mouth` 3-101.11 Food Safe and Unadulterated * 3-301.12 Preventin=Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification .590.604(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* - Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(1) I Labeling of Ingredients ]. Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.1Specialized gMethods* Devices 3-502.12 Redued oxygen x enpacka 'ng,criteria* 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 HandDrying Provision Denotes critical item in the federal 1999 rood Cade or I O1 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: I ' I(" Date: / ! /J Page:_ Of nem Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,. No. Reference R-Red Nem Verified - PLEASEPRINT CLEARLY cJ. f 1 I b 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 untary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Emersion 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 su�ISei sion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 410FAFF Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolin Methods for PHFs 14 Food or Color Additives 19 PHF Not and Cold Holding 3-50L16(B) Cold PHFs Maintained at or below 3-202.72 Additives* 590.004(17) 41°145°F* 3-302.14 Protection from Unapproved Additives* 590.00 (F) Hot PHFs Maintained at above 15 Poisonous or Toxic Substances 140'17. * 7-101.11 Identifying Information-Original 3-501.16(A) Roastc Held at or above 1300F. Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control" 7-202.11 .Restriction-Presence and Use* 590.004H) Variance Re uhr;ment 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* POPUREQUIREMENTS ONS HSPS(HSP) HIGHLYSUSCEPTIBLE 7-204.11 Sanitizers.Critetia-Chemicals* LATI 7-204.12 Chemicals for WashingProduce,Ctitexia* 21 3-801.11(A) Unpasteurized Pre-packaged Iuices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels* 3-801.11(8 Use of Pastemized E * 7-205.11 Incidental Foal Contact,Lubricants* 3-801.1.1(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* y 7-206.12 - Rodent Bait Stations* Raw Seed Sprouts Served. 7-206.13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Foo)Package Not Re-sensed. Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or _PHFs Not Otherwise Processed to Eliminate 3-40i.11A(1)(2) Eggs- 155°F 15 Seo. PCO ens*E�.1/11 Eggs-Immediate Service 145°F15sec* 3-302.13 1 Purized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E: " Animals-155°F 15 sec. 3.401.11(8)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS 3401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section .590.009(A)-(D)in sec.* catering, mobile food, temporary and 3401)UA)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145017* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 340131(A)(1)(b) All Other PHFs-145'F i5 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETA L 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 factors listed above, can be 3403.11(0) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140017* 590.004. 3403.i l tE) Retraining Unsliced Portions of Beef Item Goad Retail Practices FC 590.000 Roasts* - 23. Management and Personnel FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 i 25. Equipment and Utensils J FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. Water Plumbingand Waste FC-5 .006 70°F Within 2 Hours and From XT 27. P sical Facili : FC-6 007 to 41'F/45'F Within 4 Hours. * 26. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41017/45017 30. Other - Within 4 Hours* ssxx4:ex. *Denotes critical item in the federal 1999 Food Cade or 105 CMR 590.000. Massachusetts Depa rtment,of .Public Health Salem Board of HealtW' Division of Food and Drugs 120 Washington Street,4 th Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT 'Tel. (978) 741-1800 Fax(978)f 745-0343 NameDat Type of Operation(s) Tvoe of Inspection 1 _)I l ( /J W-Food Service ] Routine Address (TW T t- I Rik LlRetail E] Re-inspectionwtr� '^ Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Dale:I r�j �> Owner HACCP YM ❑ Temporary ❑ Pre-operation c ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑General Complaint In:.5 ,� Permit No. ElOtherOut: 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 -.y ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities C-EMPLOYEE HEALTH_ -.. _ =pONTECTIOFROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded � _- `�! 'S.Toxic Chemicals r FOOD FROM_APPROVED SOURCE � � ,.. - [14. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially 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- 97 19. Hot and Cold Holding El 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE-POPULATIONS(HSP)! ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic PracticestCONSUMER ADVISORY �c' ❑22. Posting of Consumer Advisories Violations Related to Good Retail-Pra-ctices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions t immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below 23.C x p g 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-9)(990.009) 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)(591.001) 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(: 1pIyV� Inspector's Signature: Print: PIC's Signature: Print: Page of-Pages Cv\�1�11 S ��Z 1bG I� Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assn mentofRes neibilit * 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Fo(xls* 590.003(B) Demonstration of ledge* Contamination from Raw Ingredients Person in charge-duties 3-302.11(A)(2) Raw Aminal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(0) Responsibility of.the person in charge to 3-302.11(A) I Food Protection* require reporting by food employees and 3-302.1.5 Washing Fruits:and Vey*etables a plicams* 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) Returned Fwd and Reservice of Food* 590.003 G- Reporting by Person in Char e* 3 590.003(D) Exclusions and Restrictions* DispostonofAduteratedorContaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fad* 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Foci in a Hermetically Sealed Container* Sanitizaflon Temperatures* 3-201.13 Fluid.Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.11 Drinking Water tion an Approved System* 4-601.1 I(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinkin Water* 590.006(B) Water Meets Standards in 310 CMR 220" 4-602.1'1 Cleaning Frequency of Equipment Food Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.1 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 Add Mushrooms Approved by Regulatory Authoritym2-301.11 - Clean Condition-Hands and Ars* 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* 11 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eatin .Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.1.5 Package Inte ria * 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(F) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* - Employees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(]) Labeling o1 Ingredients' 5-204.11 Location and Placement* g Conformance with Approved Procedures 5-205.11. Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.1.1essin g Methods* Devices 3-502.12 RPen packaging,criteria* 6-301.11 Handwashing Cleanser,.Availabilit 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision Denotes critic£d item in the tedet-A 1999 Foal Cade or 105 CMR 590.000. CITY-OF SALEM BOARD OF HEALTH Establishment Name: _ It Date: Pageof Rem Code C--critical Item No. ReferDESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- ence R-Red Item . i Vaned PLEASE PRINT CLEARLY o v I nv 1-� � Cu ( n f \L t �� C .7G C UN S I f r I F3 7 a Discussion With Person in Charge: Corrective Action Required: ❑ .No es 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 6inspection 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 dollarssu pension/revocation of ❑ Embargo ❑ Emergency Closure your food permit /p (( ❑ Voluntary Disposal ❑ Other: 3-501A4(C) PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Jaw Cooled to Factors(Reins 1-22).(Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS3'50 L 15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3,202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-302.14 Protection from Unapproved Additives* 590.004(5) 4101450 F* 15 Poisonous or Toxic Substances - 3-501.16(A) Hot PHFs Maintained at or above 140T. * 7-101.11 Identifying Information-Original 3-501.16(A) RoastsHeld at or above 130°F. Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora e* 3-501.19 Time as a Public Health Contra." 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 Sanitizers.Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 DtvinR Agents.Criteria* I,Beverages with Warning labels* 7-205.11 Incidental Food Contact,Iatbricants* 3-801.11(B) Use of Pasteurized Eggs- 7-206.11 *7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.12 Rodent Bait Stations* Raw Seed S us Not Served. 7-206.13 Tracking Powders,Pest Control and 3_801.11(C) Uno »ed Food Packa Not Re-served. Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Ani mal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(t)(2) Eggs- l55°F 15 Sec. - Patho ens.*E"°`"°"nom" Eggs-Immediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3-401.11(6)(1)(2) Pork and Beef Roast- 130°5121 min* 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-)65'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 goad retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3.403AI(A)&(D) PHFs 165T 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 riskfactors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Cade and 105 CMR 140°F* 590.000. 3403.1118) Remaining Unsliced Portions of Beef Rem I Good Retail Practices .Fc 590.000 Roasts': - 2i 3. Mananement and Personnel FC-2, .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 _004 25. Equipment and Utensils FC-4 .005 1 3-501.14(A) Cooling Cooked PHFs from 140°F to _R6- Plumbing and Waste FC-5 .006 70°F Within 2 Hous and From 70'F 27. physical FacilityFC-6 .007 to 41°F/450F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.148) Cooling PHFs Made From Ambient 29. 'Special Requirements ,009 Temperature Ingredients to 41°17145°F X Other Within 4 Hours* s:suota,�mutxa< "Denotes critical item in the tederai 1999 Food Cade or 105 CMR 590.000. F CITY OF SALEM / BOARD OF HEALTH Establishment Name: K l D.f�^ Date: o Page: 3 of Nem Code C-critical i Item R No. Reference R-Red Red kDESCRIPTION OF VIOLATION/PLAN OF CORRECTION bete- Verlfled PLEASE PRINT CLEARLY "t r'(4 1 f(ObO r S — – v 7 E S ( QQ 0,1 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 .f ❑ Voluntary Compliance O Employee astriction violations before the next inspection, to observe all conditions as des ibed, and to 1 Exclusion yy Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understa d that 1C/ noncompliance may result in daily fines of twenty-five dollar ors sp nsion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: r t 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(Items 1-22) lCont.) - 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(B) Cold PHFs Maintained at or below 590.004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above I40°F.* 7-101.11 Identifying Information-Original 3,50L16(A) Roasts Held at or above 130'F. Containers* 7-102.11, Common Name-Working Containers* 20 Time as a Public Health Control 7-201.1.1 1 Separation-Storage* 3-501.19 Time as a Public Heithb Control- 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Ilse* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 7-204.11 SanChemicalszers.Criteria i Chemicals, 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Thein eats.Criteria* 3-801.11B) Use of Pasteurized E * - 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or PartiallyCooked Amaral 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 TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs _ - Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- I55°F 15 Sec. - Pathogens.'"' "r`0°' Eggs-Immediate Service 145'Ff5sec-- 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fisb.Meats&Game:: E * Animals-155°F 15 sec.* 3401.11(B)(1)(2) Pork and Beef Roast-130°F 121 lain* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155OF 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145`F* 590.009 violations relating to good retail 3401.12 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 PRFs-145°F 15 sea 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3403.11(B) Microwave 165°F 2 Minute Standing Critical:and non-critical violations,which do not relate to the - Time* - foodborne illness interventions and riskfactors listed above,can be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. _ 3-403.11(E) - Remaining Unsliccd Portions of Beef Mem Good Retail Practices .FC 540.000 Roasts"` 23. Mana ement and Personnel FC-2 .003 18 Proper Cooling of PHFs 24. Food and Foal Protection FC-3 .004 3-501.14(A) CoolingCooked PHFs from (40°Fro F6 Equipment meM and Utensils FC-4 26. Watec lFmbity and Waste 1 FC-5 .006 I 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 Matenals ! FC 7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. -Special Requirements .004 Temperature Ingredients to 41°F/4.5'F 30Other _ Within 4 Hours* s,.garo,,,,trurxex 'Denotes critical item in the federal 1999 Ford Cale m105 CMR 590.900. Commonwealth of Massachusetts i City of Salem Board of Health Kimberley Driscoll Mayor 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2010 ESTABLISHMENT NAME: Knights of Columbus File Number:BHF-2004-000002 94 Washington Square East Salem MA 01970 LOCATED AT: 0094 WASHINGTON SQUARE EA SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0143 Jan 4,2010 Dec 31,2010 $25.00 ESTABLISHMENT Total Fees: $25.00 PERMIT EXPIRES IDecember 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 r CITY OF SALEM, MASSACHUSETTS • J, s BOARD OF HEALTH 120 WASHINGTON STREET,4j"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT_ k<y\k*l:n-E C-o Wrybo , TEL# R7`5-0y� - 3 408 ADDRESS OF ESTABLISHMENT-914 tl)zsLlN 5<� est — FAX#=- MAILING ADDRESS(if different)- V.n . 13 nx 3,)- 01Q-M EMAIL-Business': Website: K u C S-al_ ,., • Ole-(, OWNER'S NAME TEL# q7&-7YS - ?)'-(o3 ADDRESS y`f W251nr {ar �a i act Sa�pv (ry) ►7 OI�j7D STREET CITY STATE ZIP solnv. Mtztt7Lt-1 /y1��90 CERTIFIED FOOD MANAGERS NAME(S) ?- 4y%rk hntarnctk CERTIFICATE#(S) lylyy72 (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON t n e!L S M I Z t O cl-( HOME TEL# X11£Z 74 - X14(_ ©PyS_f 4P-ES WR `a �Mondayk :;� Tuesday Wetlnesday , I j Thursdaq r Fntla I Saturda :g Suptl3y ' HOURS OF OPERATION 13 o rA +, 1 3 PM+0 ' P m -1-0 -'bn'n -(-n 3 D M 10 �U L PV j" Please write in lime of day. Forezamplellam-11 L WrvN ii lftM l ft) +7J I t TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES (N� less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 RESTAURANT YES less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES /�JO ) $100 CHILDCARE SERVICES/NURSINGHC 15C --------------___--_ ------------------------------------------------------- - ------------------- - ------------------ 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) K� 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 returns an paid all state axes required un/der the law. 04 - �S�� GI Signature VDate Social Security or Federal Identification Number. ------------------------ ---- - -- ---- --- — --------------- Revised 424/07 FOODAP2008.adm Check#&Date $ •*.1#+{1 .-v,...,}k'..6,i` '+r^+,c,'Ks,,i,..ri.: w-A.^ «s"n:��m.Y4?@ir:..A :. i g N'...�ti �,. �,.. .I;. .,.. a :a, s' b -AA Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,41h Floor g Salem, MA 01970-3523 11' FOOD ESTABLISHMENT INSPECTION REPORT E` Tel. (978) 741-1800 Faj(97.8) 745-0343 Namekntq�I Date T e of Operation(s) Type of Inspection p ( b u j (O Food Service El Routine Addressjttj � L Risk Retail W'Re-inspection 7 Level ❑ Residential Kitchen Previous Inspection Telephone f� ❑ Mobile Date: (o�t�0qq Owner /(( -TICHACCP YM ❑ Temporary re-operatidn L.N I P ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint In: 4/-z ❑ HACCP Inspectorl'D Out: Permit No. ElOther Each violation checked requi es 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) ❑ s9o.00g(F) ❑ action-as determined by the Board of Health. 'FOOD PROTECTION MANAdEMENt n"i� ��"s�7'- ,! ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties fl~: 9. 7i ewu�xmrmmwp iefp - ❑ 13 Handwash Facilities EMPLOYEE HEALTH, � ^ �, ' r m 20.�_ „m` �� ,PROTECTiON FROM CHEMICALS atl 1 fir° E "' ❑ 2. Reporting of Diseases by Food Employee and PIC .F El 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El15.Toxic Chemicals ^FOOD FROM APPROVED SOURCE mr�„y `„„�„4; ""'wq ,` ,0 ❑ 4. Food and Water from Approved Source iIMElTEMPERATURE CONTROL'S(PNoteiStially Hazardous Fti6da)^ "� t:. &;m, El 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118.Cooling 'PROTECTION FROM CONTAMINATION "".`.jjT r"'"""`f ❑ 19. Hot and Cold Holding ❑ 6. Separation/Segregation/Protection El 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing `:REQUIREMENTS FOR HIGHLY$USGEP.TIBLE POPULATIONS(HSP)„ El21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices (,CONSUMER ADVISORy;" E]22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C 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)(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 7�Physical Facility (FC-6)(590.007)' have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (1C-7)(59o.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days Of receipt of this order. 30. Other DATE OF RE-INSPECTION: C ^ S's901nspectFomKte.tla On&-� �1/n Q�� /�" 1 Ins a r' r p cto -' e. ` V Print: P'sSig tur : Print: r Pagel bL Pages L�A2 V JOCJ LLL �2 v � _ 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 of Responsibility* 3-302.1.1(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Foods* 2-103.11. Person to charge--duties Contamination from Raw ingredients 3-302.11(A)(2) Raw An9utal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and - Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(0) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions Food 3-701.1'1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food into Henueticall y Sealed Container* Sanitization Tent eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 lee Made From Potable Drinking Water* concentration and hardness.* 5-1.01..1.1 Drinking Water from an Approved System* 4-601A I(A) Equipment Food Contact Surfaces and Utensils Clean" 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 3 LO 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* ig Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulafo Authorit 2-301.1.1, Clean Condition-Hands and Anns* 3-202.18 Shellstock Identification Present* 2-301.1.2 Cleaning Pr(=durc* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* FT.- Good Hygienic Practical 5 ReceivingfCondition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 - PHFs Received at Proper Temperatures* X01.12 Discharges From the Eyes,Nose and 3-202.L5 Package Inte it * Mouth* 3-101.11, Food Safe and Unadulterated* 330L 12 Preventing Contamination When Tasting* 6 Tags/Records:Shellatock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* ConvenienV Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.1.2 Reduced ax en acka 'ng;criteria* 6-301.11 Handwashin Cleanser,Availability 8-103.12 Confnrmance with Approved Procedures* 6-301.1.2 Hand.Drying Provision °Denotes critical item in the federal 1999 Fcxxl Cale or 105 CNIR 590.000. - a 'r CITY OF SALEM 11 BOARD OF HEALTH Establishment Name: h ro Date: Page: a of—� f item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference R-Red Item ,Verified `` PLEASE PRINT CLEARLY 0 ' r 1 t7 . l e I — A , f 1 yF i i k � 1 t 1 jj5[b 5 k' fDiscussion With Person in Charge: Corrective Actron Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct allVoluntary 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/Fedgal Food Code. I understand th noncompliance may result in daily firs of t'' enty-five dollars or susp n io /revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary. isposal 0 Other: 4 r I i 3-501 14((') P1(Fs Received at Temperatures Violations Related to Foodborne Illness Interventions end Risk According to Law Cooled to Factors(items 1-221 (Cont) _ _ _ 41=F/45`F Within a Hours- x _ PROTECTION FROM CHEMICALS 3-501.15 Coolim,Methods for PHFs -- 19 PHF Hot and Cold Holding 14 Food or Calor Additives 3-501.1'6(B) Cold PHFs((Maintained at or below 3-202-12 Additives" 590,004(F) 41`/45°F- 3-302.14 Protection fir om]Jnapprmed Additives* 3_j01.i6;A' }iot PRFg 15 Poisonous or Toxic Substances - J Maintained at or above �--- 101.11 Jc� lent+t n lnfom,t+cn--OnI40'F. * +oa+ — I Contait s _ 3-501,16(A) Rca sts Held at or above 130"F. Time as a Public Health Control —� lo2.11 C'utnnmu Vxme St >rl.i. on ting," 1 - — Itm+.as a IublttHealth Comrol° 202.11 Ete tMct on F's xn n uid t ��� `r)U.G(111ti) tnanccRc. uirunent __.. FCondn on of Lsv REQUIREMENTS FOR HIGHLY SUSCEPTIBLE -203.(1 Toxi(�f,ontainea, f'rohibition," 204.11 Sannveu Craer+a Chunic Ic � r POPULATITIONS(HSP) 7'04.12 Chnix+lsfor'& tN 1 (duce Critcrra". 1 iSt)t IItA) i unp+ ieurwd rh c. pac..t,9ed JuiceS and j (- �� &etre. with Wa n+n Lal+ W I�-7-20414 Drvi�env._Cntula _ _ 1 '.g0; IIIB) lJ, cfPuc[eivi7cdlS�_ _ 1( .1,-2it5 ]1 Laad ntal f xx1 Contact.-l,tlh, eapts' +_h01 1103) R:nv II P steini C q& d An+teal Pax(a+t.9 l--206.(1 — Re i++cl d t sr.Pe nude C, teu i — i { Aaw tic-d S+r at.Not Svrvca t 7-206.12 Rtxli n r3 a S::st,on - + -- -- —' ,30ti.'f 4 9-r.+rk nij POt+Ylc P's,Coptr") end 1 ARc mtu ma � -�-- -�-- — --- CONSUMER ADVISORY j 224)0.:11 -o+t5un+r litriseit Pnsird lbrCon"Ittnption or TIME(CEMPERATURECONTROLS i in al 1 vrJ That art. tia c UnderuxIke+,I r f 16 Proper Cooking Temperatures for ( lotnthir +u t'ra<ss n o ENclinare ` L PHFs t1411t Ytl ti 1 15va LSC , , l,un dnw Scx rcc 1 ,51 15s eez , .: iU� '� f Stcnn d f (,:Sub + nm tr Raw ShOl - Glint. 1 -:(11,2'11)' -� ( ,n minn+ '} sh S4e- � S _ Animal's SPECIAL RE_OUiREMENTS -(01,11-13 ---2) I '-- o f> d{ Ko tit 1 r'+ , I�' min-*-� r- 9"')A0 lA"-tD ( \ii�l a , n (it 5e hc+ :JO.Eh))(A) fUj in —' �i 40L: (A)f_ k u i Ki1 Kc Mrata 1 i 5 15 1 j cateuue moh&,.t xril temp laip and. dC11.I1(Ai"3j 1iTrnpiry `A'iid C+an. Suitt (i'(iF_s, rezid nt +l kilchcn a}ter aiot S should tie j Sirf" i!Con i in Fish, cehitcd ,(oder the appropriat ie�(:ions A, it to fxxlltcrll s 4{il.l.'rf I 'ATAtn:..,t BOJ :oa a .ts,: iac,tdrs. (?t`tcr i 3 - r + 17 i Rahea+inx t ar riot Holding VIOLA RELATED TO GOOD RETAIL PRACTICES 1 * X3.11+ 1) t17, Hill".If 'F + sc _ .: (IfeotS2S-iii) 401.11(li) Vu owtvc iii I n+ifiSnndia," Crtur r' 1rd rr r+ ur :nt +c rf xr.t u)rrri do+,ra + <srF r „ r 1 �tc _ +wedbrnu tllut ovoir,i1+ m anti; F)atrorc li uc t t+�� (onjw �— 1 ,-103.1JtC') fnmmu_ia:IN l',o<a:cd2k} 11ird- � 4s+u ;ii Jit JAm-wg ter in, of Inc Feud Codc and Jr1 40'F ` oG O0 J + :5-0;13.ii(F) 2c nia,Hina UrOwed Pceoonti A tieeF i tem T Good Retail Practices _ QFC u3t1.90{t 1, h ia5tc* ) . r°Aanayr'mc rt a.+d Per i+rnrl FG_ 2 00 3 Proper Caoiing of PHFs --I 24 Fcvxt and o>o Prote<non._ .,.. + FC: 3 (44_ -- -- -1 26 Fq_uimlon and(J 1130 F; a +n% '-5o1.f=1(A) C ixAn>Cook d PHFs fr rm I UJ F to � 26 f � . .. _ _ I F-- + -- __ t 411-/45.F Within ? Hour,, _ 7d 1 Pc75 nous-br ---- 3� .. !F 4 UGC r+ fWithin flour,; and From 79''}' 2 -tewl!s.._ + -C _ 7 h3 501,14i$i � Cri l+ut;1`1 IF; M+Cin From 1mh+ent � L'19, + Summa. atR tc+rEn'en UC? luaperaont lnrreoieurs tr dl"ti745`F 1 {_30 other_ Within in 41lcwts ' ._ _n;i, '.ecq >dc.. ir Inc t ttciOf4 r:)u Myrv,7•i ',.'n,..y�,:.r ...y.Tag;.,�* .^k'-d ,Usw��vosd�MrY7t�:�wt".Erit�mt°.l'. ;-h+•+:,•r. '•t,'�^ara,.64r•" -lk+r:Y"t k.�',.,.s„(;,i Ei . .. .:f Mr°fchl4'`"✓. n,� Massachusetts Department of Public Health i Salem Board Health Division of Food and Drugs Sal Washington S Street,4 Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT TFL (978) 741-1800 Fax (978) 7w45-0343 Name ( Dat Tvoe of Ooeration(sl Type of Inspection IC) (p Food Service ] Routine Address Risk Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone _ ElMobile Date: Owner /� HACCP YM ElTemporary ElPre-operation 1ElCaterer El Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint In: - El El Inspector OZ ° Permit No. ❑Other Each violation checked requires an°explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health-hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. r r j "FOOD PROTECTION-MANAGEMENT-fn Z n .' d e,�. 12. Prevention of Contamination from Hands Ir �� u�,e�„�wr mom; El } ❑ 1 PIC Assigned/Knowledgeable/Duties y ❑ 13. Handwash Facilities EMPLOYEE HEALTH s a . ., .-..» ,....^.. ark" `PROTEC'110NFROMCHEMICALS071� 3 ' -irx' 1'tg'rirrtm5i',. ❑2. Reporting of Diseases by Food Employee and PIC �'•�» � m� •1 m ��� - � �-b�mm �1•�� f ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE d"-11,W ❑ 4. Food and Water from Approved SourcetTIMFJTEMPERATURE CONTROLS(FoteMFally Ha',csrdous Fopd9)s' `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 ( PROTECTION FROM CONTAMINATION"; ❑ 19. Hot and Cold Holding rF , mwns.t,r . ,.�wu.uaa.. rw,w ' EA'. ❑ 8 Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ,REQUIREMENT$FOR yIGMLYSUSGEPTtBLE POPULATIok-6- ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing p -- �..:.; 1 CONSUME RADVISOFtY." r, , . ... '' ,®. ib,00.u.�' " �' .,„y E:111. Good Hygienic Practices - ❑22. Posting of Consumer Advisories .,....a'm J Violations Related to Good Lail 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 `ell R by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(690.0 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-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 r _. 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 590MVp tFom -14.da n 0 /1 Inspector's Signature: Print: PIC's Signator .`, Print: t�FT .1 c fel ( TNT/2 Page�tf 3Pa ges Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 1 Cross-contamination , 1 590.003(A) Assignment oFResponsibility* 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 chane-duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.(H)3(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reset-vice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* q 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* - 4-501.111 Manual Warewashing-Ho(Water 3-201.12 Food in a Henneticall y Sealed Container* Sanitization Tem eratures*`--i - 3-201.13 Fluid,Milk 4-501.112 MechanicalWarewashinb Hot Water 3-202.13 Shell Ms* Sanitization Temperatures* 3-202.14 E.>s and Milk Products.Pasteurized* 4-SOL]14 Chemical Sutitiaation-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Water from an Approved System*tem* 4-60L1](A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean" 590.0(I6(B) 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, ,Fcequencyof Sanitization of Utensils and 3-201.14 Fish and Recreaflonally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Saintization-HotWaterand 3-201.15 -- Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Author" 2-301.11 Clean Condition-Hands and Anns�' 3-202.18 Shellstock Identification Present* 2-301.12 CleaninS Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eatiiig,Dii ingorUsing Tobacco* 3-202.11, PHFs Received at Proper Temperatures* 2-401.12 Discharges:From the Eyes,Nose and - 3-202,t5 Package Inte it•* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventina Contamination When Tasting" 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Ent to ecs* 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 Capacities* acities* 590.004(J) Labeling of Ingredients* 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maitnenauce /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision *Denotes critical item in the Waal 1999 Faxl Cale or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Kn I r, klt 'i \ \ r Date: /� U Page:_ of Item Codo, C—Critical Item \ DESCRIPTIION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item .Verified i PLEASE PRINT CLEARLY & t� C-)VeA 60_L4 04C 7111"(717 r !r c1 bJ 7 C c lka tdonn (X11- u Rc _ t _ - I Lihn P - Yam- Oz G/!I✓I i �: (d ;. - -- - ' Discussion With Person in Charge: Corrective Action Required: ❑ No I❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ 1 violations before the next inspection, to observe all conditions as described, and to Exclusion , P Fie-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 r your food permit. (� �- 1 /� . ❑ Voluntary Disposal 0 Other: 1 ?-501.14((} PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Lain Cooled to - Factors(items 1-22) (Cont) - __ 41'Fl45"F Within 4 Hour,. * _ PROTECTION FROM CHEMICALS 3-5(11.15 Cooling Methods forPHFs 14Food or Color Additives 19 PHF Hat and Fold Holding —— 3-501.16(B) Cold PHFs Maintained at or below 3-203.12 Add tive,* 590,0W(F) 41°/45`F" 3-302.14 Protcttionfrom Unapproved Additives* gSp1.iG(A} ilotPHfcMaintained;it orabove 15 Poisonous or Toxic Substances -- -{ 140'1-*. 7-101.11 hlentdymgInfo)maII ,tta' 1 .¢_sill ftp a x _ Cont inter" _. (A ) _ Ro sts Held at or.ibove 13WF. � 1✓20 Time as a Public Health Control t 102.11 Cornn � m> S ,rl „tr t nu.= j ' 101.11 Sia r«n Sru,3k _ 2 �t!1 I 4 '[iml as i Public health Couo�, �( 72R.)1 Ret u.<.on- Fr unu-uid 1, e Qf1('a1rF4) Y n_m;r Ru nimmeut 7-202.12 l Condit on of Us' 7-203 11 Topic Cowwnc-t Probibinuns" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE (HSPS _ I t-ZUd.11 Samtncas C'citerti Chunic is _POPULATIONS � ' . 1116&.01,11 3-801.1 I(A) lmo tcui,z<d Crc av}icd Juc Chelrucal�fol ec mid7 204.12 dc CiRete( estilt Hna il 7-204.14 DiFi2 4reumCriier 127 i-80! 11(13) of Pastewi7,d t }n x0511 hxdnttl ! xlContact ( ;.St 11 D) — _ Pol - C,KwdAnhwdFoidai;id 7 'o6 l 1 FLentu,,Pt[Tv Pe iiu le..C,tteu t R Se,ri 5tt .he Scr'vc t 1- 1704.12 , Rodeill h„7 S:360,711' r-'---- , ( ._--- i 1( _ - C , tFc ic,� Fu<;o {'ac��,ir Not R 'arced. , G6.ls 1 r.,c4.t t 'y ,twv:., 1 :.�; ontr,J and - _ - - T------ __CONSUMER ADVISORY TTMElrEMPERATURECONTROLS x3-60' 1 ConSmyror (h1ROil ,nrd;arPcrostanptinnc � y{, Proper fboktt g Ten.pesetuins for ---����---PPHFs _ _ 1 I t 0th ti ie t-oar ss a �l lu trn rs. 11 �.—. ..:;01.1.1 At (,- , -55- 1 5 c— - f c int i„m tr S�, to 17 195see- —0 _1 12 kPushteanr�vn t"rc � _ to, k-Axle sftol j 4UlJ tt 1,;2.t C mix tt„< } ch f -,� ', G4111, _ 11,_k, 1 x.. - .__.. SPECIAL REQUIREMENTS fi of Ko st 01 i'I rn;T” -- --- a -� - Vi(In Qi lL' Lx,u ±.,!h�4,-vt (D)in l-i L"(A! atel tr n, hrk food � 1 p rat nt, -40L11(AT3j I I'nnr 1k'i,9Gall,ieStu—edp(ir.;;'- rtsidntml kitchen opcniiiions AwkildlFa 1 ' C ,.f}r,,�C.�ni2n,t tFiob At at. ( , dchii d und'I the approjIN'tIt" •ct ii(?115 i to e K:O,,t,.—, 'L._t�;•; 1a w, _ iCi.._ t t i '.. _____ _._..- .-_ __ . -.._. i I_9 }A he3Gn�t�, i#nt Hol ,nU JJf}Lst FfQti417ELATCt> fG >i.—QO J RETk.._.JL t R61CT{CS .II, A) iD, ( VH16.1 i c - ( ttternv23-30) - 40:7.1 d6; t1x,,,,t !ve P'� r`2{411 ru < SL7rdittg Crpa<t and raa-u;xi,.ctl n:?rti„rt.,.which do wn r inrr aHl r i 1+ouh, m 7A, , iaret wnt, no r r`rr 4 Jart-,rc Gw i t rt,e (ante, "i3.I1rCi� � C„umuria�ltl',c acd ,2CiFtt+,d�� join,1or-hcfi41iwiga .or. -) ,huloxfC.>deCu,?1' . CIIR -T- 14;i3,I itfl 1 t<„s,f I`tei v _ �18� `v0c, 0(tofP ('1 , andF( xI roic o 1 FC 3 x j 18 Proper Cooling of fPHFsh7y -- e--- 1 l4A) x = ra} i at,t Plumbmqu c W e, i 7WF Within 2 Hour, and From 70`1' t aFa itt}-- 1 F( 1 s 007_ - 41 'i 45"r V t! m ,H,u�-.,--------- --- � nxer ia , rr X61. t.Ua i4(6) t lK its III-IF, 'ti tin Front Ambient t w 9 Sr,., .i tl F t2t utmc�t a UC9 F.mpe aurrBrod�er,s tc. J f 1--30 Oth-.er .... . . _ Aifhind lieu CITY OF SALEM BOARD OF HEALTH bEstablishment Name: / �. Date: o Page:� of Item code.- C-Critical item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference R-Red Item .Verified PLEASE PRINT CLEARLY - I J� I (. �I- 1 , D I A IC 14— <-- I ! \ �. r Lialk Malfc- . zl re s/c / o_ /rf-t �_At A-%A Ir o Discussion With Person in Charge: Corrective Action Required: ❑ No ,q' yes- �r J 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 r Exclusion violations before the next ins P �j Re-inspection Scheduled ❑ Emergency Suspension i comply with all mandates of the Mass/Federal Food Code. I understand that �V noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure ° { your food permit. IC�j j C2Voluntary Disposal 0 Other: _- 3-561.14(C} 'PHFs Received tit Temperatures Violations Related to Foodborne Illness Interventions and Risk Ancording to Law Cooled to Factors(/terns 1-22) (Cont) I I'F/45'F Within 4 Hours. 3-5(11.15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS _ 1g PHF Hot and Cold holding 14 Food or Color Additives 3.501.16(13) Cold PHFx Maintained at or below 3-262.12 A(hitives'r _ 590.(H)4(F) 41°/45°F" 3-362.14 Protection Prom Unapproved Additives' 3-5D L16{A} Hnt t HP;:1faintaiued For above 15 Poisonous or Toxic Substances w 7 101.11 Identifying Information-Ou final _ k:ontur er . t R71 1 ti{A) kwsm Held at or alone 57) , ( �7-1102.1( Comronn A'ainc° R nki,+r' rent m rs"— x-26 �.-- f .._ Time as a Public haatth Contro4 i 7-20[A 1 Sr a auory Sirnag<" -- r�>01. _ �rm�as a Public Health( omroF '.21)2.11_ rte tntion_-Pr s.nce and t _--� I_t> nanCc Rc uittnrettf —� L- - ------_ 7 262.12 — Condition:,of!1s,; 7-^_63 11 Toxo C o gainer Prop bi uo.r REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 sannverk C.rita r, Chemic h POPULATIONS(HSPL_ _ 7-?�M1.13 Cit nuc el+'tar tit. rchurt )cuc.e Crrecta` I �r��'SOLI1(.AjIl;np .temiied Pte pod .geS Juices m:d �I Ile4ec w ITN nh Naimn 1.ab �7t 04.14 Drving At erre C.naut 1 —f 3G_ I1(H)-I Us, of Pute.wvrdter: .— '7- (15.11 hard tit 1t >,xl ct ttu latbtcats-...__ II(5) K.nr nPutiAti ( ,4nd An anal poor)a id 7 ') ;i it- n t d r.Pc aerate C.ittetl) _ !?t S t fiats Not 1 7 26G.11 Rxirt 13S:eaom ! ( --i 1. —.. r_..—. .._- ._. -. . ' I CONSUMER ADVISORY TIMEITEMPERATURE CON P.OLS A X60_ I I r t:or, u 1 of 4ilsisol r'u6t x3 for(:m..nir)ptiun Of mu.1 1 I d t rst rc Rtit Cu.der; ked s 16 —�1 Proper Cooking Temperatures for- 1 1 PNFs ( 1 -1 x.111 r IS r'Ti t n 1 t 1 1111in T _—..._-.� f i7 r fin r n ro t ,OL11 rl(t t = e �ri 55 x 77 10'311 1 r. nr dr , :,t RimSletl �2 - F s ina cu tie Se il.r 1,511 s=ec - 1 .°.� ' 1 t ( .1C C I C , ntr c y {ei)s k 6a 1 r _. _ ._ _ t e: SPECIAL REOUiREIL'uN1S I 4f�1 1"13 {10) Ito rj 'i tZi t - 1 ') r 1 Ctv-� -- - _.._. - _ ._. ._ - - 59J-.,f<)(Altstd ` r1M a ;1 `rc tut )t,tiH)3in u) - t C } I a v a td j : 41'l li+A �+ ;t-ti PIt k o iIj r t *,'Fu`kdli1i � ctiidttrl 111,itchrn ell r :ilv ut,ld as I Ct.t£itu;Con a f t. 1 ts --] l htvaf. 1 d!'Jiilt C imocr thc 3pprr notate ,Cions - .li_i i fM)s'7 f ...__—._..._ _i VIOLA 2 - Rel to nor Hot Hoidtn X1 10 NS RELC,0 4TED aG 00 RETAIL PRACTICES +03.ih 1}C.0?�t IEl (r� r u � {1ien15;.3-,3sit 403.11(A taut ti�tva 117 1 2 Ntinut' Si:ndinc Cr , rr, I,rt nr t rui vtt 1tt rt ntc, x7«! dor ua; art t s!tor I 1111< 1 w(lb oil i dlv,k t, i 'i! n i en,1 1":,f.)th f rs I i ai' )(, coin vl' 1 t3.I1tC-) in)urria It f§ca -rid 2tr l".+xi- � c rn+ iir h, uip 'r r) e;i liw Food Codeand 10 CM!", I fb F 1 1(E) _� +(7PU) , 3-40. '� +)unnr,L ,�l rrU Porht ns n! 11,x1 (_Mena ` Ctoad Retail PrtatmeS fC 5^p.17tJ:7 M'in9yr'meri and Per m i I _ rG l 1 Oot- ..{_ 1 t Food rad Foal Prot. tion FC t 0C: 11g i Proper Cooling of PHFs + -- --- -+- + L .4. _.m� __.. .__ .—..— ___ I_2b 1 E.gulpnloni r,�d Uferi t n 0; Stil.14(A) x( n Catk PHFs Crum I '('to -" l" YJ iter PI mot yU C NJ '� IPG 5 0n`�ibp 1 1 `:4utin t l Too r. .:rad From r)'i' i l2-"L rhsrai F14'At . . ` FC, r 007 1 t d F -t:F Roo to d Hnu ' i l 26 1 P(Nsoriods or T ox;f kinitif ils C 7 NA3 ; -501.14 _iB_--i 1 PHR sicirt�iow r 3 rS^:,. ' From 1 R<t lnvrecwi tittr i tm_c'tt _ _. tt ... .. i Commonwealth of Massachusetts s t City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 1211912008 ESTABLISHMENT NAME: Knights of Columbus File Number:BOF-2064.060002 94 Washington Square East Salem MA 01970 LOCATED AT: 0094 WASHINGTON SQUARE EA SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1 Notes FOOD SERVICE BHP-2009-0084 Dec 19,2008 Dec 31,2009 $25.00 ESTABLISHMENT Total Fees: $25.00 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 d CITY OF SALEM, MASSACHUSETTS + • BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MYOR _ DIONNE@SALEM.COM RECEIVED imI /omD JANET DIONNE, DEC c82008 ACTING HEALTH AGENT C: Y OF SA; L:.1 BOARD OF HLALTH 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT n\!kL4-� TEL# ADDRESS OF ESTABLISHMENT q Wa�ntvt��a� L �t FAX# -- MAILING ADDRESS(if different) ? -0 - EMAIL- Business': -u •EMAIL- Business': OWNER'SNAME C=6(uyv \)-, Soct-Ll ok Salrx T—Inc TEL# �17� SYS' 3 `f o8 ADDRESS Ql 4 11)251^% nn-ir-n4 S� ��� S zl ew In )+ 6 STREET — CITY STATE �`/f4 ZIP Sn1A%1 MlZ tuc N CERTIFIED FOOD MANAGER'SNAME(S) 0B,+u-trK- 08tzrue14 CERTIFICATE#(S) r�fl F�t�Z (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON t�Ginyv�{ L. S (�(1I- -1OGt-L HOME TEL# oOgI6 DAYS OF OPERATION Monday ..l J 7uesda `.Wednesda ,,,Thursdayfrda Saturday Sunday, HOURS OF OPERATION Please write in time of day. �� N For example 11 am-11 pm �-'E-o 1 `7 � ) t-( 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 YES NO less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ------------------------------------------------------ ------ ----- --------------------------------------------------------------------------------------------- BED/BREAKFAST/ YES NO $1b0 CHILDCARE SERVICES ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO135 ALL NON-PROFIT(such as church kitchens) NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health, Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax retums d paid all state taxes required under the law. - I' ii- a!�—(- o R Y- 3-s7 sg If Si a ate - Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date C41 ��� Z/�,�r� $ 0094 Washington Square EA Knights of Columbus City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-3408 Handwash Facilities FAIL Critical ] RED Owner: Comment:The bar hand wash sink found obstructed. Hand wash sinks must be kept clear and accessible at all times and used for Columbus Society of Salem—1 hand washing only. PIC: Violations Related to Good Retail Practices (Blue Items) Equipment and Utensils FAIL Non-Critical BLUE Inspector: Comment:The Arctic refrigerator needs a general cleaning. David Greenbaum Date Inspected:Correct By: The Maytag refrigerator/freezer needs a thorough cleaning. 6/25/2007 The freezer compartment of the Maytag unit needs a visible,accurate thermometer. Risk Level: The oven needs a general cleaning. Permit Number: The counter at the pizza cooker needs a thorough cleaning. BHP-2007-0105 The pizza cooker needs a thorough cleaning. Status: PARTIAL COMPLY The microwave needs a thorough cleaning. #of Critical Violations: Relabel the 3 bay sink. 1 Time IN: Time OUT: The walls around the 3 bay sink need a thorough cleaning. GENERAL COMMENTS: Urgency Description(s): BLUE: Manager to notify the Board of Health within one week that the above violations 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®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 25,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 25,2007 ) Page 2 oft z r, , ..r. ...i• i .P,k.•"4>�' °'l;°"�'"w'3l"* #' �+-ISA,.-" ,;,a .. t` + i � f � 0 -i ar* v93] S s xk N 4yyy 'a'3f%. !°R $ .,...+ yt m+ 't.'de+.f � tN Commonwealth of Massachtisetts * <.t a14x CityofSalem, -Board of Health lcmbt trey Driscoll 120 Washington Street,4th Floor _ Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Knights of Columbus File Numbec.BHF-2004-000002 94 Washington Square East Salem MA 01970 LOCATED AT: 0094 WASHINGTON SQUARE EA SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0124 Jan 3,2008 Dec 31,2008 $25.00 ESTABLISHMENT Total Fees: $25.00 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 Codes beofre any-revonations;improvements;or equipment changes-are made,all plans for such must be submitted to and approved bytM Salem Board of Health. Page 12 of 37 r 0 3 CITY OF SALEM, MASSAC HUSEM c BOARD OF HEALTH r 120 WASHINGTON STREET,4' FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR Jscoma)SALeM.OOM JOANNE Soon, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT k< KL5;Z!" 3C r,t%LDIe 6S TEL# ADDRESS OF ESTABLISHMENT q `( 1.pU25�tv�cZiM S� 55fi FAX# MAILING ADDRESS(if different) 9•0 rn)k d 15-?(3 EMAIL-Business': Website: OWNER'S NAME + TEL# ADDRESS 9(4 LJ- STREET CITY STATE ZIP 3c�t� lM\�-LbcF� /o72r�ff CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) /a7 2FQ (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON KeLttA?{-� J UAVI�20 -( HOME TEL# DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION Please write in lime of day. 3-ii,.O (2 S ('L (L '3 +n ( 3'l U (For example 1 tam-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YE NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 - - - -- -------------------------------------------------------- less -------------------------------------------- --------- less than 25 seats =$140 (Cutdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 - - BED/BREAKFAST/ --------------------------------------------------------$--1-0--0- -10--0- ----- CHILDCARE SERVICES -------------------- ------.......------- - - 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) ES 0 $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 return d paid all taxes required upnder the law. i�in,C Signature Date Social Security or Federal Identification Number ---------------------------------------- ---------------------gg -------------------------------------------- ---- Revised 4/24/07 FOODAP2008.adm Checkft&Date n( $ r ,�O��'' 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 JOA SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT C* K,,51 5, 4 Cc Vii. hu TEL# (��� M `3 W ADDRESS OF ESTABLISHMENT p I "'4A5 A 1 hOK S5 E FAX# - - MAILING ADDRESS(if different) T• d • RW oX EMAIL--Business': J Owner's: U OWNER'S NAME C'd i VU JUx Sari 6 GF S��Q{. �h ( TEL# ADDRESS PC Por 3d- STREET Ep? �/ A� CITY 1 STATE h tZIP CERTIFIED FOOD MANAGER'S NAME(S) b%, A;-)',cck CERTIFICATE#(S)�� Ln _ SG'kh 5• AQ h / 3� (Required in an establishment where potentially hazardous foodisprepared) 1 rf EMERGENCY RESPONSE PERSON �c r� 1~ } HOME TEL# UAYSOFOPEflATtON Monday Tuesday Wednesday Thursday Friday Saturday Sunday NOOKS OF OPERATION . . Qa - tA \ ��� " /tPlease write in time of day. 3fA_ IAA3f/A-IAM3P/1- JA, 3PM-IM, 3DD1- )!A.h (far eyamole tfam-itoml TYPE OF ESTABLISHMENTS FEE (check only) RETAIL STORE YES Nf O J 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/SREAKFAST YES NO $100 -- --- .-- ---- .. . .. - - - - ----------- .. ADDITIONAL-PERMITS_ - MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR O $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 knowledge and belief, haaftled all st to taz returns and paid 0 stagye xes required under the law. Mi ure Date Social Security or Federal Identific tion Number - ----------------------------- - ----------- ------ ------------ ------------------------------------------------------------------- ------------ Revised 11/13106 FOODAP2007.adm Check#&Date 3 �__ / p��(z 5 •�,J'�,�d This recognizes that N C to ;N Jerry L Ryan cn� r M i� RWCr + �I Y`.- 6 has completed the requirements for or sSi.. .cure v d V p Standard First Aid Ev e A 7-CT aar a ARC N rt'her MA � conducted by o r t h e a s t ARC of Northeast Massachusetts - - $ Dale completed 8/23/2006 Holder's Signature The American Red Cross recognizes this certificate- V /4 as valid for 3 year(s)from completion daze. �" Y "Cert.653999(Rev.Oct 200 1), assw=e=y,F ...�..�_.. C Am,W 6 Md Coss 'nus recognizes that ins ttLct01 S S '"ature A N Jerry L Ryan " V O o has completed the requirements for (� / -e 4) a CPR/AFa_Adult QW ARC No�t�`east MA conducted b _. , _ ..�-"u:.. .. Ho de/'s Signature . z ARC of Northeast Massachusetts o, Date completed g23/200ti to -cert,653999.(Rev.Oct.2001) The American Red Cross recognizes this certificate as wand for I year(s)from completion date. t TAN < M} r; t.X'V,S. .w,j P{• '4^ ,7''atre k ' xti ' ae..o v� '.3 �, •r. ,�2' ..� Yp+3 t*Y n �y-V r ° !{ 4 4 � '�At @@4''.� d= R, r F t s +PTRr F Gommanwealth of Msssachasetts , >•" �' *���� '�+�� '`r$r�"? w..f�"�f�"�:fFa'�``, �"`'a�f��x�t...,. '' '�g�, y;, .n �,� � £ �'R. s i{�t` } i•� �1n..T- 'itr�lwY`'�h?I��'r �k1`�S '$ A` ,�F� h X h �5 �3�`M 'P 1%wfi • ,� • �.5 ��� � Boar�dofHeelth � � iw:�wc*�:-- x '�'�{ a t ,y,�'� ��` u`k"�,v. � v � ,✓` .; tGmbette Dnscoll SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Knights of Columbus File Number:BHF-2004-000002 94 Washington Square East Salem MA 01970 LOCATED AT: 0094 WASHINGTON SQUARE EA SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0105 Dec 20,2006 Dec 31,2007 $25.00 ESTABLISHMENT Total Fees: $25.00 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 7 of 23 0094 Washington Square EA Knights of Columbus City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency -Telephone: Violations Related to Good Retail Practices (Blue Items) 745-3408 Equipment and Utensils FAIL Non-Critical BLUE Owner:, iy.. Comment:The Maytag refrigerator/freezer needs a thorough cleaning. Columbus Society of Salem PIC: The Atctic refrigerator needs a thorough cleaning. The microwave needs a general cleaning. Inspector: The Kelvinator refrigerator/freezer in the upstairs kitchen needs a thorough cleaning. David Greenbaum Date Inspected: Correct By: The GE freezer in the upstairs kitchen needs a thorough cleaning and defrosting. 813112006 Relable the 3 bay sink"Wash,Rinse,Sanitize" Risk Level The walls in the upstairs kitchen have an accumulation of food spills and splatter. Thoroughly clean the walls Permit Number: GENERAL COMMENTS: BHP-2006-0083 773: Status: SIGNED OFF #of Critical Violations: 01- 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. Aug 31,2006) 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 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 31,2006 ) Page 2 oft t` r � � -„'w+6. ->:,� ��-+.+,w•;.....�- .r b� e.v'. .sr.-{ix 3 ri i��^�,^y �,#` '9a ' ,a q�, a £„ ,� . ,w„`.",rp��'R'NrN �'x1"a ^•.;ra-'+RAfi e^'Cv.?F 41;t"?k :%w^rr• _-yr.avi--. .n^ryN?y^+,,.i±t'�^�'”'�T�'M.!`kS*�'"+�X�`nEf,';,.'t9; ah:fYgMT+Y,�n,`�C3Pa�,�ps�r, ,?rd.'i - Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTE 01/03/2006 WHO'S PLACE OF BUSINESS IS: Knights of Columbus File Number:BHF-2004-0002 94 Washington Square East Salem MA 01970 LOCATED AT: 0094 WASHINGTON SQUARE EA SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0083 Jan 3,2006 Dec 31,2006 $25.00 ESTABLISHMENT Total Fees: $25.00 PERMIT EXPIRES IDecember3l, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 22 of 23 i CITY OF SALEM, MASSACHUSETTS o� 3 BOARD OF HEALTH / a 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 �"0N6 TEL. 978-741-1800 060 STANLEY J. LISOVICZ, JR. FAX 978-745-0343 nn017), �, Oc Vi'/, MAYOR WWW.SALEM.COM &0 0F 20 J JOANNE SCOTT, MPH, RS, CHO '1 HEALTH AGENT OF q�F tiFq�N 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD EUABLISHMENT NAME OF ESTABLISHMENT C eluw�ov� met e t�& SaLea„ TELCC��# 9TH 7`d�'" �tidOsr ADDRESS OF ESTABLISHMENT Qy U�2�L�i kiZ0 J5 Y 2 e�+ i MRD It-9ZO MAIL!NG ADDRESS (if different) �, IJ . ��_� '�Ms 6, pnMIA 6 1120 OWNER'S NAME Ct)[upkbvs SOQ-c� rt :!ZWm ADDRESS hU2 2S 2UsY� CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAnME(S)T k, -iW I CERTIFICATE#(s) / 02 V� TZt-yk .L 1,2A OCH /6-7,Lg-y 7 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON J 1 Ae4-� -7 M(-24 Ly-t(HOME TEL# HOURS OF OPERATION: Mon.31v2Tue.3-/z- Wed.3A=-Thu.3-1`r- Fri.,Ll Sat.jz. f Sun. /-2-- 11- 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 O ^/� / ^ less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 - - .... ...- ... ....................................................... - ..----------......-------------------- ------ ....... BED/BREAKFAST YES O $100 --------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR Y 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 kan ief, have filed all state tax returns and paid all state taxes required under the law. l /z- s -o�� opt- ass-?eg i Signature Date Social Security or Federal Identification Number -------- - ---- f r Revised 11/03/05 FOODAP2.adm Check#&Datel SIV 0094 Washington Square EA Knights of Columbus City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 745-3408 Non-compliance with: Not Done Owner:-. ' a Anti-Choking PASS ❑ Columbus Society of Salem Tobacco PASS ❑ PIC: FOOD PROTECTION MANAGEMENT Not Done Inspector: 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 PASS RED -9/29/2005 Personnel with Infections Restricted/Excluded PASS RED "Risk Level: f FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASS ❑Q RED BHP-2005-0277 Receiving/Condition PASSd❑ RED Status: Tags/Records/Accuracy of Ingredient Statements PASS ❑ RED SIGNED OFF #Of Critical Violations: Conformance with Approved Procedures/HACCP PASS RED Plans 2 . _ Time IN Time OUT: Notes: 336: t : Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical- violations�,must be corrected ` immediately or within 10 days)(Non-critical violations GeoTMS0 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 29,2005 ) Page I of 3 0094 Washington Square EA Knights of Columbus must be corrected Immediately PROTECTION FROM CONTAMINATION Not Done Of Within 90 days) `. Separation/Segregation/Protection FAIL Critical ❑d RED Beer bottles found stored in ice machine. RED: Do not store beer bottles in the ice Violations Related to machine to prevent cross contamination. Foodborne Illness Interventions Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑Q RED Ice scoop on top of ice machine. Keep a .. sanitized ice scoop in ice handle side up or and Risk Factors Re uire ( 4 in a sanitized container labeled"ice scoop immediate corrective action) only" Proper Adequate Handwashing PASS ❑J RED Good Hygienic Practices PASS ❑Q RED Prevention of Contamination from Hands PASS ❑Q RED Handwash Facilities PASS ❑d RED PROTECTION FROM CHEMICALS Not Done Approved Food or Color Additives PASS RED Toxic Chemicals PASS ❑J RED TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done Cooking Temperatures PASS ❑J RED Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS ❑J RED - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS (] RED GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 29,2005 ) Page 2 of 0094 Washington Square EA Knights of Columbus 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 The microwave needs a thorough cleaning. The Whirlpool refrigerator needs a visible - accurate thermometer. Make sure all freezers and refrigerators in the catering kitchen are clean and have visible accurate thermometers. 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 J GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 29,2005 ) Page 3 of ct- ,,,a 1'4, ° ,-� _,7a - a: fli Av 1 r 1 ,fi . wst--' "^a', '*"` ^'.F"'"'.` -+*-i�rrY^ rord t,'°;"ry'r�'( nl^ A 4 v '.�nrr '-L .q i..�'4s'S .Lx'"w` 'F-E"Y^�,kC'^" •f�'�'4?!Wttt >1'Y^y� . ,CITY OF SALE,M9 MASSACHUSETTS 4 * n sof,; :y:'�a `4.• vR7 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: FOOD SERVICE Name of Establishment: Knights of Columbus Address of Establishment: 94 Washington Square East Owner's Name: Columbus Society of Salem Inc. Restrictions: Application Date: 12/6/2004 Permit for Food Establishment 182-05 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. r � HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH + 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01 970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT CoU Hv6)& TEL# 3`� t 6 ADDRESS OF ESTABLISHIMENT 01,4 MAILING ADDRESS ((if different) OWNER'S NAME I,OIV v%k)f%I7:, SO c,&41 -oo TEL# ADDRESS_ q-( CITY ztp , STAT ZIP 0 t "t7o CERTIFIED FOOD MANAGER'S NAME(S) TDAti >11C2 U1c N CERTIFICATE#(s) ✓��'�� N� Pzhrr�t� rA t-�!-LOON (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# HOURS OF OPERATION: Mon.3-I2Tue3—liWed.3-tzThu. 3-1-LFri.3-1 Sat. --1 -1 Sun. 3—M TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES !O less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 6 6 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 4Z $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchem.) ES NO S2 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 owl a an , have filedall st to to ret ms and aid all state taxes required under the law. iso - - 7 9/ SignatureDate Social Security or Federal Identification Number ----------------------- -------------------------------------------- ------------------ - Revised 11/03/03 FOODAP2.adm Check#&Date ���� ll 3676 CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH s 73 120 WASHINGTON STREET, 4TH FLOOR o 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: Knights of Columbus Address of Establishment: 94 Washington Square East Owner's Name: Columbus Society of Salem Inc. Restrictions: Application Date: 12/4/2003 Permit for Food Establishment 95-04 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 o CITY OF SALEM, MASSACHL >3 q, ;_ ;r a BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 DECD -2003 TEL. 97 8-74 1-1800 STANLEY DSOVIGZ, JR. FAX 978-745-0343 CITY OF SALEMO BOARD I= I EAT�+ JOANNE SCOTT, MPH, RS, CHO BIJ Ll Y /': MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPppERATEE A FOOD ESTABLISHMENT ( NAME OF ESTABLISHMENT 0(U A 6 5 n(J6C/e'( 6COle TEL# ADDRESS OF ESTABLISHMENT 97 MAILING ADDRESS (if different) PO Bok 3 Z & 00W 1 OWNER'S NAME S6 r Q_ G� G%sne L TEL# ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) PatncL 5 r�1z 1oc� CERTIFICATE#(s) /07Zgq 7 1 0', ' n S Vtii7 peck (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON j65e( \ ��� c1n o HOME TEL# 070 7�(5'Zo1 P M PM PM Pµ (/M PA PM HOURS OF OPERATION: Mon.7/2 Tue.742- Wed.�42- Thu.3-%Z%3oFri.3-!2,3cSat.3-(Z;315Sun.3-12'.36 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES N less than 1000sq.ft. =$ 50 .o 1000-10,000sq.ft. =$100 /f j more than 10,000sq.ft. =$250 RESTAURANT YES 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 O $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowa and belief, have filed all state tax returns and paid all state taxes required under the law. )q� Cir /2-/-e3 O`I Z -s-S -?$ q 1 f Signature Date Social Security or Federal Identification Number - ----- -- - ---- -7r77 Revised 11/03/03 F00DAP2.adm Check#&Date_ 64i 80 1211 12063 Massachusetts Department of Public Health Salem Board S Health M 120 Washington Street,4'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978)745-0343 Name Date J Type of Operationfs) Type of Insueotion xjJ l6 ( Cid tl$ G I�7 D EJ'Food Service ❑ Routine Address Risk ❑ Retail E]-Re-inspection W T/.f NC v 44 &Afr Level ❑ Residential Kitchen Previous Inspection Telephone7 *3 5W8 ❑ Mobile Date: HAGCP YIN ❑ Temporary [:1 Pre-operation Owner , 3 ❑ Caterer ❑ Suspect illness Person in Charge(PIG) Time ❑ Bed&Breakfast El Complaint ❑ HACCP In: Inspector �+ r A i letfNb� Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-comptiance,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 CWEMICALS '' ' - ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ---- ; TIMEtTEMPERATURE CONTROLS(Potentially Haiardous 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 ❑ 8. Separation/ Segregation!Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ ,CONSUMER ADVISORY11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions jq immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): V of Health. Nan-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 G t4 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-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. It aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 5:5901nspeclFOrm64o.doc s ctor' " n reg Print: PIC's Signature: �'" Print: 11�W4 .7 / 1, / Page of 2 Pages Violations Related to Foodborne Illness interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT R Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated hom 590 003(B) I Demonste cion of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge--duties Contamination from Raw ingredients 3-30111(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) I Food Piotecfion* applicants* 3-302.15 Washing Fruits and Ve,',etubies 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils'* Chane* Contamination from the Consumer 590.003(0) Re ortinrt by Person in Char e* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590 O3iE) Removal of Exclusions and Restrictions Food 3-701.11. Discarding or Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590,004(A-B)- Compliance with Food Law* 4-501.11 1 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 Warewashrng-Hot Water 3-202.13Shell E,,gs* Salutizatitm Temperatures* 3-202.14 Fees and Milk Products.Pasteurized" 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. * 3-202.16 Ice Made'From Potable Drinking Water* 4-601..11(A) Equipment Food Contact Surfaces and 5-101 A I Drinking Water from an Approved System Utensils Clean' _ 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequenw of Equipment Food- 590.006(B) WaterMeets 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 Recreational ly Caught Molluscan Fond Contact Surfaces of Er ui anent* 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 ulatoAuthorit 2-301.1 7. Clean Condition--Hands and Arms* 3-202.t8 Shellstock Identification Present" 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash" 3-201.17 Game Animals* 11 Good Hygienic Practices Es Receiving/Condition 2-401.11 Eatin ,Drinkin or:Using Tobacco* 3 202.11. PRFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes.Nose and Month" 3-202.15 Package lnteerit * 3-101.11 Food Safe and Unadulterated ° 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 6 Tags/Records:Sheilstock 3-202.18 Shellsmck identification* 590.004(E) Preventing Contamination from 3-203.12 She1'istock;Identification Maintained* Employees* Tags/Records:Fish Products I3 Handwash Facilities 3-402.11 Parasite Destruction* Convenlentiy Located and Accessible 3-402.12 Records.Creation and Retention" 5-203.11 Numbers and Ca aoities* 590.0040) Labeling of Ingredients` 5-204.11. Location and Placemenfr 7 Conformance with Approved Procedures 5-20.5.1.1 Accessibility, Operation and Maintenance fHACCP Plans Suppiied with Soap and Hand Drying 3-502.11. Specialized Processin Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.-11 Handwashupg Cleanscr.Availability 8-103.1.2 Conformance with Approved Procedures* 6-301.'12 Hand Drying Provision '*Denote,critical item is the tedcral 1999 Food(:ods or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: K rJt o-ki-P OF r,!5LtlA90rL Date: i7 Page: 2 of � Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY 41-L- (,1 6L Ir i i' Ct norf G� /kS u 1 .Je�i ll _ _V6wtKE yr r� ry cfi c vJ t Ore rIS J" [ .G g ,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/ violations before the next inspection, to observe all conditions as described, and to Exclusion P LI 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 LI Embargo LI Emergency Closure ;your food permit. % ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFS Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(items 1.22) (Cont.) 41`'F/450.F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFS 14 PHF Hot and Cold Holding 14 Food or Color Additives 3-501.16(B) Cold PFIFs Maintained at or below 3-202.12 Additives* 590.004(17) 410/450 F* Rote 3-302.'14 tion from Unapproved Una roved Additives* 3-501.16(A) Hot PHFS Maintained at or above 15 Poisonous or Toxic Substances 140 F. * 7-101..11 Identifying information-Original 3-501.t6(A) Roasts Held at or above 130°17. Containers* 7-102.11 Common Name-Working*Containers* Time as a Public Health Control 7-201.11 Se aration-Storage' 3-501,19 Time as a Public Health Control* 7-202.11 Restriction-lk590.004(H) Variance Re uirementesence and Use 7-202.12 Conditions of Use" 7-203.11 Toxic Containers-Prohibitions'` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sattitizert.Criteria-Chemicals" POPULATIONS(HSP) 7-204.1.2 Chemicals for Washing Produce,Criteria, 21 3-80[A I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Cnteri:i* Beverages with Warning 1 ibels* 3-801.1J(B) Use of Pasteurized Fees* 7-205.11 Incidental Food C ont1M, Lubricants* 3-801.1 t(D) Raw or Partially Ccwked Anunal Food and 7-206.11. Restricted Use Pesticides.Criteria* Raw Seed Sprouts Not Served.,r 7-206.12 Rodent Bait Stations' 3-8)1.11(C) Unopened Food Package Not Re-served. 7-206.13 'Frac,king Powders,Pest Control and Momtanna* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Ccoking Temperatures for Not Otherwise Processed to Eliminate PHFS Erremov r aom 3-401.L 1 A(i)(2) Eggs- 155'F 15 Sec. Pathogens.�" B s-hmnedtatc Service l45`F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats Sc Game E s* Anirnuils- 155'F 15 sec. 3-401 11(13)(1)(2) Pork and Beef Roast - 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec * catering,mobile food,temporary mid 3-401_1I(A)(3) Poultry,Wild Came, Stuf`fedPHFs, residential kitchen operations should be Stuffing Containing Fish, Meat, debited wider dieappropriate sections Poultry or Ratites-165-F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-nmsde,Intact Beef Steaks interventions and risk factors. Oilier 145oF* 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. 3-40 1.11(A)(1)(b) All Other PHFS-145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 1-403.11(A)&(D) PHPs 165'F 15 sec. * (items 23-30) 3-403.14(B) Microwave- 165'F 2 Minute Standine Criri(al and non-critical violations, which do not relate to the Time* .foodborne illness intervenflons and risk fac2or.s listed above, can be 3-403.11(C) Commercially Processed RTE Food- ,found in the following sections of the Food Code and 10.5 CMR '140'F* .590.000. 3-403.11(5) Remaining Unsliced Portions of Beef Item Good Retail Practices lec 590.000 Roasts* 23. Management and Personnel..... ___ FC-2 .003 Ig Proper Cooling of PRFs 24. Food and Food Protection _ FC-3 .004 L.L25. Equipment and Utensils FC-4 .005 3-501.J,I(A) Cooling Cooked PHFS from 14WF to - 26 Water.Flumbing and Waste FC-5 006 70'F Withhi 2 Hours and From 70'F 27. Physical Facility _ FC-6 707 to 41.'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-50'1.14(B) Coling PHFS Made From Ambient 29. Special Requirements _ .009 Temperature ingredients to 4l`F/45F 30.......„__Other Within 4 Ileum' I1.1r int1,'6 2d" ''Denotes critical iters in the federal 1999 Food Code or 105 CMR 590 000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name //'' Date N/C//J �S (_d O/77/3US G n s T Rof Inspection utie Fooa Address v AlasS /i w /" S4 iS7- Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone z ❑ Mobile Date: Owner n 7 /� HACCP Y/N ❑ Temporary ElPre-operation D X/ rr �,t-'' ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: El HACCP InspectorOut: Permit No. El Other !.Nw � G¢tf6NiRAv>~ O 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 _ [713. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS - ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMENEMPERATURE CONTROLS(Potentially 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 ❑j8. Separation/Segregation/Protection El20.Time As a Public Health Control 4 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El21. Food and Food Preparation for HSP F-1 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY. . - _ El22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of t/ 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: S 590MVWFom -14.aoc f Inspector's Signature: Print: PIC's Signature: Print: �r/��/GG'ktl 4ilp42 Page-L of*Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT R Cross-contamination I 590003(A) AssipinientofResponsibility'' 3-;02.11(A)(1) Raw Animal Foods Separated from 790.003(B)_.. Demonstration of Knowledge* Cooked and RTF.Foods" 2-103.11 Person in charge-duties Contamination from Raw fngredients 3-302.11(A)(2) Raw Animal Foods Separated firom Bach EMPLOYEE HEALTH Other` 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by foal employees and 3-302.1 It A) Food Protection* a lieants* 3-302.15 Washing Fruits and Ve«etables 590.003(F) Responsibility Of A Foal Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Re ortinn by Person in Charge* 3-306.14(A)(B) Returned Food and Reseivice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.0031E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditionhrg 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* 4-501.111. Manual Warewashing-[lot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Te-m erahtres* 3-281.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk PrOdUCtS.Pasteurized* 4-501.114 Chcndcal Sanitization-temp..pH, 3-202.16 Ice Made From Potable Drinkint,Water's concentration and hardness. * 5-101.11 Drinking Water from an Approved Svstetn'k 4-60111(A) EquipmantFoodContact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4-602-11 Cleaning Frequency ofEquipment Fooxl- 590.006(B) Water Meets Standards in 310 CMR 22-0* Contact Surfaces and Utensils' Shellfish and Fish Froman Approved Source 4-702-11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Foal Contact Surfaces of Equipment* Shellfish 4-703.1 t Methods of Sanitization--Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* lg Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition--Hands and Arms" 3-20218 Shellstock Identification Present* 2-301.12 ('leanm Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash" 3-201.17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2-401.11 Eatin ,Drinkin or Usm*Tobacco* 3-202.11 PHFs Received at proper Tem ici atures* 2-401.12 Discharges From the Eyes.Nose and 3-202.15 Package Into i.t•* Month* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing ContaminationWhen Tastin ;. 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.13 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* - Employees' TagstRecords:Fish Products 13 Handwash Facilities _ 3-402.11 Parasite Destruction:" Conveniently Located and Accessible 3-402.12 Records.Creation. Retention* 5-203.11 Numbers and Capacities* 590.0012 Reboring of ingredients" 5-204.11 Location and Placement* g Conformance with Approved Procedures 5-205,11Accessibility, Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Devices 3-502.12Reduced oxygen )ack * ,agin ,criteria* 6-301.11 1-landwashmv Cleanser.Availability 8-103.12 j Conformance with Approved procedures* 6-301.12 Hand Drying Provision '"Denotes critical item in the federal 1999 Food(ode or 105 CMR 590-000. CITY OF SALEM BOARD OF HEALTH Establishment Name: f( lekl5 OF (oCo ne'els Date: a iol-py Page: of Item Code C'—Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date ' No. Reference R—Red Item - Verified " PLEASE PRINT CLEARLY /,VdJEC776W A614 lW OOe+MSi'1i+IRT 9 c rRr /s ApV 3*'n4, o "C.6 6jrr?"jf- 43 40. C / 3X~ va 6& iK /t6 ,vIA" to T, U W A- ref A c£0 " )Cel V/.Sfitr / G voil " S t(J K.- VW1X_ ClimACLS 4C ALL, 97A 4J=. 2S C, f74& n K6 AtrV k vi eS 2S 15Gr_ Sf ov- k� WN 49 tOrrziii " 2 s'Ar`t,i'ied+4' A ril_ /N -'/ rnOd A Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have red this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars ors open ion/revocation of ❑ Embargo ❑ Emergency closure your food permit. �� �. ❑ Voluntary Disposal 0 Other: V ,-50L14(C) PHFS Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont) 41'F/45°F Within 4 Hours. '" PROTECTION FROM CHEMICALS 3-501.15 Coolm Methods for PHIS 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501..16(B) Cold Pt1Fs Maintained at or belov, 590.004(,F) 41'/45°F* 3-302.14 Protection from Una p roved Additives* 3-501.16(A) Hitt PHFS Maintained at or above 15 Poisonous or Toxic Substances 40"F 7-101.11 IdeContainers Infonmition-(h'io na( 3-501.16(A) Roasts Held at or above 130'F. Containers* 7-10211 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Se aratio t-Stora^e" 3-501.19 Time as a Public Health Control* 590.004 H) Variance Requirement 7-202.11 Restriction�-Presence and Use* ( - 7-202.12 Conditions ofldse* 7.203.11 Toxic Containers-Prohibitionsv REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sat»tizers,Criteria-Chemicals" POPULATIONS(HSP) 7-204.12 Chemicals for Washing Prodnc;e,Citcna* 21 3-80'L.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels' 7-204.14 Drvin Aents,Criteria' 3-801.11(13) Use of Pasteurized hags* 7-205.11 Incidental Food Contact,Lubricants* 7-206.11 Restricted Use Pesticides. Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Spouts Not Served. '" 7-20612 Rodent Bait Stations* 3-$0'1.11(C:) Unopened Food Package Not Re-served. 7-206.,13 'Cracking Powders,Pest Control and , Monitoring* CONSUMER ADVISORY TIMET TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw. Undercooked or lfi Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFS exernvs vi�wi 3-401.11A(1)(2) Eggs- 155F 1.5.Sec. Pathogens.* E es-Inmedtate Service 14501-,15sec* 3-302.13 Pasteurized Eggs Substittne for Raw Shell 3-401.11(A)(2,) Comminuted Fish,Meats &Game Eggs* Animals- 155'F 15 sec.* 3-401.11(B)(I)(2) Pork and Beef Roast•.-130°F 121 tern* SPECIAL REQUIREMENTS 3-401.11.(A)(2) Ratites,Injected Meats-155'F 15 590.009(A){D) Violations of Section 590.009(A)-(D)in sec. * catering. mobile food,temporary and 3-401-11(A)(3) Poultry,Wild Game, Stuffed PHFS, residential.kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr'or Ratites-165°P 15 sec.. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle, Imact'Beef Steaks interventions and tisk factors. Other 1450F* 590.009 violations relating to good retail 3-401.12 Raw Anittial Foods Cooked in.a practices should be debited under#29- Microwave 165'F* I Special Requirements. 3-401-11(A)(1)(b) All Other PHFS- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(4)&(I)) PHF,,165°P 15 sec. * (items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Tune* ,foodborne illness intervennons and risk joctors listed above, can be 3-403.11(C) Commercially Processed RTE Food- ,found in the f6flouiing sections of the Food Code and 105 CMR 14WF* 590.000. 3-40111(E) Remaining Unsliced Portions of Beef /tam Good Retail Practices FC _580.600 Roasts* 23. Management and PersonnelFC-2 .003 1$ Proper Cooling of PHFS 24. 1 Food and Food Protection _ FC_-3 .004 25. Equipment and Utensils FC-4 .005 -. - ,1) Cooling Cooked PEiF's from 140`P G) 26. Water, Plumbinq and Waste FC-5 _ .006 70'F Within 2 Hours and From 70'F 27. Pbsical Facility, FC-6 .007 =�- - Co 41.°Ft45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC_- 7 1. .008 _1 501.1403) Eooling PHF,Made From Ambient 29. Special Requirements _ .009 - Temperattire Ingredients to 41"17/45"F 30 _Other 1_ Within 41-Iours'" ''Denotes critical item w tic(oderal WcA)Food Code or 105 CNIR 590 000. CITY OF SALEM BOARD OF HEALTH Establishment Name: dG /' woteoS Date:4&iake _ Page: 3 of 17 Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY � I i i i Pr r t i urArldlilyt- �,eA, e � 14 c- OS d, A r 46 i i I giscussion 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-fivedolls or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: • U 3-501.1.4(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 law 4 Homs. * , PROTECTION FROM CHEMICALS 3-501.15 Ca line Med ads for PHFs --- --- 19 PHF Hot and Cold Holding 14 Pond iv p Calor Additives 3-50L16(B) Cold PHFs Maintained at or below 3-202.12 Addritvesi590.004(F) 410/45° F* 3-302.14 Protecrion from I,'na roved Additives* 3-501.I6(A) Ifot 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- 7-10211 Common Name-Workin.Containers* 20 Time as a Public Health Control 7-201.11 Se aralion-Storage* 3-501.19 Time as a Public Health Control* 7-20211 Restriction-Presence and Use* 590.004(1{) Variance Requirement 7-202.12 Conditions of Ilse* 7-203.1.1 Toxic Containers-,Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11Sanitizers,Criteria-Chemicals' POPULATIONS HSP) 7-204.12 Chemicals for Washin¢Produce.Criteria* 2'1 3-801.1 1(A) Unpasteurized Pre-packaged Juices and 7-204.14 Dr Ing A ents,Criteria* Beverages with Warning labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs* 7-206.1 t Restricted Use Pesticides. Criteria* 3-801.1.t(D) Raw or Partially Cooked Anitml Foal and Raw Seed Sprouts Not Served. * 7-206.13 Trae.king Powders,7-206.12 Rodent Baitens,Stations`Pest Control and 3-801.11(C) Unopened Food Package Not Re-served, " Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of AnhnFal ods`that are Raw,Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Elim nate Enacnve1 1700,1 3-401.11A 1 2 Fb>b> Pathogens.*LSS F 15 Sec. 3.302,13 Pasteurized Eggs Substitute for Raw Shell E s Lrtmcdtat.eServicc 145°F]Ssec* 3-401.11(A)(2) Comminuted Fish,Meats&Game E"s* Animals- 155"F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should he 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, Imact 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- Micaowave. 165°F* Special Requirements. 3-401.1'l(A)(1)(b) All OtherPHFs- 145°F'15 sec. l7 Reheating for Hot Harding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(I)) PHFs 165'T'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 TimO .foodborne illness interventions and riskf rttors listed above, can be 3-403.1.1(C) Commercially Processed RTE Fold- found in the following,sections of the Food Code and/OS CMR 140'F* .590.000. 3-403.11(E) Remaining UnslicedPortions ofBeef Item Good Retail PracticesFC 590.000 Roasts* 23. Management and Personnel_ FC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection _ FC-3 .004 25. __ Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140"F to 26. Water,Plumbin and Waste FC-5� 0_06 70°F Within 2 flours and From 70°F 27. Physical Facility FC-6 .007 to 41.7/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501_14(B) Curling PHFs Made From Ambient 29_ Special Requirements .009 Temperature Ingredients to 41017145°F 30__ _ Other Within 4 Hours=r swororwo *Denotes crutcai item in the federal 1999 Food Code or 105 CMR 59(t000- IMPORTANT MESSAGE FOR DATE �—Z TIME r U P.M. M OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ 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 �n hcil�s� �c� n o r t SIGNED S��.OPS FORM 4009 ��YII MADE IN U.S.A. r NOTES r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET. 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVI¢, 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 : Columbus Society of Salem Inc . Name of Establishment : Knights of Columbus Address of Establishment : 94 Washington Square East Type of Establishment : FOOD SERVICE Application Date : 12/16/2002 Restrictions : Permit for Food Establishment 99-03 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 0• CITY OF SALEM, MASSACHUSETTS o I I11 BOARD OF HEALTH Ivll� • �. 120 WASHINGTON STREET, 4TH FLOOR DEC 13 2002 e SALEM, MA 01970 q�'�Ail� TEL. 978-741-1800 Ci i •f OF SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Ki ir_b,l S A Q1 vrh 6vS TEL# (178) 7-ly-3510$ ADDRESS OF ESTABLISHMENT q / �0.5h1rl ori S^ . EF5+ MAILING ADDRESS (if different) SIn,vr,A- OWNER'S NAME G'd Q M 6'" SaCJ e d-„ TEL# 7 711S--3416a ADDRESS CITY Said— STATE j!/!h__ _ ZIP—0257y CERTIFIED FOOD MANAGER'S NAME(S) Da{v,a� Vv\LloU4 CERTIFICATE#(s) lo-;, L(;- 7 XJAIti Vht-2-JOL! (07 z-£- 'Fs- (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON :To f ,L. t \x A o HOME TEL#_12L2 -S 2QIg HOURS OF OPERATION: Monue 1v jZq Wedl -I?Af hu3f/L' FriV4&Sat%Zc12A Sun.1?g-1 A TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES t� less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES ® $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES N 50 ALL NON-PROFIT(such as church kitchens) ES N099-a-5 $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 b knowleldg and be ief, have filed all stat&tf x returns and paid all state taxes required under the law. Qf y zSS789/ S' at a Date Social Security or Federal Identification Number --------------------------- ------------------------------------ Revised 11/25/02 FOODAP2.adm Check#6 Date I .�^ac- /ago'--��7-