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KWIK SHOP MARKET AND DELI - ESTABLISHMENTS k w l k SA o f M04 44 Jai i 10 Jiff c{1�� AV? ftNIVERSAL® UNV-12110 -MADE IN USA \`rJ TAINAIII FO STRYRY MPI RECYCIID® l INITIATIVE CONTENT10% Cemfetl Rb"Sareln POSTCONSUle wwx.sfiyroytem wy Xumm I i Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name ,n Date T e of O orations T f inspection Food Service Routine Address / ,� Risk Retail ❑Re-inspection ` ) ° 9ti�+'vL (tel Level ❑ Residential Kitchen Previous Inspection Telephone El Mobile Date: Owner " HACCP Y/N El Temporary ElPre-operationMt -P0/t. ❑ Caterer ❑Suspect Illness Person in Charge(PIC) /l Time ❑ Bed&Breakfast ❑ General Complaint Ins actor11 JJ In:Ua.3/( r) - ElHACCP P Glee e 1. Out: Permit No. ❑Other Each violation checked requires anie planation 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);D 590.009(F)A action as determined by the Board of Health. J3-OOD PROTECTION MANAGEMENT __ __ - ❑ 12. Prevention of Contamination from Hands 1. PIC Assigned/Knowledgeable%Duties ElEMPLOYEE HEALTH 13. Handwash Facilities L ---- 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-F-ood and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potent___y_"azardoueFoo_d_s). ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures m ❑ 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 s ❑ B. Separation/Segregation/Protection _ ❑20.Time As a Public Health Control �) [REQUIREMENTS FOR HIGHLY SUSCEPTIBLE_POPULATIONS.(HSP)' E] 9. Food Contact Surfaces Cleaning,a�nd Sanitizing El 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwas/hin/g El 11.Good Hygienic Practices (',/,/,� CONSUMER.ADVISORY_ -- _ 022. 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 X 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water,Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you CJS 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)(590.001) 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: s:580MSIaF m 14.oc T1 u Inspector's Signature: Print: lE I^a o d PIC's Signature: Wit' ,C-haS Page ofa Pages � , `. vt a. 7 11 i �tA 7c_ i Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(]) Raw Animal Foods Separated from I 590.003(A) Assignment of Responsibility* Cooked and RTE Forxis* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11. Person in charge duties 3-302.11(A)(2) Raw Animal Foods Separated from Hacb Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of.the person in charge to 3-302.11(A) Food Protection* require repotting by food employees and 3-302.15 1 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Ilfensiis* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Resctvice of Food* 590.003(G) Re orting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501..11. Manual Warewashing-Hot Water - 3-201.1.2 Food in a Hermetical) Scaled caled.Container* Sanitization Temperatures"' 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.,13 Shell Eggs* Sanitization Temperatures* 3-202.14 F;cgs and Milk Products.Pasteurized* 4-501.11,4 Chemical.Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water* concentration and hardness. * 5-101.11 Dri liking 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 22.041 4-602.11 Cleaning Frequency of Equipment Food- ShelHish and Fish From an Approved Source Contact Surfaces and Utensils 4-702.11 Frequency of Sanitization of Utensils and - 3-201.14 Fish and Recreationally Caught Molluscan Foci Contact Surfaces of Equipment* Shellfish* 4-70311 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Pasted Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.1.1 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges.From the Eyes, Nose and 3-202.15 Package hue i[ * Mouth* 3-101.1 l Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Taga/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification *� 590.004(E) Preventing Contamination from 3-203.12 Shellstockldentifieation Maintained* Em to ees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3402.12 Rea)rds.Creniion and Retention* 5-203.11. Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement* 9 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502. Specialized Pgrocessing Methods* Devices 3-502.12 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 federal 1999 Food Code ur 105 CM R 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:yu k, Cot zzpDate: I cl-1()—(o Page: of _ Item Code C-Critical Item No. Reference R-Red RedItem " DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,- tt PLEASE PRINT CLEARLY Verified G1L Cin , G0c_-6 o�'S _ '=AI_V�.Q x IJ ((f-X t An/t/ (iA/1 1 — a ,, CLi0 ' `{L0 toP I �) '�IU x.CLf1 ,' ,.Y-4AJ1 !/f lAAAAr nt�4_i 1u1 1 _ 7A1.41 ��rs r cru r 0 n_ ep/-164� f, Ni03� - ))0 , -('e +(-v 4p'. N`. %I .�_ of S.D .i r' / 7/D ',BP�.`- Z �_j _eQ" _ 't-. �.• , t �I�� /V11LE Q 9.« P Ic to AK ovv-, l tlJ(� t�/'lN-!.� � �i (J/1 ��. (n" n , VN/l F9 t (7 V 1D AT Discussion With Person in Charge: Corrective Action Required: ❑ .No t7fes 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 El Re-inspection Scheduled 13 Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: .. 3-501.14(C) PHFs Received at Temperatures , Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(Items 7-22) (Cont.) 41.°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives*' 590.004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 3-501.16(0) Hot PHFs Maintained at above 15 Poisonous or Toxic Substances 7-101..11 Identifying Information-Original 140 3-501.16(0) Roasts sec 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" 7-202AI .Restriction-PresenceandUse* 590.004H) 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 Dtying Agents.Criteria* Beverages with Warning Labels* 3-801.118) Use of Pasteurized E * 7-205-11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or PartiallyCooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Na Served.* 7-206.12 Rodent Bait Stations" 3-ROI.L i(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY - TIME/TEMPERATURE CONTROLS 22 3-603.11 Constmrer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs_ Not Otherwise Processed to Eliminate Pathogens.* 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Fh " rn.7oo, Eggs-Immediate Service 145°F1Ssec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec. „' 3.401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS _ 3.401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec * catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401;11(A)(1)(6) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403AI(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3403.11(B) Microwave-965°F 2 Minute Standing Critical.and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000, 3403.11(E) Remaining Unsticed Portions of Beef Hem Good 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 3-501.14(0) Cooling Cooked PHFs from 140°F to 25. Equipment and Utensils I FC-4 .005 26. Water Plumbing and Waste I FC-5 .006 70°F Within 2 Homs and From 70"F - 27. - Physical Facility FC-6 .007 to 41°F/45°F Within 4 Hours. * 28. Poisonous or Toxic Matenais ! FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30• Other Within 4 Hours" *emotes critical Item in the federal 1999 Foal Code or 105 CMR 590.000. .� ., r .::°^�='�-�v+.w nr-car*wn.dMn.Ais^Y.`f�+:+.:•s.�nt`i.r�-.wr``3".'.. .. .4...-+.kw....^K`»..wrxr� ,e`.. .. s1 ` ..('"""' u 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 Type of Operation(s) Tvoe of Inspection QFood.ServiceRoutine Address \ / Risk 'Retail �Re-inspection () ` �a Cr/vl 1 Level n Residential Kitchen Previous Inspection Telephone 5 El Mobile Date: Owner HACCP Y/N ElTemporary ElPro-operation ?Q, p , Z oAAieA ❑ Caterer ❑ Suspect Illness Person in Charge(PIC)00MTime pn�n� El Bed&Breakfast El General Complaint El HACCID Inspector �� I O ^� OuIn.t r + I Permit No. ❑Other Each violation checked requiresCan 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) l[J 590.009(F) action as determined by the Board of Health. L FOOD PROTECTION MAHAGEMENTd ,",",�,' e; ,a min,;m Ei ,�z; ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH 7-137 rei T _ a . g 3 ° s : ....,...#�.._,a ..�,,.,m.�c '�€3-`,�,,,..�c�._. .o.,�.e.a a.,m. ,� -0AOTECTfON FROM CHEMICALS,i',� 'j °` Ir El2. Reporting of Diseases by Food Employee and PICM�h,. El 14.Approved Food or Color Additives El 3.. Personnel with Infections Restricted/Excluded El El Toxic Chemicals FOOD FROM APPROVED SOURCE �, 11 " �e"i"+�w ,��.y��, „`�t ; ❑ 4. Food and Water from Approved Source Foods)iip� it xr, O [15. Receiving/Condition El 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating x ❑ 7. Conformance with Approved Procedures/HACCP Plans , ❑ 18.Cooling PROTECTION FROM CONTAMINATIONIa= , ❑ 19. Hot and Cold Holding m .,n,. v,. . .UamiX=o � ��.Xµ•tiagn �. 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control z ` 19 9. Food Contact Surfaces Cleaning and Sanitizing ;.;REQUIREMENTS FOR,HIGHLY SUSCEPTIBLE POPULATIONS(At0);a'; ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices rV '?NSUMEp ADVISORY'g J ,m F : ,m ("A\ 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) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3)(9590.90.0 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 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: \0 sssoinspecrFamr-ia.aoc 0 ( 011 n �� m Inspector's Signature: - U�j A Print:/: I 1 (_ (A PIC's Signature: \ Print: �. L f . 2 T Page, of ges Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 7 590.003(A) Assignment of Responsibility* 3-302.1.1(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-1.03.11. Person in charge--duties Contamination from Raw Ingredients 3-302.1.1(A)(2) Raw Animal Foals Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by foal employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washtn Fm.its and Ve �etables 590 003(F) Responsibility Of A Food Employee Or An 3-304.11 Foal Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(') Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes* 4 1Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-561.1 l I Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Ten eratures* 3-201.13 Fluid Milk and'Milk Products* 4-501.112 Mechanical Warewashing-HotWater 3-202.13 Shell Eg gs* Sanitization Temperatures* 3-202.14 E �s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and Contact hardness, 5-101.11 DrinkingWater from an Approved System* 4-fi0 i..1 i(A) UteEqunsils Cl Food Contact Surfaces and 590.006' A) Bottled DrinkingWater* Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.01` Contac[Surfaces and Utensils' Shellfish and Fish From an Approved Source 4702.11. Frequency of Sanirizaflon of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Foal Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11, Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.1.2 Cleanin Procedure* 590.004(0) Wild Mushrooms" 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices $ Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11, Fail Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 1.2 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* to Em ees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.0040) Labeling of Ingredients' 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.1. Specialized Methods* Devices 3-502.12 Reduced ox gen packa m.-,criteria* 6-30111Handwa shin Cleanser, Availability 8-103.12 Conformance with A roved Procedures* 6-301.1.2 Hand Drying Provision *Denotes critical item in the federal 1999 Foml Code or 105 CMR 590.000. - BOARD OF HEALTH Establishment Name:,/a�1 ,S`(1 IV��i QP (fn P P t_ Date: � i�l Page: rj_of Item Code C-Critical Item DESCRIPTION OF VIOLATION [PLAN OF CORRECTION Bate ¢ No. Reference R—Red Item - rLEase aatNr cueaaw —}' n -,q Verified } V, IV 0 oL �p _`_I Xd . (� l _ S �l l 1 �r � - n, e A n = �, VA 9'0 _ F fill _ I.Aw Al1 D EK _ D - — i/) ) 1n.A `!'f\.r1. %VF,/:Vvl v� In.TSA P_ kL(/l- R AX-JA n C'A,c /Q...e 1 0 1 1,t 4—Gt A,j A nn PJJA. 1��1 ,t:. U �¢` n 0/1A�A A !r,cia/ b 0-14A dZ0 LJ9 I I kk Discussion With Person in Char i ). V Corrective Action Required: -- ❑No ❑Yes v ❑ Voluntary Compliance ❑ Employee Restriction/ ii Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension _4 ❑ Embargo ❑ Emergency Closure f ❑ Voluntary Disposal ❑ Other 's t FORM 7348 (REV. 7/2000) HOBBS & WARREN, - BOSTON This Form Approved by the Department of Public Health tt Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont) According to Law Cooled to1'F/45'F Within 4 Hours.* - z 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(8) Cold PHFs Maintained at or below 3-202.14 Protection from Una roved Additives* 590.004(F) 41'F/45'F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 1-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130'E* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying A eats,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Effective 1/1/2001 3-401.11A(I)(2) Eggs- 155'F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145'F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155'F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(6)(1)(2) Pork and Beef Roast- 130'F 121 Min.* catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155'F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodbome illness Poultry or Ratites- 165'F 15 Sec.* interventions and risk factors.Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145'F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165'F* 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165'F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165'F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140'F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. Water, Plumbing and Waste FC-5 .006 70'F Within 2 Hours and from 70'F 27. Physical Facility FC-6 .007 to 4I'F/45'F Within 4 Hours.* 26. Poisonous or Toxic Materials FC-7 .006 3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial Requirements .009 Temperature Ingredients to 41'F/45'F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. i i CITY OF SALEM BOARD OF HEALTH � Sllll Establishment NameA4,04up � Y)r� VQ_t ojv-k--- �JLe Date: Page:_ ._ of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date 11 No. Reference R-Red Item Verifled n PLEASE PRINT CLEARLY (' _ ( tee Pl7J SP X tn.&n. 1PXP`_ C 1-\ AX-PAA oaJ . ,IVArjs, - r,-P J � � pu 'JOn _i -`fin nryk-mo 7�_4 A S , 10_X Al � (n .4I� j 0� Ali ,, _ P AOn/Ian Xn �irn� P o/1 �I 01 0 - �_ _ I n On A4V . C �t- - v X�-Pi1/\/)A,r %A nA/Ack--s: ) 4, C i �y Discussion With Person in Charge: Corrective Action Required: ❑ Y Y E I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that p ❑ Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure `t your food permit. ❑ Voluntary Disposal ❑ Other: -501.14((:) PHFs Received at Temperatures . Violations Related to Foodborne fitness Interventions and Risk According to Law Cowled to Factors(tionna 1.22) (Cont) 41`F/45°F Within 4 Hours, PROTECTION FROM CHEMICALS 3-5(11.15_ Cowlini•McWcds for PHFs 19 PHF Hot and Gold Holding 14 Food or Color Additives q-501.16(B) Cold PHF,Maintained at or below 3-202.12 Additives-' _ 590.0114(F) 41°/45°f 3-30114 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances ;_jt)1 16t.Aj llix PfLFMni v n aiaesl at or abI �� 140"1-,* 1101.1.1 kt lentityinglntonnation-Ori.ina_ ove Roosts field at or above 190' 1 C onlatl en �---{{ -- ----�'---- - Llt� . Time as a Public Health Control i r 102,11 Comnntn ti'titrre Wildii rn:C nxnir r+ -- —.� S-- z ,l)1 I lin i a•, t Pyhlto Health—Cono 7202.1(-201-11 lai tic o_ 5uiia �- ._ _. _ tesnuc.n-Yr.uncewd [,.( � -- 4(i OOliH) sr anti Rc mament 7-20'2J2 Condoions,ofUse __ 7-30111 Toxic Ccmuline(s-ProhibltionE* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ( 204.17 Samuret, Criuv Lhci uc rh - -- 7204.12 Chuuicrk for tilachi k teh ice Cti+tna`�. - FI-1-7 St)1IItA) Unpitcmvrd Prepackaged Jvicac atd� 1 i - � Rtvettze$with4tiatmi I.ri�lsa"" I 7 _05 1 L nd�wiai lt�>,xl� c,nrsc't . —� ` b0r I i(H} _ lis of Pa"teunn�l —y i I ntit c i i .' 3 W,1 1 1 tl)) Kau or PatuAl Ctklkt d Animal FoI d and— El U6 (t Reniii f dtule rode. Cutcui — — - -- Not Sc_r._v-_c—1 C> __._l-_ `Ii puncd F(xxi 1'acrt..i idol R S._UN-c"JRodcn 3 ut Sli nz 1 Tracking Powde .intl . alid =! _—. I Yinnnoun�-' CONSUMER ADVISORY _ TIMElTEMPERATURF CONTROLS �Y�3-60,11 t onwm r z Air srn v t'ua d Ior t o ,at ption of r - - ---� ,m r,r,l1,4)dInti nc Raw, lrm ruxil.ertr ' 16 Proper Cooking Tempera ares for t PHFs dot Oth<rm isa ora o*,v d uv ihrnn i e r-t-01.t1A h(:: ( r< 1 Li ( ( its an J t i), S ihch tt( to) flat, Shed ._... �� tn11'{ 1'ov- i c imp itic e o h Mea' ti w:- 1 �- —1 __. ..... ------------ SPECIAL _ _SPc IAL REQUIREMENTS 18! i r9)21 �i 'o i6 i ii u Ro t I 7 i 121 nrui` --- T ,hitt ( R,mtc,, 11 MLl jta 15 F f4)ti.�)t Ai- i> `rto!at <o oi Section i I caterin, aiobd,toi%,d ttap,raty and i t 4tll.11i A} }) - r!'t r r ,Vdil9 Cra1 ie Sodtr vht 5 i it.ti.d u' .tl lale S,cn opel tat + aodd "e , tSn?ii-Ccin umcttp,i . h .,�.. � f :kbita, .,.nilrtltctltitauttiiatc �calttni: ., r?h(" • ,. :. .. � 1Fi.inti ttvi uii til Uiil� >_ li�i„ 1 n Reheating for tint of inq ✓IOLAF- Nb REL. TSD TQ GCBtJ0 FtCTAW 1 riCcS F + 103.InA)kii)1_� Sikl 1fi_t i rc Itet11523Jttt , 419.11Q9) �Micl of ivc-I+5 F 2 Mmn sl-mdinr C it a'.'nlid n rF2tiva/ 1,1, a :tm. ilhichdo .or cklIr _-T-�l rl il - ____� ilii 7( tc'ilt i s F ,�riraF ne .'u d t'i t/ o it r,r 1;'ri f rr- art oe 1123. l tC�)- i t rm.ac.r:risdv Yitx_x:cei tt'I F Fix'xt- I i rtr,� in : z,r to • i,y:er nr r,t-;ne Food C ode at t t=i.- L 40'F' U i)a ' i -ttt?.3 (tenCo oRetail Parcs1{ -t Kc i nog Lnct ed P'.:two s Of 3('c. � -- FC_ 590000 t avi =_ 00 1 2e Frnd and �Prnte:nor .... VC t 00 L 18 --�— Proper Cooling of PHFs J - �- I..,—.—,., _?u ria ivirnt end Uteiisits _ f_c i i+0 —7-T— .5T'Fi I(A) (ili'low G'xtk.d PIIFs f( m lv V F to } F La Na'. r PI.'nbing rod ,al ,tP.._ l FC ilasin2ikx to From t`.7�` �2 P,ys(raFa iih-- PC-6 CiC`7_ 01 W11h c "P 45 tl iv (Etna( _-, i 1 2ci i cis rts or Tnwc M trrs3i- i FG_ r f0 -5t11.IAi8i C<r tine f i1F. 41..de F,mt Ainh e n I L_ ` So . + fi--- 1 ( 1 T n` runic. In i ca(.2,:=i .1 FidS<F `17Gi1 2.-i�YiiYCYf 1 i) n..•t.,!'. i )`,tOiA.i i c ,: ai5( 4 "1: iUo' r � 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 740-9955 Separation/Segregation/Protection FAIL Critical RED Owner: Comment:The GE freezer has potentially hazardous food stored with ready to eat food. Store all PHF separate from RTE food to Elie J. Zeaiter prevent cross contamination. PIC: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED Rahif Sleiman Comment:The cutting board on the Beverage air deli unit is stained and scored. Resurface or replace the cutting board. Inspector: The sanitizer found to be too strong at 200ppm. Chlorine sanitizer should be between 50-100ppm. David Greenbaum Handwash Facilities FAIL Critical ❑d RED Date Inspected:Correct By: Comment:The hand wash sink does not drain properly. Repair sink to drain properly. 9/3/2010 Risk Level Permit Number: BHP-2010-0236 Status: VIOLATION #of Critical Violations: 4 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(970)741-1600 GeOTMS®2010 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 20,2010 ) Page I of • , Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions Comment: Price labels are obscuring expiration/sell by dates. Do not obscure any expiration/sell by with price labels. and Risk Factors (Require immediate corrective action) The following items removed outdated or damaged: 3-Quarts of milk 4-Strawberry milk _ 1 -pound of butter 2-Lays chips 1 -Baby food 2-Delmonte peaches 1 -Quaker oats 2-cake mix 1 -Coffee 3-Pop tarts 2-rice-a-roni 1 -chicken bouillon cubes 1 -Kraft parmesan cheese. Closely monitor all expiration/sell by dates to insure no expired product is out for sale. Equipment and Utensils FAIL Non-Critical BLUE Comment:The Beverage air deli unit has an accumulation of food debris. Thoroughly clean this unit. The Kenmore5 freezer needs a thorough cleaning and defrosting. The GE freezer needs a thorough cleaning and defrosting. The sanitizer log is not being maintained.Sanitizer log must be completed on a daily basis. The slush freezer has an accumulation of food spills and splatter. Thoroughly clean this unit. The True deli unit has a build up of ice. Have the unit serviced to insure proper operation. Invoice for service must be forwarded to the Board of Health. The restroom is cluttered with trash and is dirty. Thoroughly clean the restroom including all fixtures. The backroom needs a thorough cleaning and organizing. The walk in needs a thorough cleaning and organizing. The front ice cream freezer needs a thorough cleaning and defrosting. The Beverage air counter unit needs thorough cleaning. The coffee area needs a thorough cleaning. The entire establishment is in need of thorough cleaning and organizing. Physical Facility FAIL Non-Critical BLUE Cnmmonf•Thor.oro flioe and fr„If Moe fhrnun hnuf fhie oefahuchmonf rlwn or fn enfant 1ho Iironeod nocf mnfrnl nnornfnr and City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2010 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 20,2010 ) Page 2 of Item Status Violation Critical Urgency exterminate as often as needed to abate the problem. Reinspection will be on Monday, September 13,2010. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2010 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 20,2010 ) Page 3 of Vssachutsetts Department of Public Health Salem Board of Health 120 Washington Street,4t"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name 1 I pp._ Date Type of Operation(s) Type of Insoection ( A c, oo C 1. [1 -� Q IN Food Service Routine Address P Risk Retail Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone /1 I ism _ ❑ Mobile Date: Owner / �(J HACCP YIN ❑ Temporary ❑ Pre-operation Y� ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ElBed&Breakfast ❑❑ General HACCP Complaint Inspector ) a Out: `%�Iftryl/1 Permit No. ❑ Other Each violation checked requiresxplanation 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. ,6 FOOD PROTECTION MANAGEMENT; "�"_�„ t ( , ,141 , ! ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH "�" � 1 El 13. 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 ❑ 15 Toxic Chemicals FOOD FROMood and ROVED SOURCE App" ;„ ;,, o,4 ,�„. �._,�8<.,.w... -." TIME/TEMPERATURE CONTROLS Potential) Hazardous Foods a� q ❑ 4. Food and Water from Approved Source aL ... �, .I„,row J',W, �. Y.z. .. .0 E"! ), ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATK)N'" `A ! ❑ 19. Hot and Cold Holding Lyy�� i- -- grafi _ _ _it ,�" m1 111, 8. Separation/Segregation/Protection -A ❑20.Time As a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing ";REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(iiSP) El 21. Food and Food Preparation for HSP �/ 10. Proper Adequate Handwashing 0411. Good Hygienic Practices _CONSUMER ADVISORY'-'-'-' ao a., y I,M ❑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 inspe tion 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 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(550.005) establishment operations. If aggrieved by this order, you l% 27. Physical Facility (FC-5)(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:5Mnsp CIFVm 14, o Inspector's Signature: O Print: dD Y._) t Q ( _„r-(, v PIC's Signature: .lU [' Print: ("L i ZC�` T CX` Page of�$ages C� Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination , 1 596.003(A) Assignment of Responsibility* 3-302.11(A)(1.) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11. Person in charge-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 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) ExclusionsandRestrictions* Disposition of Adulterated or Contaminated - 590.003(E) 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* 4-501.1.11. Manual Warewashing-Hot Water 3-201.12 rood in a Hermetically Sealed Container* Sanitization Temperatures* 3-20t.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.1.3 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. * 5401.11 Drinking Water from an Approved System* 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* 4-602.1 t Cleaning Frequency of Equipment Food-. 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 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 Regulatoty Authority 2-301.11. Clean Condition-Hands and Arms"' 3-202.18 Shellstock Identification Present* 2-301..1.2 Cleaning Procedure* 590.004(C) Wild Mushroams* 2-301.14 When to Wash` 3-201.1.7 Game Animals* 1.1 Good Hygienic Practices g Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 PreventinE Contamination When Tasting'; 6 Tags/Records;Shellstock 12 Prevention of Contamination from Hands 3-20118 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintainc& Employees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible - 3-403.12 1 Records,Creation and Retention* 5-203.11 Numbers and Ca acities* 590.004(J) 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 6-301.11 Handv ashin Cleanser,Availability 3-502.1.2 Reduced oxygen packaging.criteria* 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision Denotes critical item in the federal 1999 Food Code or 105 CNIR 590.000, y, l CITY OF SALEM \ BOARD OF HEALTH Establishment Name: /�l 1 Lt1� ��h , Mw.,I[.g Date: `�� 1(0—C)6) Pager of _ -- �T �- Item Code c-Critical Item V DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Y No. Reference R-Red Item Verified PLEASE PRINT CLEARLY F \ O i I obA p, L , { 1A44 t I n I, n n'� I�r�Y n n d _ _ nil . T Q nn, j I-1 'JA ,� \ �1�N — 11�_Al - i � n n n..n inn � d �ii ry/ w I �0 AV (/In - v � - l✓ 0I%,It sn n n J'r,. i, n� nn niX I . �_ -A .0 2 d' l� c\ - t1 ,tome. In Iry i v� = fAI- A ".T - � .pv'•rn�A /vl ,, '� __�r_ n --hla./i /in , n Y n n,• i .0; �;a , L! ),'lt it �A „nn,Gr IAr� �'1) /.)O {� GARAOAA OL� nn �1\ f .\ X /.^.' •� -^ V e :,'1 n Nn 1/I 1 0, n iY A n n n 0 0J N 019 /fy _G LranC ,Ai `V ^V K _ J n_n_n 1•/ t*1nA.^TC-14 ._! - n.,, ., _LYiIO rn, rd: n,. 1n AL AA1` v,s 9'r. . _ Discussion ith Person in Charge: J �Y ,\ CorrectivAction Required: ❑ No ? Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Emersion p ❑ Re-inspection Scheduled ❑ Emergency Suspension f comply with all mandates of the Mass/Federal Food Code. I understand that i noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ry ❑ Voluntary Disposal ❑ Other: i 3-5(11.)4(C) PHFs Received at'i-emperatures Violations Rotated to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Itehrs I-W) (Cont) 41°A/45`P Witbin 4 H(ws. * _ PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Gold Holding 3-501.16(B) Cold PHA.Maintained at or below 3-202.12 Additives'" 590,N)4(F) 41`/45°A 3-302,14 I'rottction tion[Unapproved Additives'' 15 Poisonous or Toxic Substances 1-501.16(A) I lot I'H1 s Maintained at or above ((11.11 Identifying infoimunon- On toil oa'FF� Y E 5(11.76(A) Roasts Held at or above (3U°F, _ Ctnuamen _ -- r-- -- 1 1102.11 --3�Go<nmmn Nam Working C ontt llwIl- t _ _ Time as a Public Health Control OtJ 1 Via:tn<n Stt tap —�� ( I :(1 I _ Pim[ a, t Public Health Conttrol- 7-D)2.1 Re tnuuvi -Pr strwe'nid Les," 7-202.12 Canditkan of Uso' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.tl .Toxic Gnnainen,-Pmhibit.ions"' POPULATIONS(HS 2(W.1I Samnzetti <ritai to Chunic tis -- Ct1.12 Chum[ifs ttr Washa�_t oducc C n'e,ia, 2t ; 8111 1111)TtJnl : tcm:xed Pty i,asS tged Jtnees r�td i-- -- �� Beve + e tvith w is;w h' 1 7 ?(A I Di cing Ai cnts.Criteria' i-- -- _ — - c 80! 11(B) Us c I Pa'tennyc.d k e r /...705 it Incid mal t xxlrimiur lobiicants 1 :l '?-206.11 R^n ul dsr Pc Iiwtes,C—vel _ I `—S0.1,' 1( )) Caw x 2ujall C lnunal cxnand Raw St,ed Stioaw x< ec-s 7 1 — - , Cla Roc13n SMIO _- r.xxi fac. ig. itis _061 t 1 rci Ft it,1'm+de Psi Co»inl w3 I '. _, _ - _ _-� C'ONSURIER ADVISORY _ 2' 1 (iii.' '1`I l^�Snntet i('ISi?it till dhN Co omption of --� TItsElTEMPERATURE CONTROLS 1 +h Proper Cooking Teinpera.ores?ar � � van." rc+vkits is Kit- Lnderc aU,i v; 1 PHFs 1{AAI i i i1K Iain 15 S t �. ' � 1 iewa t 1-7, - 4 _ f �it Srtt11 l eL . ._—._ i 1 .. ' tnic i ._ _ _ - -- ._ . .._--__ �....—.�..I s mus- 1 l e l sec . _ SPECIAL REQUIREMENTS 1 <01.ii(B)(I i2) i Coit udh d Ru st - ! t t 1�1 nst' 1 -- d .;.et( .it_ _ � r.,nc -, . -1c. .i lgcn, , sL> --� i�' ' ,`,'i_ DY � Vice) : n ,t j e e ilcr t� mobil,, .)) toga{ rm and 1 POlfrv, "Vila( ,;. ,.(:n+ cd l l Fr , n,;ia t . .t1 sicYi .a.a_,;tsla ., "rsuld lie �• n i .i },ift i p f':5(1i 1h r°1 .... ...... 3 i _ ?(e>�) 1 1 ttlelta� )ct Y Ciii12 i jebil,%f 3? l h ting for Hot Hok1€nq VIOLATIONS PULA TED TO GOOD RETAu, PRACTICES IfG tits 23-30) 1(1'.1111) Sii ivc- I{s 1 hinit St.ndingf Ci rraand f i mial sic a t� nca,h.d" /- tti 1`:1 1 Pte _ ( {ruthr ,ne iii sr iniv;i.entwr+t !rtJah0lW;be Commmz,Comm—slalIVt'icx ,,JRL# h>xi rc mi ni h t rr ( wlin ` lie Food( ah,o tt (891 .-40311{E) Rcmaiung l.islicei Porm,ns oiti,.et ( Item Goo?Retail PracUoes FC 530A66 { h?act: t 3 R-0anagi me t a:.d P r s, el FC 2 i 60 24 !g - -- Fooand niPolero Proper Cooling of PHFs - st ao04 Cr nPntabtUes:is t . 5Ctl4lA) ; 25 ViF.. 1 ` 7) 11 Within ' I lours ad Froin ITT I >7 Ph s a Fa 4tp FC 6 W,7- _—_ [ 111745 F44 Within Mani _ ^: nal or -xi R A+als-- Fc 5 501.iJ{Lt) f tit lmq MIF Mad. C ont Ambien i_. S S,,Vvolaf R r.1 iiernts�i pOR i Within_, t . i t.. e;;alna2li .n.i•„I_.i,c i '.. 1'aid ,:c..:?OS l.1 ti7i:. i CITY OF SALEM BOARD OF HEALTH 2 Establishment Name: ( '(, C7�1ui ) ��! : k _ Date: o—f(n-r Page: 3 of Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF QbRRECTION Date No. Reference R-Red Item ,Verified PL ASE PRINT CLEARLY f _ �.. lam/ �,M _ /' - ri if Pte_/ !'A, \ tom' ( A OAn. 10. .nnn a n. ,0 1}7 D n t Dn ,.> i10 /'n v o -17 _ Q �-t- A ,0 7(LI.—, 67 n 10/1 / \ i � p rn .Q �J .Q __�n�,Y�-.A (1A V�. VAa n.l „� o n A\ /)�)� AN 0 �JIn * Tn_rAr / n19n 1,91 " —/1 t r) Inn eA L-r OAA A /1 W �!/M i r n n (- r/n A l AA n n t ,.w c � I Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ 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 twentyy-ffiiive�dollars or suspension/revocation of El Embargo Ll Emergency Closure t your food permit. 0 Voluntary Disposal 0 Other: 3-.SOI.1.4fC) PHFs Rec6ved at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Lain Cooled to Factors(Ilehts 1.22) (Cont) 4 1 F/45`'F Within 4 Haw s. _ PROTECTION FROM CHEMICALS 3-501.15 Ccroling Methods for PHFs F9 PHF Hot and Cold Holding lq food or Color Additives 3;5(11.16(6) Cold PHF+Maintained at or below 3-20212 Additive"(' 590.003(Fl 41%45°F 3-302.14 _ Protcdion from llnupproved Addttive_s" ; X01 16(A) Hot PHF Maintained at or above FS Poisonous or Toxic Substances � IAOF. 71(11.11 Identifytoglofoimatmn Original Contars* _� e '111.16[ Rla+sts Held at or abuse hl0`F. 2020 I Time as a Public Health Control —' 7-10211 Common'Nanic Norkin ani ur,ra�'__� _ q 5p; llm!.as:c Public l'{caltit Conhtzl' 7201.11 `i atauun�Shnagc: 1 ay - " .r R,ttA! . -Yil�i'•�. M l ^'+f:(g'' O.T' rV< t },' capn�,y�',f.`.,. _.. ... �+'+C'+�ii�.t�df.*v'!'�.i�. :'.�'; h�Mry 6�'r",k'. ..tr•'ril�.'ti*rd.'Fh+'ts4.iJ"'"v.�- 'Y. "'t. m�'' t Massachusetts Department of Public. Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4 Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date. T e of 0 eration s Tvoe of Insoection ^�- 1 1 k�X. Pt: At,A 1_).p p -;�y x Food Service 1��, Routine Addres /7 �CP� �� I Risk (.'Retail uRe-inspection \_ Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP YM [-I El Pre-operation o rfA( p ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In:-j % (U7vt ❑ HACCP Inspector ' Out:3 d l 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)V 590.009(F) action as determined by the Board of Health. FOOD PROT�CTION.MAHAGEMENT ''"„ `.; ,:." „,; ; � ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH a �,a k ;,� :l . "_� :12-1, 1'•'�� 3aaiu _ :. nPROTECTION FROM t:HEMICALS".`="`:'"�'R�3S "�.,"" � El 21 Reporting of Diseases by Food Employee and PIC _--° �a== ❑ 14.Approved Food or Color Additives ❑ 3: Personnel with Infections Restricted/Excluded tf 15 Toxic Chemicals 'FOOD FROM APPROVED SUURQl3:� „ A4 ",!_Adm 1�0❑ 4. Food and Water from A roved Source 4 fM&EMPERATURE CONTROLS(t+otentlaW HaiardousFoode) pp A,�d��=ate ❑ 5. Receiving/Condition ❑ 16 Cooking Temperatures ..F ❑ 17. Reheating �❑ 6. Tags/Records/Accuracy of Ingredient Statements 9 7., Conformance with Approved Procedures/HACCP Plans El 18. Cooling ei P(( TECTION FROM CONTAMINATIONf El 19. Hot and Cold Holding 1 k .'a€ 51 8.f ,. Separation/Segregation/Protection El 20.Time As a Public Health Control 9: Food Contact Surfaces Cleaning and Sanitizing ni ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing r 11/ 6lC 11.Good Hygienic Practices O 1CONSUMERADVISORY_ VI_ �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-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 O 27. Physical Facility (FO-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: �n ` I oil R- � Inspector's Signature: -0 Print: / ` ( '� u PIC'sSignature: / ' - Print: v r Page of 3ages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination . 1 596.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foots Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 103.11 Person in charge-_duties _ Contamination from Raw Ingredients 3-302.1.1(A,)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1.1(A) Food Protection" a olicants* 3-30115 WashmE Fruits and Ve etables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* - Contamination from the Consumer 590.003(G) Reportingg 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 I Food* 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law'* 4-501.I I I Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Seated Container* Sandi zation Temperatures* 3-201.13 Fluid Mitk 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.* 5-1.01.1.1 Drinking Water from an Approved S stem* 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 22.04" 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish Froman Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatoty Author 2-301.11. Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* -590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2401_11. Satin ,Drinkin*or Usin Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to ees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction" Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 3-402,4( RecLabe lingrds,Creation and Retention* 5-2(4.1.1 Location and Placement* 590.004(7) Labeling of Ingredients' g Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance MACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 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 federal 1999 Faxl Code or 105 CM It 590.000. S 1 S CITY OF SALEM '' /I BOARD OF HEALT Establishment Name:b� n 1 S�Tn� .\ trl�o$ a . 1 11 �Qa . ate: - - Page: of Item Code C=Critical ItemDate V DESCRIPTION OF VIOLA OFCORRECTION eo. . Verified No. Reference R-Red Item J 1 PLEASE PRINT CLEARLY i OD n-�i P / .A , in, 1 /�n��. Y10i1f9 , AO / L "00 i , I _^ftk J_ 1P�n / A. O �I V, t�h . /V n - �Vk\k 3fI n OGJ�n a I V 17) P (��1<A e /�x n k/ e "T �'40" n 1J/A' /r,t/ (01-)A4+0 n V/fin n_n_ iaa -Ae DAO .0 i LA .rA l✓Y7DA ! — 01 nn AV A 4VA4 Zl,l 0 I_nn nj 0 v -7� �4j. I '1 Ulf vV fi , RD. . ✓ : Po. a 1; AOD n \ _ ` �y � \X� P� Lit�<.�i'],� �(/1/��h�f r—t'/�2.i��1X 0 rn V n n o� V10 A ��n� A--) f rA ,r�4_-,�9- � - ��CRL _ ( AA ��11L moo. l nrl� !�V 71. L 02s� c�un �/ In 4 / { r v ((AINt/� XA : An C'Yt.n�o .>-�- -> �( Y v i FFA pl, to in, IA Discussion With Person in Charge: Corrective Action Required: -❑ No y❑/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 t0 g/Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that 4 noncompliance may result in daily fines of twe�ntyy- the dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. (� // r (7q- i3� / ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness Interventions and Risk Accordi ag to Lay. Cr"ed to Factors(Itesm 1-22) (Conti I I�F/45*F Within 4 Homs 3-50115 Coolim,lvlcffiod.�for PRFs PROTECTION FROM CHEMICALS PHF Hot and Gold Holding---- r=--- — -- Food or Color Additives F3-5()1j6(B) Cold PHFs MArritained at or below201- 12 590 004(F) 41�14�0 F* 370214 pcote<L'tLi�on�Irqffl ljo �diqvc�" 3-L01,16(A) Hot FHFq Maijuamed at or above Is f-- Poisonous or Toxic Substances 140'F, 101,11 7 idem"ifying infrinaita, - Od'ical I 16(A) Roasts Held at or ab,vr 30T 1 Containers* --------..... Time as a Public Health Control 7-162.71- - I Common'Narne 1�0 ---I -ELI—A)qi(�1111111 LluersL- -�-50119 Time a�a Public Health Control' 7-201.11 S��* 7-202.17—'Tiic,sricn,n,-pro,,,,n��kjuse arianoa 7-20112 Coadittow of Use, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-201[I Toxic Copunner,-- POPULATIO�S� 7264.17 —Sanitimrq,Criterio-Chenricils� HSfJ__--I 7'0-4-12 Chenucals for W 3-801,11(A) 7-104.14 Drvui I lcflr`.Criteria" Beverd?es with Warning Lal)010 3-801 A I(B) Uvc ol'Ptcteurizcd big, Incidental Fo,od Comacc 1-ubt icaiusl� 7-205,11 3-801.11(t)) Raw or Prulotliv Cuo*ed Ain nslForA and 7-205.1E- 71-1 7IT,-1c'F�—�.p e�6c i d e s'C r i I e r I a" -111, "1,-)) RaW SL"d routs]Noi Served - r-�416.112 Rooleal Boit scqitsl�' ) --------------------- TTO 3-801,11(0 Tracking foowder�;,Pst Control In', 3 - CONSUMER ADVISORY 22 3-60; 1 I Consumer,Advisory Posted lior Cougnmption of TIMErTEMPERATURE CONTROLSAuroral F,xt&Thaiare Raw, Undoxcx)oked or Proper Cooking Temperatures far w Not Othetwise Pnwessutuninuseto — PHFa Pa , ,1'�3101.11 A(l)(2" F4 - 15,5-F 15 --EtTSt)2.13 ,Subste toRaw Shell Service 145Tl 5�se 3,; Pagteurizcd Egg. 1(1){, CormnurulW%Ft Meats&- Game AmmqLs- 15.5"F 15 sec. SPECIAL REQUIREMENTS 3-461Pork and Bed Roast -2 10F121 tran* - 3-"401.11(A)(2) saucer,ho cd %Rats - 155'F t5 590.009(A)-(D) Violations of Section 590.009(A)-(D) in cileringmobi1cfo(A,ternporary and resident al kitchen ctpcf4tirms,�liould be 3-401-F 1 i,A)(3) Poultry,Wild Game,Stuffed Scoffing Coat tining Fish,Metal debited under the appropriate,sections Poultry of Ramos-165"T 15 xc� alxwe if rel oed to focdborne illnoss locact Beo,01caks inlet ventions acid risk factors, Otbcr 145"l; 590.009 violations relatino to good retail 940l.l2 Raw Animal Foi)&Coi)kcd to a practices should be debited under#29 Microwave 105'F Special Requirements. 5-4 Ali()the,11FIF, 45F-15 .... .... i7Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-40THAT&(6) If-IF, 155T1,,-)wc. (Items 23-30) 3-403.11(B) Microwave- 155°F 2 Nlimao Standing Critical and non-critical violodionj, which do nor relate to the Time, foodborne illtor-ts auct'ventiom and risk factors listed above, (air he (C) commercraiiv Pjwesseif RfE Food Pound in the ftAlowingsections of the Food Codeand 105 CA41i 140'F -T,R13 i io�) Rcinainirc, Lus1Ac®d Portions of BeefFG 590" Roast'�� ------d Per------------- nel------------ 24� Food and Food Protection FC -3 M4 i 18 Proper Cooling of PHFS ---- 25—iE i()IA,I(A) ('Miliag C�x)kcd PFIFs firon) 1401F to ----- _MTt and J�tnsl s. -4 G05 q�j 6: 1 W atec tlaabiqg wid_'Naste FC 70"F Witton 2 Hours wal From 701, Fadfitv FC-6 1 007 w 4J 1�145^F%"ithin 4 fiotw,, 8 po no a or T FC-7 008 u�e Fooliog,PHF�,Madu From Ambient 29 S Teraivrature ingredients to 4PF/45'F Within 4 ll<str� •Defi,AVS Mfk3l RNe HI IW f0de,"': V)')'o F001i Clgle Of 105( M1 %591)000, } CITY OF SALEM BOARD OF HEALTH Establishment Name: l i tl _ 'l o(,a an Date: Page: �7 of _item = ,Code C-critical Item -., ,, DESCRIPTION OF,VIOLATION/PLAN OF CORRECTION Date I' °No. �Reterence R'_Red Item "q' * Verified PLEASE PRINT CLEARLY (`o..A Q /n. c e"-J=2 A A /'L�_. Y t(o AA( o .61 '1+ n n In,A �n _ .✓a 0_n X17 (7 n iV 0 AM 1 M R r I�7 &L)f,{0 l ) _0 Y h .� () a 1`-"7 �•Y \X-.(-(,L� (V V 0.en_1�v1 '/v(.�_A �n` (AA t o \ U / (\ . J t 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 g Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to bRe-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that _-_ W eev � noncompliance may result in daily fines of twenty_-five dollars or suspension/revocation of ❑ Embargo 'Y ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: 3-51)1.14 0. PHR Rerkeived Violations Related to Foodborne illness Interventions and Risk According to Lrox CMod to Factors(!tents (Cont) -;I'F/45'F Within 4 Hours_ 3-SOL 15 Coolin"Methods for PHFs PROTECTION FROM CHEMICALS F--- 1=4 LL9 PHF Hot and Gold Holding — — 3-5m Ib(B) Cold PHFs Maintained at or below1-202,32 Addifivk�,�* 5r0 004F) -11 /45"F* 7-302 l4 Plotect;oli FTGIHhn nr>roved Additives"` ------—————------------------- Porsorous or Toxic Substances 3-50 i,I O(A) Hot PHFsMaintained at or above-:55F1 I F Illerailying Infoinvitiork - Original -- 140F. Reams Held at or above 130"F, Time as a Public Health Control ,-102,11 Coarroon V�qmc��err� 3-501 101 9 I Time as a Public Stealth Corins,1-- -1 �,gwadon:: 1-20L I I S -�'Smra *� Variar)c�c:, PSmLorierd 7-102.12 Condition",of IJ,;e, - Toxic Conlainm�--Prohibi!mmil REOUIREMENTS FOR HIGHLY SUSCEPTIBLE i-i01 I I POPULA IONS� SP) 7-204.11 sarntnek, Crile rir--Chemic kIIs* (4 7-2 ,12 Cot knlackils for Wavhizec,tod6itcria" 21 1-801,11 Unpoqicuri/ed Pre-pacl.aged Akicec Iold (A) 7-204,14 L---�—— I Reveran' s Willi Wain t.,ahals* { 205.11 Incificnialmxjconnict,iAlhl icirills' — — i-so 1,11(B) Use of Paeteurizod E F� L7.206.11 Resincled use Pc"ticides,critens, IF (f)) Rav, See(]°Jrrkruu Nor.Served, ;' 1 7-206.12 ROk(ent TiIol Sillok'Tr, L-1±01 F 'LJ�) FixxI Packs �7 206,13 T —i; Trackin!Powder�,T�i Control arid Rfionno inn CONSUMER ADVISORY I TIMforCou.Namption o( E/TEMPERATURE CONTROLS ures io-r-- Aflimol FirAThat are Raw, Undarvookcd of Proper Cooking Temporal Not 01hemise r1roiassed to 11iminale. PHFS Path A(lk(2Fiigs- 155'F 15 Sec. �, 3o I Pasteurized FW1-S--bVmUr11a'Raw Shelf JIL- 2n.-W I'di tw Service r"icr 145 1 JSec" 3-401.1 UO2) conrourrilei]T-rah'Mears& Ci ane AnnnaN- i551-* I-, sec. I 3-40 1.t 1(13)(1 ii 2) N0 and Beam F eer R - 130' 121 ruin SPECIAL REOUIREMENTS 3-401.11(A)(2) Raine, Iniectd kle.av, 15'F15 590,60�)OV)71)j TViolafions of SeIction .590,(X)9(A)-(D)in eaterinsmobile tried,tempts try and I�11(A)( Pouln),Wild Game, Stotfed 1114f's; rcsidenl�al kitchen oliksatierm should be stoffim,Confamit" Fn�fiMeet, debited ander the appropriatc,;eomn% � ' 1",xiltry or katines-165"F 15 sac. abuvv it'rebuod to I'tw0horriv.jilness 3-401�IUC)13l) YShu1 nm k-111tac-r Beef—Stcaks inlet ventions and risk factors. Odiff -90.009 violations relating tet good retail 3-401 12 Rea Annnal Cookcd in a i practices should be debited under#29 - N%nokoave 16.51, Special Requirements. AllOthlti 11111-'i-- 14"T 15 sec. 1=7 Reheating I- I I I. tar Hot Holding VIOLATIONS, , RELATED TO GOOD RETAIL PRACTICES PHEk 165�F 156 iet;6 (Item,23-30) 3-403.j I(B) Microwave- 10"172 Minnie Standing Cie(al mrd non-owical violahim v. which do nen relate w the qinlO firodhome illness mr(o ventioni crud ri,%k Jak lors fired above, cam be 3-463.i I(C) (',0fnTn0rCJA bb Ill oxessedl Rl E botdi 'found in do!,toilon mg sernons of the Flood Corte and)05 CAIR Tte;7n --T F-C 50,000 3-403611(EJ I Reinamiro, un,zilrokki Pordoirk of Beef — 2336 Menu PeonneF- --gelent-andTs --------6 Proper Cooling of PHFs --- --- ------ -FC 3 004 i I Food and Food Protection 18 25, Ejqip t wjd��eLats 6 6. �-501,14(A) Ckkoling Cooked PHF�irm I z4f)'F t -6-6--66---, - E,�L 213 Walel�.Plonalineland Waste T l ---------- 1 ''0'F Wifirin 2 1 fliers and From 70IT 27, (;sonous or Tom Matenals FC—7 008 3-151.14(B} ——Coolini,PHFs Made Front Ambiew --29 --TS—)oci—al 00, Tc,mpceaturc Ingredients o,41"FAS,F j Other Within 4 lJourk' Dm,reI crinvA item In lh"iIIleral 1999 Foal CIAc,x 105(Aft 5'N,'0006 Commonwealth of Massachusetts City of Salem Kimberley Driscoll Board of Health Mayor 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/11/2010 ESTABLISHMENT NAME: Kwik Shop Market and Deli File Number:BHF-2005-000025 10 Jefferson Avenue Salem MA 01970 LOCATED AT: 0010 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0236 Jan 4,2010 Dee 31,2010 $70.00 TOBACCO VENDOR BHP-2010-0237 Jan 4,2010 Dec 31,2010 $135.00 Total Fees: $205.00 PERMITEXPIRES December 31,201.0 Board of Healthy This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS * BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DCREFNBAUM&SALFM.COM DAN71D GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Nig S(100i e P 4s1Q ,mac TEL# 97 ADDRESS OF ESTABLISHMENT _� FAX MAILING ADDRESS(if different) So o EMAIL-Business': 4Z gQ Website: cl- OWNER'S NAME CL' Zefmfc& TEL# �1 ADDRESS 6 fA Al A[ )r0 3 0a44J 14.D STREET CITY — / STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) L I r I'�� CERTIFICATE#(S) S42 j',' �:Ol (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON 13-L I E Z6 nn I�P� HOME TEL# 9r73 5-3`Z 1 ;--21 T 9A8S"OFOPERATIONtylonQasTuesday.+;M1WedngstayThursdaye ?IfyFrday:� S,aturday, � Sunday °rr HOURS OF OPERATION Please write in time of day. 'For exam eIIam-11 pm I 1 TYPE OF ESTABLISHMENT FEE (check ons RETAIL STORE ES NO less than 1000sq.ft. 1000-10,000sq.ft. $2 more than 10,000sq.ft. =$420 R-ESTA -RANT------------- ------------YES------NO---------------------------------------------e-s-s-th--a--n--2--5---se-ats---------------=-$--1--4-0----- (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------Y-------ES------------------------------------------------------------------------------------ ---------$---10-------- BED/BREAKFAST/ NO 0 CHILDCARE SERVICES/NURSING HOME ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YE5 NO $25 TOBACCO VENDOR • ( 'OS NO CnD ALL NON-PROFIT(such as church kitchens) Yff NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns arlp paid tate taxes required under the law. Signature Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date — CITY OF SALEM f(BOARD OF HEALTH n 2 r Establishment Name r �i` r,<:C 3k Y c -_-- Date: Page: %' of - Nem Cow c-ormwnem DESCRIPTION OF VIOLATION!PLAN OF ClDRRECTION No. Rehrenoo R—Rod Item n y hYBriae�S :A C PAINr O A^ Apr m _ U m VX (Vig :D X `P J �9 Discussion With Person in Charge: Corrective Action Required: ❑ No 4 ; Yes I have read this report, have had the opportunity to ask questions and agree to correct all O Voluntary Compliance ❑ Employee Restriction I Exclusion violations before the next inspection, to observe all conditions as described,and to ❑ Re-inspection Scheduled o Emergency Suspension comply with all mandates of the Mass/Federal Food Code. i understand that noncompliance may result in daily fines of wenty-five dollars or suspensionlrevocation of ❑ Embargo W Emergency Closure your food permit. ° ❑ Voluntary Disposal ❑ Other. ro l _ - CITY OF SALEM f BOARD OF HEALTH nn r- r Establishment Name: $. T }t,�n Date: � --�i�— Lfy Page: „! . of neat Code c-crNleBl Nam DESCRIPTION OF VIOLATION/PLAN OF CORRECTION 1>Bta m No. Retennoe R-Red Nam VMned,, N � p i tt7 T' m 3 r M N A L' i' eto 2A .TI X 77� - r - s r ' 12 ruA-I ' �,,.. . Discussion With Person in Charge: Correetivectton Required: ❑ No 0 Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction I violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ Re-inspect on Scheduled o Emergency Suspension comply with all mandates of the MasstFederaf Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspensiontrevocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal fl Otjter. ,p Commonwealth of Massachusetts City of Salem Board of Health IGmberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: Kwik Shop Market and Deli File Number:BHF-2005.000025 10 Jefferson Avenue Salem MA 01970 LOCATED AT: 0010 JEFFERSON AVENUE SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1 Notes RETAIL FOOD BNP-2009-0097 Dec 23,2008 Dec 31,2009 $70.00 TOBACCO VENDOR BHP-2009-0098 Dec 23,2008 Dec 31,2009 $135.00 Total Fees: $205.00 PERMIT EXPIRESDecember 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 a n CITY OF SALEM, MASSACHUSETTS n Y,H k: eap, "kBOARD OF H&TLTH . .. d ,:.-.M-.Kk ,� ., 120 WASHINGTnN STREET;4,"�rLOOR"'�•, TEL. (978) 7411800 FAX KIMBERLEY DRISCOLL ' F (978)745-, 0343 y ...n.: r'^► y� NL9YOR ]DION Nli q,SAI LSM.COM "'"! JANET DIONNE, ACTING HEALTH AGENT f v - = SAI-EM OF NEA►- ?I'I 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT fl W1 V1 S H 9P o P� S 2At r TEL# W 7 ? Lf- ADDRESS Lf-ADDRESS OF ESTABLISHMENT FAX# 17? 74 o ?`1's S- MAILING ADDRESS(if different) EMAIL- Business': igebs a Low OWNER'S NAME EL/ C ZEA IT n TEL �j � 2— S- I l ADDRESS to S ,,/J 9 o iQ V S .r ��(� jt,16 /441 o l`](v STREET CITY STATE ZIP r �r CERTIFIED FOOD MANAGER'S NAME(S) CL7 E !E 19 l�E P, CERTIFICATE#(S) S)�G ' (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYS OFAPERATION ; Monday'. ;'7 ' Juesda Wednesday- '. ,Thursd Frida Sunda HOURS OF OPERATION i Please write in time of day. Cj —t I�.G � fir 14>((.,. i 614 S (A v l 6" BFB i (`. 4 )' ' !f^ (Forexamplellam-11pm) '�-LI f�`; lc;ou ! (s;a5 i �Di �=� /.D.'v© /o uo 5,,,.. P TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 c,� 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 $100 CHILDCARESERVICES ---------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $1351/ ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and p ' all state taxes reAuired under the law. Signature Date �y Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date�`I I 1�,C/h $a'�z 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem i RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 740-9955 Separation/Segregation/Protection FAIL Critical RED (Owner: _ Cel�cftosc ent:The Beverage air deli unit has crab meat stored with lettuce. Store all potentially hazardous food separate from ready to Elie J.Zeaiter �ed to prevent cross contamination. PIC: Food onu ce"s Cleaning and Sanitizing FAIL Critical RED Amy LeClerc Co ant:The meat slicer has an accumulation of grime and food debris. Thoroughly clean and sanitize the meat slicer after each Inspector: I David Greenbaum Th tting board on the Beverage air deli unit is badly stained and scored. Resurface or replace the cutting board. Date Inspected:Correct By: Th ,�,3-bay sink is not being used to properly wash,rinse and sanitize dishes and utensils. The 3 bay sink must be used in a three 10/10/2008 part system to properly wash,rinse and sanitize all dishes and utensils. Risk Level: Permit Number: BHP-2008-0009 $Status: VIOLATION #of Critical Violations: 3 'Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 16,2008 ) Page 1 of I Item Status Violation Critical Urgency RED ' Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Foo ,Protection FAIL Critical BLUE Foodborne Illness Interventions mm and Risk Factors (Require ent: There are price labels obscuring expiration/sell by dates. Do not obscure expiration/sell by dates with price labels. immediate corrective action) The following 1 em removed outdatedD 1 -Utz par"' ix 2-Aunt 6mima pancake mix 1 -P er Bar 1 itz crackers 114-Slim Jims 9-Slim Jim beef jerky 6-Wonder bread Closely monitor all expiration dates. Equipment and Utensils FAIL Non-Critical BLUE Comment:The True deli case has a broken thermometer. Provide a new,visible,accurate thermometer. T me unit needs a thorough cleaning. �e'Woods slush freezer needs a thorough cleaning. Ts�e"unit needs a visible,accurate thermometer. The•Woods freezer has abroken/damaged gasket. Repair or rplace the gasket. Th average air deli unit needs a thorough cleaning inside and out. Zh -s'heeiv�es where the canned/dry goods are stored need a thorough cleaning. 10 C nmore 5 freezer needs a thorough cleaning and defrosting. - IT unit needs a visible,accurate thermometer. TP61GEE freezer needs a thorough cleaning and defrosting. (J.h€same unit needs a visible,accurate thermometer. Z�p.wir shelving in the walk in has grime and mold. Thoroughly clean these shelves. Tr he avers a air Dasani unit needs a visible,accurate thermometer. ,ITThe/Uct�ic air ice cream freezer needs a thorough cleaning. C/vide a sign in the restroom stating"Employees Must Wash Hands Before Returning to Work" Physical Facility - FAIL BLUE (.Comment:The front door found in the open position. All openeong to the exterior must be sealed. Other-See No *s FAIL BLUE 0C mment: New equipment has been added to this establishment. Owner must present a plan to the Board of Health prior to adding City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 16,2008 ) Page 2 of Item Status Violation Critical Urgency equipment or making changes in the establishment. Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 16,2008 ) Page 3 of 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: 1 740-9955 Owner: ( Elie J.Zeaiter PIC: Elie Zeaiter Inspector: David Greenbaum Date Inspected:ICorrect By: 110/23/2008 Risk Level`. Permit Number: BHP-2008-0009 Status: SIGNED OFF #of Critical Violations: 0 j Time INiTime.OUT: #Urgency Description(s): BLUE: All violations cited in the 10/10/08 inspection report have been corrected. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 lays)(Non-critical violations must be corrected immediately. or within 90days) I - - ___ -----1 City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 30,2008 ) Page 1 oft Item Status Violation Critical Urgency RED: ,Violations Related to Foodborne Illness Interventions `and Risk Factors (Require immediate corrective action) a City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 30,2008 ) Page 2 oj2 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 740-9955 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: Comment:Meat slicer requires thorough cleaning. Elie J. Zealter Violations Related to Good Retail Practices (Blue Items) PIC: Equipment and Utensils FAIL Non-Critical BLUE Amy LeClerc Inspector: Comment: Dasani cooler missing thermometer;provide visible,accurate internal thermometer. Elizabeth Salandrea GENERAL COMMENTS: Date Inspected:Correct By: All other violations from 3/5/08 inspection report have been corrected. 3/5/2008 Risk Level: Permit Number: BHP-2008-0009 Status: SIGNED OFF #of Critical Violations: 1 Time IN: .Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately " or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 17,2008 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventionsl and Risk Factors (Require immediate corrective action) ILL- Li City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 17,2008 ) Page 2 of ` 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency lTelephone: y PROTECTION FROM CONTAMINATION i 740-9955 Food Contact urfaces Cleaning and Sanitizing FAIL Critical ❑� RED r Owner: omment:Cutting board scored and stained. Resurface or replace cutting board. Elie J. Zeaiter PIC: -Meat slicer requires thorough cleaning. Elie Zeaiter TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Inspector: Hot and Cold Holding FAIL Critical ❑Q RED Elizabeth Salandrea omment:Slush freezer holding at 30°F. Repair freezer to maintain temperature of 0°F. Date Inspected:Correct By: 3/5/2008 Risk Level: Permit Number: BHP-2008-0009 Status: VIOLATION #of Critical Violations: 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical I violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 07,2008 ) Page I of Item Status Violation Critical Urgency RED: '" Violations Related to Good Retail Practices (Blue Items) Violations Related to j Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions; and Risk Factors (Require omment: Uncovered buckets of slush in the slush freezer.Cover all foods in storage to prevent cross contamination. immediate corrective action) The following items found outdated: 59 aquafina wellness waters 29 bottles soda 20 nature valley granola bars 8 starbucks double shots 8 lemon pies '6 garelick farms milk chugs 4 pkgs ballpark hot dogs k�§arelick farms milk 2 bottles salad dressing 2 garelick farms sour cream 1 miracle whip 1 betty crocker au gratin potatos Owner to closely monitor all expiration dates. Equipment and Utensils FAIL Non-Critical BLUE �mment: Microwave requires general cleaning. 'entire food prep area, including walls and shelves, needs thorough cleaning. all GE freezer requires defrosting and general cleaning. mall kenmore freezer requires defrosting and general cleaning. Fume unit missing thermometer; provide visible,accurate internal thermometer. �hroom requires general cleaning. Wk shelves in cooler have accumulation of spills and mold;thoroughly clean the milk shelves. 4ffor'ont Pepsi cooler requires general cleaning. ont dasani cooler requires general cleaning. — Same unit missing thermometer; provide visible,accurate internal thermometer. offee area requires general cleaning. Physical Facility FAIL Non-Critical BLUE de'omment: Lights in back room missing covers; provide covers for all lights. 116110'me ceiling tiles missing in back room; replace ceiling tiles. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 07,2008 ) Page 2 of . r Item Status Violation Critical Urgency Ceiling tile in disrepair in bathroom; repair or replace tile. GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 07,2008 ) Page 3 of Commonwealth of Massachusetts ♦ City of Salem Board of Health 1Gmbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Kwik Shop Market and Deli File Number:BHF-2005-000025 10 Jefferson Avenue Salem MA 01970 LOCATED AT: 0010 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0009 Jan 3,2008 Dec 31,2008 $70.00 TOBACCO VENDOR BHP-2008-0038 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 9 of 15 QTY OF SALEM, MASSACHUSETTS c BOARD OF HEALTH 120 WASHINGTON STREET,4' FLOOR 'ISL. (978) 741-1800 KINMERLEY DRISCOLL FAX(978)745-0343 MAYOR ISCOTT@SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Lwin_ �! TEL# 19 � Y� 7 IU-99d:Y ADDRESS OF ESTABLISHMENT f oFAX# MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAME [ . P 1 2 ,eC4i er 1I TEL# ADDRESS Ern b rr\ S pec Lei H L1 I9 LU STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYS OF OPERATION Monday TuesdayWednesday Thursday Fhday Saturday Sunda HOURS OF OPERATION Please write in time of day. For example Ilam-11 TYPE OF ESTABLISHMENT FEEcheck onl RETAIL STORE E NO less than 100osq.ff. _$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ---------------------------ES§------NO d---------------------------------...-------Il- ..ess. -than" ---2 5 se's'e" ..ats------------- ----140---- RESTAURANT Y (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 -------------------- ------ O-------------------------------------------------------------------------------O------------------------------------------------------------------------------------------' BED/BREAKFAST/ YES NO $100 CHILDCARESERVICES--.-... ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO TOBACCO VENDOR ® NO 13 ALL NON-PROFIT(such as church kitchens) YES NO $2 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have fled all state tax returns and paid state to s required under the law. Signature Date Social Security or Federal Identification Number ----------------------------------------------------------------A- �—j� �j- -------------,—y---------------------------- Revised 4/24/07 FOODAP2008.adm Check0&Date�Qq. /2A:Aa 7 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 740-9955 Handwash Facilities FAIL Critical RED Owner Comment:The bath room hand wash sink had a hot water temperature of 103°F. Restore hot water at a minimum temperature of Elie J.Zeaiter 110°F. PIC: ', Violations Related to Good Retail Practices (Blue Items) Elie Zeaiter Physical Facility FAIL Non-Critical BLUE Inspector: Comment:There are water damaged/missing ceiling tiles in the back room. Investigate the source of the leak and repair. Replace David Greenbaum all damaged or missing tiles. Date Inspected:Correct By: 8/2/2007 All lights in the back room must be shielded from breakage. Risk Level: GENERAL COMMENTS: The above violations are going to be corrected on Friday, August 3, 2007. Permit Number: BHP-2007-0023 All other violations cited in the 7/26/07 inspection report have been corrected. Status: SIGNED OFF #of Critical Violations: 7 Time IN: Time OUT: I Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 02,2007 ) Page 1 oft 1 Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 02,2007 ) Page 2 oft 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM TAMINATION 740-9955 Food Conta4Saces Cleaning and Sanitizing FAIL Critical ❑� RED Owner: C ere are dirty utensils in the food prep area. All utensils must be properly cleaned and sanitized after use. Elie J. Zeaiter PIC: The eat slicer has an accumulation of grime. Properly clean and sanitize the meat slicer after each use. Angela Hewitt Han a Fac" ' s FAIL Critical d❑ RED Inspector: omment:The back hand wash sink is missing paper towels. Provide disposable paper towels at this hand wash sink at all times. David Greenbaum lThe bathroom hand wash sink had a hot water temperature of 103°F. Restore hot water at a minimum temperature of 110°F. Date Inspected:Correct By: TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 712612007 Hot and Cold Ho ding FAIL Critical ❑ RED Risk Level: �:J,—Comment:The slush freezer had a temperature of 40°F. Repair unit to maintain a temperature of 0°F or below. Permit Number: BHP-2007-0023 Status: VIOLATION #of Critical Violations: 4 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 26,2007 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require C ment:There are price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price labels. immediate corrective action) The following items found outdated: 1 -package of hot dtigs 1 -Cracker Ba rel cheese 2:Whipp cream 3- uick chocolate milk Lays chips 3-Natures Valley granola bars Owner to closely monitor all expiration dates. Equipment and Utensils FAIL Non-Critical BLUE C menta The microwave needs a general cleaning. e canned goods and shelves need a thorough cleaning. te freezer has an accumulation of grime. Thoroughly clean the outside of this freezer. bslu h freezer has an accumulation of food spills and splatter. Thoroughly clean the slush freezer. T front hand wash sink does not drain properly. Repair sink to drain properly. T w m flooring needs a thorough cleaning,including under all racks and shelves. oth front ice cream freezers need visible,accurate thermometers. Physical Facility FAIL Non-Critical BLUE Comment:There are water damaged/missing ceiling tiles in the back room. Investigate the source of the leak and repair. Replace all damaged or missing tiles. All lights in the back room must be shielded from breakage. GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 26,2007 ) Page 2 oft 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 740-9955 PIC Assigned/Knowledgeable/Duties FAIL Non-Critical [.I RED Owner: Comment: The owner does not have a Serve Safe certificate posted. Owner to post certification immediately. Owner must provide Elie J. Zeaiter the Board of Health with a valid Serve Safe certification. PIC: PROTECTION FROM CONTAMINATION Matthew Gray Food Contact Surfaces Cleaning and Sanitizing FAIL Critical 91 RED Inspector: Comment: The meat slicer has an accumulation of food debris. Thoroughly clean and sanitize the meat slicer after each use. David Greenbaum Violations Related to Good Retail Practices (Blue Items) Date Inspected:Correct By: Equipment and Utensils FAIL Non-Critical BLUE 1/11/2007 Risk Level: Comment:The Kenmore5 freezer is missing a thermometer. Provide a visible,accurate thermometer in this freezer. 1 The slush freezer needs a visible,accurate thermometer. Permit Number: BHP-2007-0023 Physical Facility FAIL Non-Critical BLUE Status: Comment:There are many water stained ceiling tiles throughout the establishment. Investigate the source of the leak and repair. PARTIAL COMPLY Replace all stained water tiles. # of Critical Violations: GENERAL COMMENTS: 2 All other violations cited in the 1/4/07 inspection report have been corrected. Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 11,2007 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 11,2007 ) Page 2 oft Class Score Analysis- Detail Page 1 of 1 NaVocal Restaurant Associat ioti Developing the Restaurant and l±oodseivfce[oda EDUCATIONAL FOUND ' zip cede Wednesday, January L2gout Toonline Courses User: Kathy Class Score Analysis - Detail Download complel(Unformation in Microsoft Excel Class Instructor Sponsor Exam Class Exam Number Name Name location Address Date Kathy MRA Educational 333 Turnpike Rd 571566 -Murphy Foundation" MA Southborough, MA 1/10/2007 01772 Course Name Type of Training Hours of Training ServSafe Food Safety Manager Certification Exam Classroom 0 Total-Records 1 - loutof 1 Student Constituent Social Exam Pass/ Hold verall Overal Student Detail Name tD Security Formm ad % Paint Score Score ELLE ZEEU ER, 3792936 07790 0 1 e Sia/e 65 " 779 CLASS SUMMARY Class Number Examinees Avg Avg% I Domain Scores (AVG/Total Total I Passi Faiij Point Class Score Score 3TYSfib 1 1 1 0 1, 65 Bl,25% X"01 11 ❑-li'-n ;N,, p irtar Id:_ iii t1dlI a.... iGfi i�s 6 -, r i sat I .70 :'h.an ll n�nl 91a L,�qal Noticcs ilia Prr r.v r.,r;e[BuranLorg I rlv'. 71 �I m t.hi i 1MI ,ii 1 ] .i0 £"d £b£0SbL8L6T:01 :WOdzf dLT:2T L002-TT-Ntlf E"inee Score Analysis- Detail Page 1 of 1 National Restaurant Association A Developing the Restaurant and Foodservice lade EDUCATIONAL FOUNDATION t �— Got PUBLICATIONS FIND IRAININC,CLIV�5 np code Wednesday, January Lgggut To nline Courses User: Kathy I Examinee Score:-Analysis-report - Detail This report is meant for online viewing only. Printing a hard copy of this report may not be considered approp documentation to meet regulatory requirements. If you passed this course, you will receive a Certificate of Completion from the individual your proctor design responsible for exam results. If, for any reason, you need to obtain a duplicate of the original certificate issued to you click here. Course Name: ServSafe Food Safety Manager Certification Exam Student Name: ELIE ZEAITER Class Track Glass Organization Instructor Exam Exam Type of Hold Hours Certification Number Name Name Location . Date- Training Code Training Number Pa MRA Kathy 571566 Educational MA 1/10/2007 Classroom 0 5176503 Foundation* Murphy Test Pass Your Form Percent Percent Score Score 10048 75% 81 Foods 79% Clean/Sanitize/Maint. 80% Facilities 85% Personnel 90% Temp.Measuring Devices 50% Allergens 50% High-Risk Populationswoo/. iegal/Regulatory Issues 300°h Facility Layout/Design 67% Training Employees 100% i i i0 J-L, itF t.ui. ,1 :han,ff:0nr:11 { 'mow a '[�q:'hin9n tl e r£UA 2b 11 Lcgal t'1u[ices and 4-Tr, 2 1 ,r in cmaclin.I s'1J JI 5 101u 2'd £b£0SbL8L6i:01 :W021_:1 dLL:2L L002-IT-Nt3f l OnlineCxam Page I of I Examinee: ZEAITER,ELIE Registration #:SS-ZAP-835 Course: 09-ServSafe Food Safety Manager Certification Exam `Class Number: 571566 "Congratulations' You have passed this examination! N�rhaabove result is presented for your information only and is not deemed official until detailed results appear on our website. print outs of this screen are not deemed official proof of passing t examination. To gec�vey_our officLall�ert!fisates 'Certificates are mailed to your designated score and certificate distributor,Certificate distributors may be yo Instructor or proctor, the class sponsor, or your employer.The exam score is also available on the score analysis portion of the certificate_ To ReceiveyouuirOfficial fta-Minatiaq-11ei3ifts Visit www,Praef rgjMs ;-select the "Examinee Login"-option and enter your Gass number 571566 along .with your personal information to gain access to your official exam results. Official exam results should be available once your entire class has submitted their exams. Rate your experience b'd £b£05bL8L61=01 ,1,102I3 d8T:2T L002-TT-Ntif OnlineExam Page I of 1 �II�ICsB' !,=,`a7lTl Examinee; ZEA ITER—ELM 'I I S'd ctI2Os L8L6T:Ol �WMU dLP2i L802-SS-NUf IMPORTANT MESSAGE FOR A V A.M DATE TIME ' M OF PHO E CR�� --7�(C�ODE p� N M R EMENSIRN ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOUWILL CALL AGAIN WANTS TO SEE YOU RUSH ,. RETURNED YOUR CALL WILL FAX TO YOU MESSA l c ' l G co vour c o 4 a- .7- SIGNED FORM 4005 MARE IN U.S.A. NOTES . i 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: Ll Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT , 740-9955 PIC Assigned/Knowledgeable/Duties FAIL Non-Critical RED Owner: �j Comment:The owner does not have a Serve Safe certificate posted. Owner to post certification immediately. Elie J. Zeaiter PROTECTION FROM CONTAMINATION i' PIC: Separation/Se gation/Protection FAIL Critical ❑r• RED _Amy LeClerc Inspector: mment:The GE freezer has potentially hazardous foods stored directly on ready to eat food. Store PHF separate from RTE foods o prevent cross contamination. David Greenbaum Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Date Inspected:Correct By: 1/4/2007 Cs Comment:The meat slicer has an accumulation of food debris. Thoroughly clean and sanitize the meat slicer after each use. Risk Level Handwash Facilities FAIL Critical RED Co Kent:The wall hung soap dispenser in front needs to be rehung and is missing soap. Rehang the dispenser and provide soap Permit Number: all times. BHP-2007-0023 Status: VIOLATION # of Critical Violations: 5 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 04,2007 ) Page l of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Foo rotection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require mment:There are many price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price immediate corrective action) abets. The following items found outdated at the time of inspection: 2-sour cream 2-Qts egg nog 1 -pint h#, half 2•112 Ilons egg nog 1 _g on l milk 1 ira4c whip V-mayo 2-grey poupon 1 -soup 1 -baby food 1 -Pringles Owner must clisely monitor all expiration dates. Continued repeat violations of this nature will result in monetary fines being issued. Equipment and Utensils FAIL Non-Critical BLUE - t— Comm t:The Kenmore5 freezer is missing a thermometer. Provide a visible,accurate thermometer in this freezer. VTKe Woods slush freezer has an accumulation of food spills. Thoroughly clean this freezer. 4 The same unit needs a visible,accurate thermometer. T' /True deli unit needs a thorough cleaning. Tjre ca ed goods shelves need a thorough cleaning. T e mop stored in the bucket. Clean the mop and store upside down not touching any surface to air dry. The icrowave has an accumulation of food spills and splatter. Thoroughly clean the microwave. T e is no sanitizing log being maintained. Maintain a daily sanitizing log. Log left at the time of inspection. 09,01reezer in the window needs a visible,accurate thermometer. Physical Faal' FAIL Non-Critical BLUE omment:The bathroom light fixture is falling. Repair and resecure the light fixture. There are many water stained ceiling tiles throughout the establishment. Investigate the source of the leak and repair. Replace all stained water tiles. 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. Jan 04,2007 ) Page 2 of Item Status Violation Critical Urgency GENERAL COMMENTS: 1085:Reinspection in one week, all violations to be corrected. Cityof Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 04,2007 ) Page 3 of CITY OF SALEM, MASSACHUSETTS RECEIVED BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR - SALEM, MA 01970 DEC - 4 2006 TEL. 978-741-1800 CITY OF SALEM Fax 978-745-0343 BOARD OF HEALTH Kimberley Driscoll WWW,SALEM,COM r,. Mayor .JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Katt f4 54(ori SK6A TEL# ADDRESS OF ESTABLISHMENT_ FAX# (793 / 74 o7 7 61- MAILING ADDRESS (if different) EMAIL--Business': 64 ___Owner's: — OWNER'S NAME Fl 1 ZEA i 'rE TEL# q'29 _7.2f!5:9/ ADDRESS 6 5f6A1l?oRA1 SA' :7= 3 re Jt d::Ej j o /4 ec STREET r- CITY // STATE �1 ZIP CERTIFIED FOOD MANAGER'S NAME(S) rL('f. LSCA! T�K CERTIFICATE#(S) O�ac o 3 o 3/"76 (Required in an establishment where potentially hazardous food is prepareedd),.� r�/� �^ EMERGENCY RESPONSE PERSON �7 / rk(1 HOME TEL#&4J RAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OfOPERATIOR fogax„A , 3 6;'3-A37130� ,� Please write In time Ofdw it^ 3 O �j q (for examplellam-110m) r - AO.A 1o:00 ''eo' ; /o5�Pv /o )OoQv yyoo '', /O ooP" ! ) 3 ' pnJ TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE ES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 C/ more than 10,000sq.ft. =$250 ------ ------YES--------NO - - -----------...----....-- -- --.._............---less--.than...--,25---se-ats--...----....---...--- RESTAURANT le =$100 25-99 seats =$150 more than 99 seats =$200 BEQ/B.RE-KFAST ----.----- . .... .... $ifl0- .... ------ --- --- ------ ...------ ..--- ......... .. --------------------- ... _..... -_..... .._.._.............-...... .... ... ... ..... ..._._..._....._... - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR ES NO $50 V�' ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number ----------- ---- ---------------------- - - - -.. - -- --- ------------------------------ ------ ---- ------------- -- ---- Revised 11113,06 FOODAP2007.adm Check#& r)ate-,�O(7�_/ . C.:2�, b - - - - - -1 lei _sy3 r - ..@ e",rv�x�, "ky s '".? + r' _et Y...W.+ff'' rr+ ,a fe;. r � of Iry r Yy h l h- ' e tsCommonwealthMassachus� f s �s -F v.�tnak Ci of Salem mf �e a �?A�:+ My '•T.iS • ,a `Board of Health F + 1Gmberley Dnsno71 ll F 3r 120 Washington Street,4th Floor':r ; ,,* , x *' « ' Ma.y0r SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: Kwik Shop Market and Deli File Number:BHF-2005-000025 10 Jefferson,Avenue Salem MA 01970 LOCATED AT: 0010 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes RETAIL FOOD BHP-2007-0023 Dec 19,2006 Dec 31,2007 . $100.00 TOBACCO VENDOR BHP-2007-0043 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $150.00 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 14 of 29 l 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone a ''' FOOD PROTECTION MANAGEMENT 740-9955 PIC Assigned/Knowledgeable/Duties FAIL ❑J RED Owner: Comment:The certification for the Certified Food Manager expired on 4127/04. Owner must enroll in a Serve Safe class and renew Elie J.Zeaiter •' his certification immediately. Owner must notify the Board of Health upon completing recertification. Y k.!'Ai." PIC: Violations Related to Good Retail Practices (Blue Items) John Morris Equipment and Utensils FAIL Non-Critical BLUE Inspector: - Comment:The slush freezer needs a visible,accurate thermometer. David Greenbaum Date Inspected: Correct By: The shelves in the wall reachin have an accumulation of mold. Thoroughly clean all shelves. 8/28/2006 Label the back and use it for the specified purpose only. s Risk Level: Physical Facility FAIL Non-Critical BLUE Permit Number: Comment:There are water damaged ceiling tiles in the back. Investigate the source of the leak and repair. Replace all damaged ceiling tiles. BHP-2006-0362 Status: Other-See Notes FAIL BLUE SIGNED OFF Comment: Owner has begun serving ice cream. This change in the menu has not been approved by the Health Agent. This .. #of CriticalViolations: establishment is ordered to immediately cease and desist serving ice cream. The owner must make a plan and present it to the 1 Health Agent for approval prior to selling any ice cream. Failure to do so will result in monetary citations being issued. Time IN, Time OUT: GENERAL COMMENTS: Urgency Description(s): 766:AII other violations cited in the 8/16/06 inspection reoprt have been corrected. BLUE: Violations Related to Good Any future repeat violations will be subject to monetary fines of$25.00 per violation being issued. 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 28,2006 ) Page I of • Item Status Violation Critical Urgency RED: Violations Related to 1 Foodborne Illness Interventions and Risk Factors(Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 28,2006 ) Page 2 oft 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: ''"-' FOOD PROTECTION MANAGEMENT 'i40-99k`': PIC Assigned/Knowledgeable/Duties FAIL ❑d RED Owner: ., ' ` Comment:The certification for the Certified Food Manager expired on 4/27/04. Owner must enroll in a Serve Safe class and renew Elie J.zeaiter fhis certification immediately. PIC: 4y PROTECTION FROM CONTAMINATION 'Jason Della Monica Separation/Segregation/Protection FAIL Critical ❑6 RED Inspector: Com nt:The GE freezer has chicken and crab meat stored with bread products. All PHF must be stored separately from RTE David Greenbaum fo to prevent cross contamination. Date Inspected: Correct By: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑J RED 8/16/2006 . Com he ice cream scoop found stored in the ice cream freezer. Ice cream scoop must be maintained in running water in Risk Level: ordance with the Food Code. Permit Number: The s no sanitizing solution in the 3 bay sink. The 3 bay sink must be used in a three part system to wash, rinse and sanitize all hes and utensils. BHP-2006-0362 Status: e'meat slicer has an accumulation of grime. Thoroughly clean and sanitize the meat slicer after each use. VIOLATION l/Th #of Critical Violations: 4 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);v'= 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 16,2006 ) Page I of Item Status Violation Critical Urgency RED: "`` Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Prot dion FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors(Require ;n"'+' C ant: Price labels obscuring expirationtsell by dates. Do not obscure any expiration/sell by dates with price labels. immediate co,ifectivE�action) The following items found outdated: 3-dog f" 1 -parmesan cheese 2-mifecle whip 3 salad dressing _,-'3-infant Tylenol 2-pringles Owner must closely monitor all expiration dates. These violations are constant repeat violations. Continued repeat violations of this nature will result in monetary citations of $25.00 per violation being issued. Equipmentt a nd UtUte ils FAIL Non-Critical BLUE .The ice cream freezer has an accumulation of food debris. Thoroughly clean the ice cream freezer. ushfreezer has an accumulation of food spills and splatter. Thoroughly clean the slush freezer inside and out. Ea.-The same unit needs a visible,accurate thermometer. LTheue deli unit needs a thorough cleaning. T microwave needs a thorough cleaning. e Ken ore 5 freezer needs a visible,accurate thermometer. T mop stored in the bucket. Clean mop and store upside down not touching any surface to air dry. walk m floor has an accumulation of trash. Thoroughly clean the floor. The shelves in the wall reachin have an accumulation of mold. Thoroughly clean all shelves. Label the back and use it for the specified purpose only. Physical Facility FAIL Non-Critical BLUE cS�Zk Comment:There are water damaged ceiling tiles in the back. Investigate the source of the leak and repair. Replace all damaged ceiling til T restroom needs a thorough cleaning including all fixtures. OtherVee Notes FAIL BLUE Comment:Owner has begun serving ice cream. This change in the menu has not been approved by the Health Agent. This establishment is ordered to immediately cease and desist serving ice cream. The owner must make a plan and present it to the VHealth Agent for approval prior to selling any ice cream. Failure to do so will result in monetary citations being issued. 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 16,2006 ) Page 2 of Item Status Violation Critical Urgency GENERAL COMMENTS: 744:Reinspection will be in on 8128106, all violations must be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 16,2006) Page 3 of CITY OF SALEM, MASSACHUSETTS • : BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT February 6,2006 Kwik Shop Market 8 Deli 10 Jefferson Avenue Salem, MA 01970 Dear Owner: On Wednesday January 25,2006 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Kwik Shop Market&Deli is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes,chewing tobacco, snuff,or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of(Two Hundred Dollar fine)for the Second offense. FOLLOWING THE THIRD(3RD)OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$200.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th floor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, e cot u. !�Flealth Agenti JS/mfp CERTIFIED MAIL: 7005 1820 0000 8814 0619 cc: North Shore Tobacco Control Program Christina Harrington, Board of Health Chairman and Members REMITTANCE ADVICE 53-179/113 KWIK SHOP OF SALEM, INC. 10 JEFFERSON AVE. SALEM,MA 01970 0 O (978)740--99,55 CHECK PAY--!f V l"ll e" x MOUNT il 8 DATE I TOTHE ORDER OF DESCRIPTION CHECK NO. e'1 0 Eastern Bank ` "'0010071;--V0-1i7q&l: 60 0ii918411' 0010 Jefferson Avenue Kwik Shop Market and Deli City Of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION J40-9955 a Food Contact Surfaces Cleaning and Sanitizing PASS Critical ❑Q RED Owner. - Comments: The 3 bay sink was not working at the time of inspection. 3 bay sink must be working during all business hours to 'I Elie J.Zeaiter wash, rinse and sanitize all dishes and utensils. According to employee sink has not been working for about a week. Repair sink PIC: to good working order immediately. Elle Zeaiter The meat slicer has an accumulation of food debris. Thoroughly clean nd sanitize the meat slicer after each use. Inspector: The only spray bottle of sanitizing solution found too weak. Sanitizing solution of proper concentration must be readily available at David Greenbaum all work stations at all times. Date Inspected: Correct By: 2/21/2006 Handwash Facilities PASS Critical 0 RED Risk Level: Comments:The front handwash sink not working. Repair handwash sink to good working order immediately. Sink has been out of order for about a week. Permit Number: The front handwash sink had no soap. Provide soap at the handwash sink at all times. BHP-2006-0362 Status: - The back handwash sink has no paper towels. Provide disposable paper towels at this sink at all times. SIGNED OFF Owner must provide a wall hung soap dispenser in the rest room. #of Critical Violations: TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 0 Hot and Cold Holding PASS Critical �/❑ RED :.Time IN: Time OUT Comments: Meat thawing at room temperature. Meat must be thawed in a refrigerator or under cold running water. Urgency Description(s). BLUE: The front True deli cooling unit has a temperature of 48°F. Repair unit to maintain a temperature of 41°F or below. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 21,2006 ) Page I oft l • Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection PASS Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comments: Price labels found obstructing expiration/sell by dates. DO NOT obscure any expiration/sell by dates with price labels. immediate corrective action) Tomatoes found stored directly on the walkin floor. All food must be stored at least 6-8 inches off the floor. There are damaged cans and boxes of food product out for sale. All cans and boxes of food product murt be in good condition for sale to the public. The following items were found outdated: 1 -BBQ sauce 1 -Can frosting 1 -Box cake mix 2-Hamburger helper 13-Peanuts Owner must closely monitor all expiration/sell by dates. Slush freezer has uncovered food. All food in storage must be covered. Equipment and Utensils PASS Non-Critical BLUE Comments:The slush needs a thorough cleaning. The Kenmore5 freezer needs a thorough cleaning and defrosting. The walkin has broken glass and trash all over the floor. Thoroughly clean walkin including under all racks. Water, Plumbing and Waste PASS BLUE Physical Facility - PASS Non-Critical BLUE Comments: The establishment is in need of a thorough cleaning and dusting. GENERAL COMMENTS: 493:AII violations cited in the 2/13/06 inspection report have been corrected. C— YV City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 21,2006 ) Page 2 oft 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: - PROTECTION FROM CONTAMINATION 740-9955 Food Contact Surface leaning and Sanitizing FAIL Criticald❑ RED Owner: Com nt: The 3 bay sink was not working at the time of inspection. 3 bay sink must be working during all business hours to wash, Elie J.Zeaiter Lr' a and sanitize all dishes and utensils. According to employee sink has not been working for about a week. Repair sink to good PIC working o r immediately. Jason Della Monica m meat slicer has an accumulation of food debris. Thoroughly cleana nd sanitize the meat slicer after each use. Inspector: The qn1y spray bottle of sanitizing solution found too weak. Sanitizing solution of proper concentration must be readily available at David Greenbaumal ork stations at all times. Date Inspected: Correct By.- 2/13/2006 Handwash Facilities FAIL Critical ❑Q RED Risk Level. Co ent: The front handwash sink not working. Repair handwash sink to good working order immediately. Sink has been out of der for about a week. Permit Number: e front h wash sink had no soap. Provide soap at the handwash sink at all times. BHP-2006-0362 Status: T ac andwash sink has no paper towels. Provide disposable paper towels at this sink at all times. VIOLATION O er must provide a wall hung soap dispenser in the rest room. #Of Critical Violations. - TIMEITEM ERATURE CONTROLS(Potentially Hazardous Foods) 4 Hot and Cold Holdin FAIL Critical ❑� RED Time IN: Time OUT: Co er�i: Meat thawing at room temperature. Meat must be thawed in a refrigerator or under cold running water. Urgency Description(s): 1/ BLUE: front True deli cooling unit has a temperature of 48°F. Repair unit to maintain a temperature of 41°F or below. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 14,2006 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comment:: Price labels found obstructing expiration/sell by dates. DO NOT obscure any expiration/sell by dates with price labels. immediate Corrective action) en Tpr of es found stored directly on the walkin floor. All food must be stored at least 6-8 inches off the floor. There a damaged cans and boxes of food product out for sale. All cans and boxes of food product murt be in good condition for sal o the public. The following items were found outdated: 1 -BBQ sauce 1 -Can frostin 1 -Box c�k mix 2-H urger helper 1 eanuts Owner must closely monitor all expiration/sell by dates. ezer h ,s uncovered food. All food in storage must be covered. ujvi��fre Equipment and Ut 'sils FAIL Non-Critical BLUE /Coln n�The slush needs a thorough cleaning. T enmores freezer needs a thorough cleaning and defrosting. The in has broken glass and trash all over the floor. Thoroughly clean walkin including under all racks. Water, umbing and Waste FAIL BLUE Physical Facilit� FAIL Non-Critical BLUE Co ment: The establishment is in need of a thorough cleaning and dusting. GENE COMMENTS: 474:Reinspection on 2121106, all violations to be corrected. CIL City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 14,2006 ) Page 2 of :... .. y, .7. Y% Commonwealth of Massachusetts City of Salem Kimberley Driscoll Board of Health. y Mayor ?` 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 02/01/2006 WHO'S PLACE OF BUSINESS IS: Kwik Shop Market and Deli File Number:BHF-2005-0025 10 Jefferson Avenue Salem MA 01970 LOCATED AT: 0010 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0362 Feb 1,2006 Dec 31,2006 $100.00 TOBACCO VENDOR BHP-2006-0363 Feb 1,2006 Dec 31,2006 $50.00 Total Fees: $150.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Hcalth. Page 3 of 5 r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH ) f s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll I WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF'ESTABLISHMENT KI (.Ur K S�ppon� (� TEL#09;,) ADDRESS OF ESTABLISHMENT zlx` — . SALEM Alw-t 7 ,D MAILING ADDRESS (if different) -So m2_ . OWNER'S NAME �'L i ZEA -re j A TEL# ADDRESS 4V 3 CITY STATE ZIP o CERTIFIED FOOD MANAGER' NAME(S) �( i F z�Ai �F6C CERTIFICATE (s) (required in an establishment where potentially hazardous food is prepared.)(: EMERGENCY RESPONSE PERSON L ( C ZCAi 1"E R HOME TEL# 5-,i1 6 Z W T 2 HOURS OF OPERATION: Mon.7-��Tue.2LWed. Z Thu. _/. Fri.-7-1. -/o Sun. 7— TYPE OF ESTABLISHM FEE (check only) RETAIL STORE ES NO / less than 1000sq.ft. d l (� more t 0,000 ,000 - 100 more than 10,000sq.ft. =$250 . . . . ......................... ........ ......................................................... ........ .. ... ..........._--------------------- RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 .....................................-----------------------------.-......--------------------------....-- BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS ----------------------------------------------------------------------------------------------------------------------------- MAKE (not just serve) ICE CREAM, YOGURT, SOF; SEEI3VE YES NO $5 TOBACCO VENDOR 6 �' $5 � NO 50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledgeand belief, have filed all state tax returns and paid all state taxes required under the law. C�^�_J ✓ �n 1 - 30- 06 O z 7 0 Signature Date Social Security or Federal Identification Number ------------------------------------------------------------------------------------------ ----------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date N 4 ��O i COURTDOCKETNO.� _.. -- - CITATION NO =, i { CITY OF ATISALEM'PD O3H9 VIOLON NOTICE NAME(LAST,FIRST,INITIAL) C STREETADDRESS CITY/TOWN STATE ZIP u, ,.y.n Dmx LICENSE NO. LIC.EXP.DATE DATE OF BIRTH flTH OO m3mN .. D 2 O OWNER'S NAME(LAST,FIRST,INITIAL) n - o 03 � E ZIP m oz STREETADDRESS �TY/� T W D mym e— m REGISTRATION NO. STA E PE YEAR COLOR m V, n •• m O _ r DATE OF VIOLATION TIMEDATE CITATION WRITTEN PERSONAL AM uuR r `-�-pG ❑PM �— 9'Oro YES n N NO e O i. LOCATION OF VIOLATION ENFORCING DEPT. �7 (OFFENSE CHAP. SECT. FINES m i 0 C O !OFFICER I.D.NO. TOTAL FINE 1$ DU wu 03 n 5 OFFICER CERTIFIES COPY GIVEN TO VIOLATOR 03133 3 z y q [ ❑ IN HAND Z OZ Xy! %�/LeLL6#iGL% .�BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 _ TEL.(508)745-9595 X 251 _ D I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON m p' REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE 1 0 PAYMENT IN THE AMOUNT OF x r � CASE# In SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL - O o = m00 w C O Z F CO V W � �I COURT DOCKET NO. O CITY SALEM CITATION NO. PD 0383 VIOLATION NOTICE 4#a7�7 NAME(LAST,FIRST,INITIAL) em)IK sme ae"' -f �e�l STREETADDRESS CITY/TOWN STATE ZIP LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNERS NAME(LAST,FIRST,INITIAL) STREETADDRESS CITY/TOWN STATE ZIP REGISTRATION NO. STATE EXP.DATE MAKERYPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL EIAM INJURY l"!•�f e LIPM ❑YES NO LOCATION OF VIOLATION ENFORCING DEPT. /o W'-'Ze'ese-A!1 dem ct1f ae.Y OFFENSE CHAP. SECT. FINES B C OFFICER LD.NO. TOTAL //�� G'ff'!G.:fT' iUJ S FINE DUE IGC/• ... OFFICER CERTIFIES COPY GIVEN TO VIOLATOR �// A p ❑ IN HAND X 71 ;?17zy4zp ii /KBY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL CITY OF SALEM, MASSACHUSETTS 0 8 BOARD OF HEALTH - 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT January 26, 2006 Elie Zeaiter Kwik Shop Market & Deli 10 Jefferson Avenue Salem, MA 01970 Dear Elie Zeaiter: You are currently operating your Food Establishment, Kwik Shop Market & Deli located at 10 Jefferson Avenue, without a Food Permit. This is in violation of the State Food Code, 105 CMR 590.000, section 8-301.11. In order to receive a 2006 Food Permit, you must: • Pay outstanding tax bills, if any • Pay outstanding tickets from the Board of Health • Pay for your 2006 Permit • Submit a completed 2006 Food Permit Application You are hereby ordered to obtain a 2006 Food Establishment Permit forthwith. Failure to do so by Monday, February 6, 2006, will result in a Board of Health Order to cease all food operations at your establishment immediately. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. An attorney may represent you. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and otlker documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Sincerely, 6b;anne Scott Health Agent .i: , i s :. I . ,., . CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH gJ 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 .� TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Kwik Shop Market and Deli Address of Establishment: 10 Jefferson Avenue Owner's Name: Elie J. Zeaiter Restrictions: Application Date: 11/19/04 Permit for Food Establishment 40-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 0010-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. V HEALTH AGENT f cad CITY OF SALEM, MASSACHUSE O BOARD OF HEALTH O 93 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 NOV 17 2004 J�'py�,IguO'" TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALEM STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEATH MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT/TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT WW t �'l (nod o e_TEL# ADDRESS OF ESTABLISHMENT p tit �P N2_. Scaw .iM� o/% 7 J JV MAILING ADDRESS (if different) t�e— OWNER'S NAME qf TEL# &2,3 � ADDRESS C S Qk fo 3 CITY STATEAJA ZIP o / C.c CERTIFIED FOOD ANAGER' AME(S) L ' 7=F, q I PRCERTIFICATE#(s)_ /3-`1eZ 4 6 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON L l 2Et9 TEA HOME TEL# HOURS OF OPERATION Mon7-/o Tue ZWed 7 /�Thu 7 /d Fri.?-/o Sat.2 ) , Sun" TYPE OF ESTABLISH ; ` " FEE"check orily, RETAIL STORE " . ES jNO+ No (%; ` A,.less than 1000sq'.ft: --$ 50 1000-10,000sq.ft. 60 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $ TOBACCO VENDOR a le -06' (Z NO ALL NON-PROFIT (such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signal �jf� - Date Social Security or Federal Identification Number — -------------- ------------- -----r31t Revised 11/03/03 FOODAP2.adm Check#&Date /i) - 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephone: T '' - - Item Status Violation Critical Urgency Nature of problem or correction 740-9955 Non-compliance with: Done :;.Owner: . Anti-Choking PASS ❑ Elie J.Zeaiter- ' _ Tobacco PASS ❑ PIC: Elie Zeaiter FOOD PROTECTION MANAGEMENT Done Inspector: ' r PIC Assigned/Knowledgeable/Duties PASS ❑ RED David Greenbaum EMPLOYEE HEALTH Done Date Inspected' Correct By s Reporting of Diseases by Food Employee and PIC PASS ❑d RED m � 9/30/2005 Personnel with Infections Restricted/Excluded PASS RED Risk Level: :! s FOOD FROM APPROVED SOURCE Done Permlt Number: Food and Water from Approved Source PASS ❑J RED BHP-2004-0218 Receiving/Condition PASS ❑d RED Status: 'r Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNED OFF. Conformance with Approved Procedures/HACCP PASS ❑ RED #of Critical Violations.,1, Plans PROTECTION FROM CONTAMINATION Done Time IN: Time OUT: Separation/Segregation/Protection PASSd❑ RED Notes' s ^ Food Contact Surfaces Cleaning and Sanitizing PASSd❑ RED 337: Proper Adequate Handwashing PASS ❑d RED x Urgency Description(s). Good Hygienic Practices PASS ❑d RED BLUE: Prevention of Contamination from Hands PASS ❑d RED Violations Related to Good Retail Practices (Critical _ Handwash Facilities PASS RED violations must be corrected immediately or within 10 days)(Non;critical violationsT GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Oct 03,2005 ) Page I oft 0010 Jefferson Avenue Kwik Shop Market and Deli must be Corrected Immediately PROTECTION FROM CHEMICALS Done or within 90 days) Approved Food or Color Additives PASSd❑ RED RED: Violations Related to Toxic Chemicals PASS d❑ RED ' Foodborne Illness InterventionsTIMEITEMPERATURE CONTROLS(Potentially Haz Done and Risk Factors (Require Cooking Temperatures PASS RED immediate Corrective action) 4 Reheating PASS ❑d RED Cooling PASS ❑d RED Hot and Cold Holding PASS RED - Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Done Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY - Done Posting of Consumer Advisories PASS RED Violations Related to Good Retail Practices (Blue Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils PASS ❑ BLUE Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE All violations cited in 9/23/05 inspection report have been corrected. GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Oct 03,2005 ) Page 2 o!2 0010 Jefferson Avenue Kwik Shop Market and Deli City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephoner ^^ _ 4 = Item Status Violation Critical Urgency Nature of problem or correction 740-9955 Non-compliance with: Not Done Owner: Anti-Choking PASS . ❑ Elie J.Zeaiter ' Tobacco PASS ❑ PIC: _ Elie Zeaiter. FOOD PROTECTION MANAGEMENT Not Done Inspector:' PIC Assigned/Knowledgeable/Duties PASS RED David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑/ RED 9/23/2005 Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level FOOD FROM APPROVED SOURCE Not Done Food and Water from Approved Source PASS ❑d RED Permit Number: BHP-2004-0218 Receiving/Condition PASS 0 RED Status: ' Tags/Records/Accuracy of Ingredient Statements PASS RED VIOLATION #Of Critical Violations: a Conformance with Approved Procedures/HACCP PASS RED Plans Time IN: '',Time OUT: Notes 319:Reinspection in one week. All violations to be corrected. _ - r Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within-10 z GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 26,2005 ) Page 1 o!3 0010 Jefferson Avenue Kwik Shop Market and Deli days)(Non-critical violations PROTECTION FROM CONTAMINATION Not Done must be corrected immediately Separation/Segregation/Protection PASS OO RED or within 90 days) RED: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑Q RED anitizing solution found too weak. VIOIatIOnS Related t0 rovide sanitizing solution of proper :,. . concentration at all workstations at all Foodborne Illness Interventions` times. and Risk Factors (Require %Ae meat slicer has an accumulation of Immediate Corrective action) food debris. Meat slicer to be cleaned and - - sanitized after each use. 4anitizer log not being maintained. anitizing log must be maintained on a daily basis. Logs left at time of inspection. Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS RED Handwash Facilities PASS RED PROTECTION FROM CHEMICALS Not Done Approved Food or Color Additives PASS ❑Q RED Toxic Chemicals PASS ❑J RED TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done Cooking Temperatures PASS ❑J RED Reheating PASS ❑�/ RED Cooling PASS ❑d RED Hot and Cold Holding PASS ❑d RED Time As a Public Health Control PASSd❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS ❑d RED GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 26,2005 ) Page 2 o!3 0010 Jefferson Avenue Kwik Shop Market and Deli Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Non-Critical ❑ BLUEitems found outdated at time of nspection. Owner will closely monitor all Expiration dates on a regular basis. eep slush products covered in storage. Equipment and Utensils FAIL Non-Critical ❑ BLUE Tjj�.�Kenmore5 freezer is missing a ) ermometer. Provide a visible, accurate the�rrmometer in this freezer. I.Ye slush freezer needs a thorough %U aning. e True reach in cooling unit has an ccumulation of food debris and grime. T oughly clean this entire unit. p to be stored hanging upside down not touching any surface. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non-Critical ❑ BLUEa wall in the food prep area has food - ills and splatter. Clean the wall and repaint. There are water stained ceiling tiles in the backroom. Investigate the source of the leak and repair. Replace all water stained ceiling tiles. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE 22-0—A —1 GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 26,2005 ) Page 3 of Massachusetts Department of Public Health Salem Board S Health Department 120 Washington Street, 4rh Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Type of OPeration(s) T e of Ins ection j e ,t+ o f 2 </6, ❑ t9od Service Routine Address Risk ©'Retail El-Re-inspection /6 J&? /GErt o+f lfd4 Level ❑ Residential Kitchen Previous Inspection Telephone 7 � f� Owner71ElElMobile Date: �u� HACCP Y/N El Temporary Pre-operation Caterer Suspect Illness Person in Charge(PIC) Time 171 Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector r ? Out. Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590-009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ,.,,. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable t Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14 Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE - -- - - TIMENEMPERATURE CONTROLS(Potentially Hazardous Foods) ' ❑ 4. Food and Water from Approved Source ❑ ❑ 16. Cooking Temperatures 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ' ' " -1 - ❑ 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 NSP ❑ 10. Proper Adequate Handwashing El 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 Health. 590.000/federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health- Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6)(590.007) have a right to a hearing. Your request must be in writing 28- Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S5sms yW+"ar 14.mc A Inspector's Signatur Print: Pages PIC's SignaPrint: Page-i of/- -Pl p4 r. Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A Assignruent of Responsibility" 3-302.11(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103 11 Person in charge--duties Contamination from Raw ingredients 3-30111(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 byfoal employees and 3-302,11(A) Food Protection* p a licants* 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* Chou ee* Contamination from the Consumer 590.003(G) Reporting by Person in Charge" 3-306.14(A)(B) Renatied Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adufterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law" 4-501.111 Manual Warewashing-Hot Water Food a klenneticull Sealed Containea* 0Mechanical WareSanitization'rem eratures* 3-201.12 Fin a 3-201.1.3 Food kand'Milk Products* 4-51.112 washing-HotWater 3-202-13 Shell Eggs* Sanitization Tem eramres'" 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hudness_ 3-202.16 Ice Made From Potable Drinking Water' 4-601.11(A) Equipment Food Contact Surfaces and 5-101-11 Drinking Water from an A revved System* Utensils Clean' 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CNIR 22.0* Contact Surfaces and Ltcnsils* 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 Ego anent* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources" to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2 Re ulato Authorityx301.1 L Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present` 2-30112 Ciemnimr Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash" 3-201.17 Game Annuals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11 F.atin Dri nkin>or Using Tobacco* 3-202.11 PflFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-20215 Package Integrity" - I Mouth* 3-107.11 Food Safe and Unadulterated,* 3-3W 01.12Preventing Contamination When Tastin=* 12 Prevention of Contamination from Hands 6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.13 Shellstock Identification* 3-203.12 Shellstock Identification Maintaine(* Handwash lFacilities Tags/Records:Fish Products 13 Haash 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3402.12 Records.Creation and Retention" 5-203.11 Numbers and Ca acities* 590.00401) Labeling of Ingredients' 5-204.11. Location and Placement* 7 Conformance with Approved Procedures 5-20511 Accessibility,O eruion and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.1 t Specialized Processing Methods* devices 3-502.12 Reduced oxygen packaging,criteria* 6-301..1 t Handwmlaing Ci&mser.Availabdit 8-103.12Conformance with A )roved Procedures" 6-301.12 Hand Drying Prorrision Denotos critical hem in rhe federal 1999 Food Cotte or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: /l✓//W J7140P Date: IZI`1em Page: 2 of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item. - Verified PLEASE PRINT CLEARLY -- - Discussion With Person in Charge: Corrective Action Required: '❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction 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 oft ty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ( l Q�� \ \\\ 9ll A� 1�1N ❑ Voluntary Disposal ❑ Other. r' -T501 14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(items 1-22) (Cont.) 41`.F/45°F Within 4 Hours. PROTECTION_FROM CHEMICALS 3-501.15 Coolim,Methods for PHFs I9 14 Food or Color Additives PHF Hat and Cold Holding 3-501.16(73) Cold PHFs Maintained at or below 3-202.72 Additives* 590.004(F) 41'/45°F� 3-302.14 Protection from Unapproved Additives* 3-50'L1Ci(A) .Hat PHFs Maintained at or above IS Poisonous or Toxic Substances 140"F. * 7-10[.11 ideContainers Information-Orio'ina( 3-50116(A) Roasts Held at or above 130°F- Containers* 7-'102.11 Common Name-Working Containers" 20 Time as a Public Health Control 7-201.11 Separation-Storage", 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and User 590.004(H) Variance Requirement 7-202.12 Conditions ofllse'k 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 7-204.[2 Chemicals for Washing Produce,G�iteria* 2I 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drvina A eats,Criteria* beveraKes with Warning Labels* 7-205.11 Incidental Food Contact.Lubricants* 3-8o I 1(73) Use of PastcutimdBggs* 7-206.'11 Restricted Use Pesticides.Criteria* -3-80LI I(D) Raw or Partially Cooked Animal'Food and Raw Seed S pouts Not Served. ,e 7-206.12 Rodent Bait Stations*Pe 3_901.17(C) Uno erred Food Package Not Re-served. 7-06.13 Tracking Powders, sl Control and Monitorin.,* CONSUMER ADVISORY TIMElTEMPERATURE CONTROLS 22 3603.17 Consumer Advisory Posted for Consumption of Animal Foods flint are Raw.Undercooked or 1h Proper Cooking Temperatures for PHFs Not Otherwise Processed to 31itn nate 1-401.1 lA(1)(2) FPath ogs- 1.55`F 15 Sec. tloeris.* rrre��e ih(200i Eggs- Immediate Service 145'F15see* 3-303.13 Pasteurized Eggs Substitute for flaw Shell 3-401.1I(A)(2) Comminuted Fish,Meats&Game Eggs* Animals- 155'F 15 sec. * 3-401.11(13)(1)(2) Porkand Beef Roast- 130°F 121 m'in't SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites, Injected Meats- 155'F 1.5 590.009(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 wider 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 Crooked in a practices should be debited under#29-- Microwave 165°F* Special.Requirements. 3-40111(A)(1)(b) All Other PHFs 145'F 15 sec. I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11 f A)&(D) PRFs 165°F 15 scc.". (Items 23-30) 3-403.11(8) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to tire Time* foodborne ilhwss interventions and risk fn(:tors listed above, can be 3-403.11(C) Commercially Pnxemed I2TF Food- _found in the follonving sections of the Food Cade and 105 CMR '140'F* 590.000. 3-403.11(E) Remaining --590.6-0-0 Unsliced Portions of,Beef Ilam Good Retail Practices FC onm Roasts* 23. Ma eend and Personnel FC-2 .003 Ig 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 M6 Water, PlumbiaWaste FC 5 .006 70`F Within 2 Hours and From 70'F 27. Ph sisal Facilav FC-6 .007 to 4['F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC -7 .008 3-501.14(8) Cooling PHFs Made From Ambient 29_ S ecial R ulrements .009 Temperature Ingredients to 41'F/450P -30, _ Other _ Within 4 flours's Denotes critical item in the ruderal 1999 Foal Code or 105 CNIR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,41h Floor Division of Food and Drugs Salem, MA 01970-3523 -FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name��f Dat Tvoe of Operation(s) Tvoe of Inspection S( a ow" I i 2t O ❑- Food Service �utine Address/t, "a Risk CJ Retail ❑ Re-inspection Telephone Level El Residential Kitchen Previous Inspection io, ?-7q /ti/ ❑ Mobile Date: Owner HACCP YM ❑ Temporary ❑ Pre-operation lfug< 2&J4/VaF4C ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) s*A[E Time ❑ Bed&Breakfast ElGeneral Complaint Inspector jj,VrO 2RL Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. I'FOOD PROTECTION MANAGEMENT - ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS" ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 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 TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition [:116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 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). -" Ll 10. Proper Adequate Handwashing ❑21. 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 �C immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 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 5901,.IFo,m 14do l! Inspector's Signature• Print: 1 ' ILZE PIC's Signature: 1Print: Page of!� Pages w v 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) Assi in ent of Res onsibility" 302.1 ((A)(l) Raw Animal Foods Separated from 590d)03(B) Demonstration of Knowledge' Cooked and RTP Foods* 2-103.11 Person in charge--duties Contamination from Raw ingredients 3-302.11(X)(2) Raw Anonal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting byfood employees and 3-302,11(A) Food Protection* at flicams* 3-302.15 Washin¢Fruits and Vegetables 590.003(F) Responsibility Of A Foci Employee Or An 3-304.11 Food Contact with Equipment and Applicant To ReportTo The Person hr Utensils* Char*& Contamination from the Consumer 590.003(G) Re ortin�by Person in Char e' 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) 1 Exclusions and Restlictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701..11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE 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- fIot Nater 3-20L.12 Food in a Hermetical) Sealed Container* Sanitization dem etamres* 3-201.13 Fluid Milk and Milk Products* 4-801.1.12 Mechanical Warewashinr, Hot Water 3-202.13 ShellEg,,s* SinrtizationTem>eratures" 202.14 E es and Milk products,Pasteurized' 4-501.114 Chemical Sanitization-temp.,pli, concenh ation and hardness.°' 3-202.16 tee Made From Potable Drinkins Water 4-601,l 1(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved Svstem' Utensils Cletn- 590.00(aA) Bottled Drinking Water* 4-602,1 t Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 31.0 CMR 220* 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 Snrfaczs ofE ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemiciil° Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2- Regulatory Author' 301.11 Clean Condition--Hands and Arms"' 3-202.18 Shellstock Identification Present* 2-301.12 Cleanim,Procedurel' 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 patina,Drinking or Using Tobacco* 3-202.11 Kips Received at proper Tem reraeurea* 2-401.12 Discharges From the Eyes.Nose and 3-202.15 Package Into it ", 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 3-202.13 Shellst'ock Identification* 590.U04(E) Preventing Contamination from 3-203,12 Shellstock Identification Maintained` Ent to ees� TagslRecords: Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-402.11. Parasite Destruction": 3-402.12 Records.Creation and Retention* 5-303,1.1 Numbers and Capacities'' 590.00-1(1):jLabeling of Ingredients' 5-204.11. Location and Placement*- q Conformance with Approved Procedures 5-205-11 Accessibility,Operation and Maintenance lHACCP Pians Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen xickaging,criteria" 6-301.11 Handwashdn Cleanser.Avattabilit &103.12 Conformance with A roved Procedures" 6-301.12 Nand Drvimg Provision 'k Denote.critical item iu fhc federal 1999 Food('ode or 105 CN1R 590.000. CITY OF SALEM BOARD OF HEALTH ,r Establishment Name: /<'G//K Plftrro PAMit&0 f-0&4 Date: /�?S`(t Page: of Item Code C—Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - - Verified PLEASE PRINT CLEARLY 0 Jli a a�� !F[ta+t if y/J7 rSCaF. d e-c aAmAiid tf#0.A0he sl7S.t Z � /J6.tI vl i /CSS Cc a <1 a+r F D �add�i s A�o Jy�/�• 0 tJ AC d sr- 4410#YA o !a N s .tlr IL A 6ea risA ter rh2.ld 41 va t2.tf &aOW t r� Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that _ noncompliance may result in daily fines of twenty—f.iveldolla.s-or suspension/revocation of ❑ Embargo ❑ Emergency Closure • your food permit. �j �� l� LlVoluntary Disposal 0 Other: 1 r 3-501.14(C) PHFS Received at'Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1.22) (Cont.) _ 41°F/45'F Within 4 Hours. '" PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFS 14 Food or Calor Additives 19 PHF Hot and Cold Holding '5-202-12 Additivea'a 3-50116(B) Cold PE-IFs Maintained at or bellow, 590,004(F) 41'/45°F* 3-302.14 Prou.clion Iram Unapproved Additives* 3-501.1(i(A) Hot PHFS Maintained at or above 1-5 Poisonous or Toxic Substances 40'F. * 7-10L11 Identifying Information-Orin nal 3-501.1.6(A) Roasts Held at or above 130'F. Containers" 7-10111 Common Name-Workin,Containerst 20 Time as a Public Health Control 7-201.11 Se ,(ration-Slot age* 3-501.19 Time as a Public Health Control* 7-202.'(1 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11t'oxicContainers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sa1-i -ers,Criterit Chemicals* POPULATIONS(HSP) 7-2(14.12 Chemicals for Wash >Produce,Criteria"` 21 3-801..1 1(A) Unpasteurized Pre-packaged Juices olid 7-204.14 Drsm A eats,(.atelia" .Beverages with Warning abets* 7-205.11 Incidental Food Contact.Lubricants* 3-801.11(B) Use of Pasteurized Eii s* 7-206.7 1 Restricted Use Pesticides.Criteria=` 3-801.11(D) Raw or Partially Cooked Aminal Fewd and Raw Seed Sprouts Not Served. ' 7-206.12 Rodent Bait Stations" 3-801.11(C) Unopened Foci Package Not Re-served. 7-206.13 Tracking*Powders,Pest Control and Monitorin,* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foo PHFS ds That are Raw,Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed toElitninate 3- Eggs- 1551- 15 Sec. Pathogens. *enecnvu rnaeooi 401.11A(li(2) E>es-Ianvectiatc Service 145°F15secr' 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish, Meats&Game Eggs' Animals-155°F 15 sec. a 3-401.11(13)(1)(2 notand Beef Roast - IMO F121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155'F '15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec, ` catering, mobile food, temporary and 3-401.1l(A)(3) Poultry,Wild Game, Stuffed PHI., residential kitchen operations should be Stuffing Containing Fish, Meat, debited under the appropriate sections Poultr r or Ratites-165'F 15 sec.s- above if related to foodborne illness 3-4011l(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'-;. 590.009 violations relating to good retail 3401.12 Raw Atonal Foods Cooked in a practices should be debited under#29- Microwave 1651-* Special Requirements. 1-40 1.11 All OtherPHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(ll) PHFS 165'F 15 sec.* (Items 23-30) 3-40111(B) Microwave- 165°F 2 Minute Standinc Critical and non-critical violations, avhich do not relate to the Time* foodborne illness interventions and risk factors listed above can be, 3-4 33.11(C) Commercially Processed RTE Food- ,found in the following sections rif the Food Code and 105 CMR 140'14* 590.000. 3-401 11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 580 000 Roasts* 23. Management 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 3-501,W(A) Cooling Cooked PRFs from 140°F to 26 Water' Plumbing and Waste FC 5 006 70'F Within 2 flours and From 70'F 27. Physical Facility FC-6 .007 to 4l.°-745°F Within 4 Hoots. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(13) Cooling PHFS Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 411P/45°F 30, Other Within 4 Hours'- "Denotes critical item in ilia federal 1999 Food Code or 105 CMR 590990. L CITY OF SALEM BOARD OF HEALTH / Establishment Name:�++�/i� t'[QDI° /Ul��/�t�F P ofsU Date: / ! � d5� Page: 2 of Item Code C-Critical item DESCRIPTION OF VIOLATION!PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY C V/ «aR,r s /nl t aawy �ctrrtAc'.4i u/�ht /6�.e • t„r R'ri �dL. /' Jro-.�.. e�atstQ /r¢2h SAtrud• Z /4,c I - a Ne)rk reir 7 034W f C r rAA1 r£ JF• 2� 4..ec Rao-�/uf nA,�ns. Ourr.ra,f._ rJrtj' [' �e y ie� �� r viMZr v-+ nrrJ>ttt ,ri*rYod dr F2hs artswss /fMvs leer rnai* 91y C S �s P c lv c rd4mi dg ,ts- r s.:c4rt grr t. aorirn^- �l r d r" 04-_r-&.r W'rje P c&_ L.tw X4NG /if r C r r✓ s urr v Jwi+V,Ar a.r- a /<� OV f[ 0L4 ,eW v cos ALA_ 0#UeX1 r rr/2rrA ? Ac Q10W fKdkftdICit /M a' i/erd'vAgcr ur yiter ALAnw Of_ R: o Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that _ noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of LJ Embargo LI Emergency Closure your food permit. f LI Voluntary Disposal Ll Other. I 3-501_14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to I,aw Cooled to Factors(items 1.22) (Cont.) 4I'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS3-561.15 Cooling Methods for PHF's 14 Food or Calor Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501_16(13) Cold PHRe Maintained at or below 590.004(F) 41`745°F* 3302.14 Protection from'1 roved Additives* '3-501.16(A) HcH PHFs Maintained at or above IS Poisonous or Toxic Substances - t40''F. 7-101.11 Identifying Information-Originai 3-501.16(A) Roasts Held at or above 130'F. Containers* 7-102.1 1 Common Name-Workim,Containers`" F2 1) Time as a Public Health Control 7-201.11 Seg aration-Stora er` 3-501.19 Time as a Public Health Control* 7-20111 Restriction-Presence and I7Se's 590.004(H) Variance Requirement 7-202.12 Conditions of Use, 7-263.11 `Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 7-204.11. Siminzers,Criteria-Chemicals` - 7-204.1.2 Chemicals for Washinit Produce,Criteria"' 21 3-801.17(A) Unpasteurized Pte-pnckagcd Juices and 7-204.14 Dr sir- tom, e I Criteria* Beverages with IN nine,labels* 3-861.11(B) Use of Pasteurized Eggs* 7-205.11 incidental Food f37ntact. Lubricants* 7-206.11 Restricted Use Pesticides.Criteria* 3-801A 1(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 'r n 12 Rodent Bait Stations" 3-801.11(C) SeisNo'13 7Y2cking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods'rhat are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.1IA(1)(2) Eggs- 155°F 15.Sec. Pathogens.*En�e, ,,goo E;$s-hnntediate Service 1451,15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shelf 3-401.11(A)(2) Comminuted Fish,Meats &Game B gs* Animals- 155'F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast-136'F 121 min* SPECIAL REQUIREMENTS 3-401.11.(A)(2) Ratites, Igjected Meats-155'F 15 590-009(A)-(D) Violations of Section 590.009(A)-(D)in sea * catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Untie, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr ar Radtee-165°P 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscly,Lttact Beef Steaks interventions and tisk factors. Other 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under J129- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PFIFs- 145'.F 15 sec. 19 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 sec.* (Items 23-30) 3-403.11(13) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and riskfaeums listed above. can be 3-403.11(C) Commercially Pnx-essed RTE Food- found in the following sections of the Food Code and 105 CMR 14WF* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retafl Practices FC 580.1000 Roasts" 23. Mana ement and Personnel_ FC-2 .003 Ig Proper Cooling of PHFs 24. Food and Food Protection - _ FC-3 1 .004 -- 3-561.1 25. Equipment and Utensils FC-4- _005.4(/t) Cooling Cooked PHFs from 140°F to 26. Water,Plumbin and Waste FC-5 .006 _ 70`F Within 2 Hours and From 70'F 27. -Physical Facility FC-_6___'_.007 _ to 41'F/45'F Within 4 Hours, * 28. Poisonous or Toxic Materials FC-7 ' .008 3-50114(B) Cooling PHFs Made FromAmbient 29. Special Reuirements Temperature Ingredients to 41 F/45°F 3 0. Other Within 4 Hours'r srvor�nm,ua.z.*� "-Denotes critical item in t6a Federal 1999 Fwd Code or 105 CMR 590000. l CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH e e 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741.1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Kwik Shop Market and Deli Address of Establishment: 10 Jefferson Avenue Owner's Name: Bassam Zeaiter Restrictions: Application Date: 12/30/2003 Permit for Food Establishment 242-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 54-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT IMPORTANT MESSAGE FOR �i DATE / 9 dd 3 TIME a of =A—A S e D PHONEDE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CAU_ TELEPHONED- PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE 7 CGi1J S NED OC FORM 4009 FORIVAOE IN U.S.A. NOTES u CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH , 120 WASHINGTON STREET, 4TH FLOOR 17 2003 SALEM, MA 01970 NOVl� / nq �Qrare TEL. 978-741-1800 CIIY' OF SALEM FAX 978-745-0343 BOARD HEALTH t STANLEY USOVICZ, JR.R D OF H€ALTH JOANNE SCOTT, MPH, R5, C.aH�O BOAR MAYOHEALTH AGENT . 2004 APPLICATION FOR S�PPERMIT�TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTTr/ t l� (r T 1 5M ?R TEL#-(( J��I ��F 9S^S ADDRESS OF ESTABLISHMENT 0(f 7� MAILING ADDRESS (if different) � VU OWNER'S NAME r A s , -Ans / TEL# ADDRESS 1 Li' fC f/ Yr po_. CITYSTATE_d ZIP?/9/9 0 CERTIFIED FOOD MMANAGER'S NAME(S) /_(F ZG_ i ERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON VL((�_Z Z:6 HOME TEL# 7(5 Z� 5 7� HOURS OF OPERATION: Mon��Tue. 7,9W/ed.2_j Thu.7T'� Fri. �9 Sat. Z—' Sun. 6 TYPE OF ESTABLISHMENT y FEE check only RETAIL STORE E NO pZ / less than 1000sq.ft. - 1000-10,000sq.ft. - 100 more than I0,000sq. 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, SO T SERVE YES NO $5 TOBACCO VENDOR ( S NO CE) ALL NON-PROFIT(such as church kitchens) YES NO $25 Please nav total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, h e filed all stat tax returns and paid all state taxes re wired under the law. Signature Date Social Security or Federal Identlfica io Number ----------------------------------------------------------------------------------- ----------- �i ------------------- Revised 11/03/03 FOODAP2.adm Check#&Date A63- (/'-if"O --:5 5y ' ..— CITY OF SALEM BOARD OF HEALTH Establishment Name: )et&/( /e-- S/del' Date: / Pager of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY G it A F-111 E:$ I J 11 d/r )3, T VT ef'M /'rof OA St4 tv� c4 �/ i 'd i� Discussion With Person in Charge: Corrective Action Required: Cl No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspensio /revocation of Ll Embargo LI Emergency Closure your food permit. ( l O �I ❑ Voluntary Disposal ❑ Other: 1 3-501.14(0) PHFS Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cowled to Factors(items 1-22) (Cont.) 41.°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFS 14 Food or Color Additives t9 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PIiFs Maintained at or below 590.004(F) 41°/45°F* 3-302.14 Protection froth Una txmed Additives'" 3.501.16(A) Hot PHFS Maintained at or above 15 Poisonous or Toxic Substances 40°F. * 7-101.11 Identifying[nformation-Orifi na 3-501.16(A) Roasts Held at of above '130T. Containers" 7-102.11 Coalition Name-Working Containers* 20 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-Presence and rise* 590.004(1-1,; Variance Requirement 7-202.12 Conditions of(-set 7-203.11 'toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria--Chemicals* POPULATIONS HSS 7-204.12 Chemicals for Washing Produce,Criteria* 21. 3-801.t 1(A) Unpasteurized Fre-packaged Juices and Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 7205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. ' 7-206.1.2 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitorine* CONSUMER ADVISORY _ TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foals That are Raw.Undercooked or lfi Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFS rn ro--rmsom 3-401.11A(l)(2) Eggs 155'F 15 Sec. Pathogens.* .. ti--s Immediate Service 145°F1.5sec* 3-302.1.3 Pasteurized Eggs Substitute for Raw Shelf 3-401.11(A)(2) Comminuted Fish.Meats&Game Eg�O 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,h)jttitted Meats-155'F IS 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. Staffed PH,Fs, 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 foodlxxrne illness 3-401.11(C)(-,) Whole-muscle.Intact Beef Steaks interventions and risk factors. Other -- 145'T It 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PRFs-- 1,45'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1.1(&)&(D) PFIFs 165'F 15 sec.* (Items 23-30) 3-403.11(13) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness intervenrions and risk factors listed above, can be 3403.1 i(C) Commercially Processed RTE Food- found in the follon ing seetioms of the Food Code and 105 CMR 14Q'F` 590.000. 3-40311(E) Remaining i.lnsliced Portions of Beef Item I Good Retail Practices ' FC 590.000 Roasts ..23:___ Mana ement and Personnel FC-2 .003 ! 1N Proper Cooling of PHFS 4. -Food and Food Protection _ FC-3 .004 -- 25. Equipment and Utensils FC 4 .005 _. 3-501.14(A) Cooling Cooked - .._.... -..---C --06 0 26. Water,Piumbm and Waste FC 5 .006 70'F Within 2 Hours and From 70'F 27. Ph sical FacilaFacllit FC-6 .007 to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFsMade FromAnnbient 29. S ecialRe uirements_ .009 Temperature Ingredients to 41'FJ45`F 30. Other Within 4 Homs* sse0;o;,anes.71„� 'Denotes crilica iwin in the federal 1999 Few Coxte w I 0 CMIt 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: e w, lr- 51?-o f Date: y- P - o Page: / of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY u w1 -/; , CeP Y( -1 W I-a- t/f G noV,141 o= v Discussion With Person in Charge: Corrective Action Requiredc ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 13 Voluntary Disposal 13 Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to I-aw Cooled to Factors(items 1.22) (Cont.) 410F/45"F Within 4 Hours. 3-501.15 Coo$nv Methods for PHFs PROTECTION FROM CHEMICALS lg PHF Hot and Cold Holding 14 Food or Color Additives 3-501.16(B) Cold MIN Maintained at or below 3-202.12 Addmves" 590.004(F) 41°/450 F* 3-302.14 Protection front Uiat roNed Addroves* 't-501.t6(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. 7-101.11 Identifying Information-Oriinat 3-501.1.6(A) Roasts Held at or above 130°F. Containers* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Sa ovarian-Storage* 3-501-19 Time as a Public Health Control* 590.004(1) Variance Requirement 7-202.1.1 Restriction-Presence and Use* 7-202.12 Codditions of Use'" 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sarnitizers,Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washing Produce,Criteria- 21 3-80'L11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 7-204.14 Drying Agent s.Criteria* .-801.11(B) Use of Pasteurized Eg,s* 7-205.11 Incidental Food Contract. Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides. Criteria* Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Sections*t 3-80'1.11(C) Unopened Food Package Ru-served. � 7-206.13 'hacking Powders,Pest Control and Monitorinn* i CONSUMER ADVISORY TIMErrEMPERATURE CONTROLS 22 3-601,11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods'rhat are Raw. Undercooked or PHFs Not Otherwise Processed to Eli n iette 3-401.1IA(1)(2) Eggs- 155F15 Sec. . Pathogens EivIi a.7ooi E ge-Imnxedtatc.Service 145°.F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* -3-401.11(A)(2) Comminuted Fish,Mears&Game Annuals- 155°F 15 sec. *" 3-401.11(0)(1.)(2) Pork and Beef Roast- 130`F 121 min* SPECIAL REQUIREMENTS 3-401.11.(A)(2) Ratites,Injected Meas-155°F 1.5 590.009(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 Poulin or Ratites-165`F l'S sec. "` above if related to foodborne illness 3-401.11.(C)(3) Whole-muscle,Intact Beet Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail. 3-401.12 Raw Animal Foods Cooked in a practices should be debited under 1129- Mierowave 165°F* 1 Special Requirements. 3-401.11(A)(1)(h) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Crilical and non-critical violations, which do not relate to the Time"` _foodborne illness interventions and risk fo(tors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.1.1(E) Remaining Unsliced Portions of Beef item TGood Retail Practices FC 580.000_ Roasts* 23. Mona ement and Personnell- _ _ FC--2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection _ FC-3 .004 25. Equipment and Utensils FC 4 ;005 3-501.14(A) Cool in,Cooked PHFs from 140°F to _---- ---.-- -.- --. 26. Water,PIu_mbin and Waste FC 5 .006 70°F Within 2 Hours and From 70°F 27. Ph sical Facility FC-6 .007 to 41°F/45°F Within 4 Hours. * 20. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29- Special Requirements _ .009 Temperature Ingredients to 41'F/45'17 30. __-Other--. --- --- ...."_. ----------- -.".-.--._...-..----- Within 411ours'" aa.ax *Denotes critical item in toe lvlesal 1999 Food Code or 105 CMR 590,000. CITY OF SALEM BOARD OF HEALTH Establishment Name: KWi tr' 5110e Date: L/ a v Page: 1 of / Item Code C Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified nPLEASE PRINT CLEARLY a / U 7 J D`P J �"' U XI S /iCJ/ - / ✓. - S .r r K l✓I W 'iC .t� a 14 Lt� 1 ✓P >r � y ( t?0 / ,f ti / �IC.�M Y- _o� ate( v: k If t 'e k` y; a k Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Violations before the next inspection, to observe all conditions as described, and to Emersion p ❑ Re-inspection Scheduled ❑ Emergency Suspension qomply with all mandates-of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency closure your food permit. 0 Voluntary Disposal 0 Other: 3-501.14(C) PIFs Received at Tennperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41°F/45''F Within 4How s. PROTECTION FROM CHEMICALS 3-501.15 Coolim Methods for PHFs 1 A Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-302.12 ProteAddiction 590.004(F) 41°/45°F* 3-302.14 Protection from Unapproved Additives* la Poisonous or Toxic Substances 3-501,16(A) I•fot PHin Fs Maintained at or above 40°F. 7-101..11 Identif}ging Information-Original 3-501.16(A) Roasts Held at or above 130'0. Comarners 7-102,11 Common Name-Working C:ontainers'" 2U Time as a Public Health Control 7-201.11 Se.natation-Storage* 3-501.19 Time as a Public Health Control* 7-202.It Restriction-Presence and Use's 590.004(H) Variance Re uirement 7-202.12 Conditions of Use,, 7-203.1.1 Toxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Swnitizers,Criteria-Chemicals" POPULATIONS(HSP) _ 7-204.12 Chemicals for Washing Pioducc. Criteria* 21 3-801.17(A) Unpasteurized Pre-packaged Juices and 7-204.14 Dr ono A ents,Criteria* Beverages with Warning Labels- 7-205.Ii Incidental Food Contact. Lubricants* 3-801.11(B) Use of Pacteurized tig�s* 7-206.11. Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or Partially Cooked Animal Point and Raw Seed Sprouts Not Served. * 7-20612 Rodent Bait Stations* 3-801.11(C') Uno erred Fond Packa*e Not Re-served. 7-206.13 Tracking Powders,Pest Control and Mtxr todn_* CONSUMER ADVISORY TIMEJEMPERATURE CONTROLS 22 3-603,i 1 Consumer Advisory Posted for Consumption of Animal Foods"Phat are Raw,Undercooked or 76 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 2) Eggs-3-401.1IA 1) Eg>.- .._ ens.*Elrec9v "'20m IA( ( 1.55 F 1.5 Sec. Pathoa E rgs-Inmedr rte Service 145°Fl3sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3=101.11.(A)(2) Cogent stated Fish,Meats&Game Eggs* Animals-155'F 15 sec.`n 3-40 1.1 l(B)(1)(2) Pork and Beef Roast_I30'F 121 min* SPECIAL REQUIREMENTS 3-40L11(A)(2) R trues,Tnjcctc.d Meats i55'F 1.5 590.0O9(A)-(D) Violations of Section 590.009(A)-(D)in Sec, * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFr, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr or Ratite,-165°I'IS sea. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foals Cooked in a practices should be debited under 1#29-- Microwave 165°'F* Special Requirements. 140 1I(A)(1)(h) All Other PHFs -- 145°.fF 15 sec. x 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.t I(A)&(D) PHFs 1650E 15 sec. * (Rents 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standins Critical and non-critical violations, which do not relate to fire Time* - foodborne itiness interventions and risk jactors listed above. can be 3-403.11(C) Commercially Processed RTE Food- found in the fatloorin,g sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Retaining Unsliced Portions(if Beef item Good Retail Practices FC 590.000 Roasts* 23. Mena ement and Personnel....,__ FC-2 .003_ 18 Proper Cooling of PRFs 24. Food and Food Protection FC-3 .004 25 EucL mot and Utensils __FC 4 3-501.14(A) Coohine Cooked PHFs from 140'F to 26. Water,Plumbing and Waste FC-5 _ 008_ 70'F Within 2 Hours and From 70'F 27. Phslcal Facilir FC-6 .007 to 41'F/45°F Witton 4 Hours.* 28. Poisonous or Toxic Materials FC--7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S eciai Re utrements _ .009 Temperature Ingredients to41cF/45°F 30 __Other ---- Within _Within 4 Hours:a rsaoto,,mnra-aux *`Denotes critical item in the.rexler81 1999 hood Code or 105 CMR 590,000. CITY OF SALEM ,(1(k BOARD OF HEALTH Establishment Name: Wl -54a a 0/1 Date: y- .2 - U y Page: ! of --7- Item Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION nate No. Reference R—Red Item Verified -. PLEASE PRINT CLEARLY 141-- r u l l�rr s �e Carr �n� Lid ' 3 6 a o 0-&t 5 L14 [f rt iairt r w !e jn 04 A�l 17 �l A dip C./ /n o S iYP /7 e vn d .i .e jWon if 5 AIrnA t.�al aI - , G4 s1— on✓S Llq dud L , r &- .4v d r i0 ( Q1 i � Ua_ I ( � o h 6UA Lt GI r5) ho-44, co se— b ` d' c1 ¢ VS � Ce x S t�ud 1 /i'I, !/Ci �/�S i. / � C..-•� �v _ Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(0) PHFS Received at'i'emperttures Violations Related to Foodborne Illness Interventions and Risk According to Late Cooled to Factors(Items 1-22) (Cont.) 41'F145"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 3-501.16(B) Cold PHFS Maintained at or below, 3-202.12 ProteAddiction 590.004(F) 410/450 F* 3-302.14 Poison u from Toxic i weed Additives* 3-50I A 6(A) .Hot PHFS Maintained at or above 1.5 Poisonous or Toxic Substances 140'F. * 7-10L11 Identifying Information-Ori;jnai 3-501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11 Common Mine_-Workino Containers 20 Time as a Public Health Control 7-20'1.1 i Separation-Storage* 3-501,19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use" 7-203.1.1 'Toxic Containers-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanidzers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce,Criteria" 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 7-204.14 Dr'in guts,Criteria" 3-801.t I(B) Use of Pasteurized&gas* 7-205.11 Incidental Food Contact.Lubricants* 7-206.11 1 Resl'rieted Use Pesticides.Criteria* 3-80LI I(D) Raw or Partially Cooked Animal Focal and Raw Seed S Hoots Not Served. 7-206.l2 Rodent Bait Stations"` '3-801.11(C) Unopened Foci Package Not Re-served. 7-206.13 'Tcaekaig Powders,Pest Control and Monitoring"` CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 k Proper Cooking Temperatures for Animal Foods'lliat are Raw,Undercooked of PHFS Not Otherwise Processed to Eliminate gL❑S*Errecevei i,roa� 3-401.t1A(1)(2) T;,gs- 155°I' L5 Sec. PllthO Fees-Immediate Service 145"F15see* 3-302.13 Pasteuriz,d Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats Fr,Gaon Eggs" Animals- 155'F 15 sec. 3-401.11.(B)(1)(2) Pork and Beef Roast- 130'F 121 mm* SPECIAL REQUIREMENTS _ 3-401.1 I(A)(2) 'Ratites,Injected Meats-155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering, mobile food, temporary and 3-40'1.11(A)(3) Poultry,Wild Game,Stuffed PHFS, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under die appropriate sections Poultr y or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11.(C)(3) Whole-muscle,Intact Beef Steaks interventions and tisk factors. Other 1450F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foals Cooked in a practices should be debited under//29- Micinwave 165°F* Special Requirements. 3-401-11(A)(1)(b) All Other PHFS-1.45'F15 sea 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES ,403.1](A)&(D) PHFS 165'F 15 sec:°h (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate io the Time" foodborne diness interveruions and rick factors listed above, can be. 3-403.11(C) Commercially Processed RTE Food- found in the f r1lowing sections of the Food Cade and 105 CMR 140°F* 590.000. 3-403.1.1(E) Remaining Unsliced Portions of Flea Item Good Retail Practices FC 580.000 Roasts* 23. Mane ement 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 3-501.1.4(A) Cooling Cooked PHFS from 140°F to - -- - - -,005----- 3-301.14(A) 26., Water,Plumbing and Waste FC-5 .006 70"F Within 21-fours and From 70".F 27. PFC-6 .007 * Materials FC-7 .008 to 41°F145 F Within 4 Hours. 28. Poisonous or Toxic Mat __ _.. 3-501.14(B) Coaling PHFS Made From Ambient 29- Sed I Re uirements ____ _000 Tempel�aune ingredients to 41'F/45'F 30,,...... Other _----------- Within 4 Hours* S 11W ,1,,0e-2,4c *'Denotes critical item in the federal 1999 Food Code or 105 CMR 590 000. f CITY OF SALEM � � BOARD OF HEALTH I Establishment Name: M04e-i Date: Page: 1-1 of Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified -PLEASE PRINT CLEARLY (y tt / El i s LT/P 5C hh' '4t f 0Di is- .r }'?a-�.:r,,:v I s �+2rtir < < ,`.` �tJO �>�Z'd✓ F'fike:<Y R'r'_sus.# t�7•`rrz r;!•^'.!a /,ems m sr7/"rf d/1// Zv S � O v 1•.�"C�S /v /-{� rl r t .-rrr tci `'>:: tsl Y"4 9 '16 J7 }}.jPr'_r-a J'irf -dt !-t3.^ � /' fA:t'.'41f:,/,j iap_f;Ji'`i t f, �`F . •> b`n �•`3wt ij? ,i 1;T G3 ' ts?c%>' 1��n"! / �,> off:^-::,ri . tp<-� ..%(�-,fit' :✓G+9 t=9(,g Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 11 ❑ Voluntary Disposal 0 Other: 3-50L 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/450F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives Iy PHF Hot and Cold Holding 3-501.16(B) Cold P1117s Maintained at or below 3-202.12 Adchttvesk 590.004(F) 41°145°F* 3-302.IA Protection from Una»roved Additives* 3-501.16(.4) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 7-101.11 Identifying Information-Original 140°F. Containers" 3-501.1.6(A) Roasts Held at or above 130°F. 7-102.11 Common Name- Working Containers` 20 Time as a Public Health Control 3-501 7-201.11 Se oration-Storage" .19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use" 5)0.004(H) Variance Ra nirement 7-202.12 Conditions of Use* 7-2(13.7.1 'Posit Container,-ProhiMtions"` REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Santuzers,Criter i t Chemicals' POPULATIONS(HSP) 7-204.12 Chemicals for W asking Produce, r teria"� 21 3-801..1 I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drvm Ai*ents,C.ntetia* Beverages with W ai nine labels* 3-801..11(B) I1 se of Pasteurized pegs* 7-205.11 Incidental Foul Contact. ,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Foal and 7-206.1 I Restricted Use Pesticides.Criteria* Raw Seed Sprouts Not Served. * 7-206.]2 Rodent Bait Stations* 3-80't.I I(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitorin<r* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3603.11 Consumer Advisory Posted for Consumption of Ib Proper Cooking Temperatures for Arrant Foods'lliat are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.i1A(1)(2) Eggs- 1.551'lSSec. Pathogens eno<ev veoo E es-Znmcdtatc Service 145°P15sec* 3-302.13 .Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) C.otruninuted Fish,Meats&Came E gs* Aninuals- 155'F 15 sec.,r 3 401.11(13)(1)(2) Pork and Beef Roast - 130'F 121 twin* SPECIAL REQUIREMENTS 3-401.11(A)(2) 'Ratites,Injected Meats-155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(10)in sec. * catering, mobile food,temporary and. 3-401..11(A)(3) Poultry,Wild Game, Stuffed PHFs, residentialkitchen 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.II(C)(3) Whole-muscle,Intact Beef Steaks interventions and tisk factors. Other 145'F* 590.009 violations relating to good retail. 3-401.12 Raw Animal Foods Cooked in a practices should be debited under 7129- Microwave 165'F* Special Requirements. 3-401,11(A)(1)(b) Aft Other PFIFs- 145'F'15 sec. " 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(.A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, ivlrich do not relate to the Time*` foodborne illness interventions and risk factors listed above, can be 3-403.11(C) COmmCoNAlly Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140'F'+ 590.000. Rated - 3-103.11(6) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roas,ts1, 23. Marractornent and Personnel __._ FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection _ _FC-3 .004 and Utensils - . 3-501.14{f\) Cooling,Cooked PHFs from 1401F to -25. Etc uipment FC 4 005 26. Water.Plumbing and Waste FC-5 ,006___ 70'F Within 2 Hours and From 70'P 27. Physical Facility _ FC_-6 .007 to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic MateriaIs_ FC--7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial R uirements _ .009 Temperature Ingredients to 4l°F/45'F30 Other Within 4 flours'I 'r waez:w° 1 Denotes critical item in the icier t 1999 Food Code or 105 CMR 5911-0x10. - Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4t" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name �y� Date E of O erotion s T, a of Inspection u// S IJ /),/1 /(PTS l V,Q/0 Food Service ® Routine Address Risk ❑ Retail ❑ Re-inspection (� 172-, FP Cl�7 e- Level ❑ Residential Kitchen Previous Inspe tion Telephone y�.� 9,�.5� E] Mobile Date:a-/�� OwnerElTemporary EllPre-operation HACCP Y/N XIP 7� yr[ ❑ Caterer ❑ Suspect Illness Person'tn Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint 7 e In: ❑ HACCP Inspector n V Al "6m / Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. .,FOOD PROTECTION MANAGEMENT, ;._ ',`.i """" ❑ 12. Prevention of Contamination from Hands ElL� 1. PIC Assigned/Knowledgeable/Duties '6 Handwash Facilities EMPLOYEEHEALTH 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 m __ ❑ 4. Food and Water from Approved Source $ MPERATURE CONTROLS(Potentially Hazardous Foods) " El5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling I PROJECTION 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) 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 �G 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 deterr(lined by the Board today, the items checked indicate violations of 105 CMR of Health._N 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of 2!�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: 5:5901nspecfFomM'44 tloc `. s ctor's ' nat e: Print: 2'7� 7 �, - PIC's Signature: Print: Page of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION �- FOOD PROTECTION MANAGEMENT S Cross-contamination l a 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from 2.003(B) Demonstration of Kit fledge"` Cooked and RTF Fuvds* 3.11. Person in charge-duties Contamination from Raw ingredients 3-302.1.1(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 3-302.1 I(A) Food Protection* applicants* 3-302.15 Washing Fruits and yqtibles 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) Re porting b 'Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food" 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) I 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* 4-501.1.11. Mannas Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem reratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization in eratures* 3-202 14 Eg>s and Milk PrllvnetS,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From potable Drinking Water, concentration and hardness.'b 5-1.01.11 Drinkin Water from an Approved System* 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- Contact Surfaces and Utensils'r Shellfish and Fish Froman Approved Source 4-70111 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surlaces of Equipment* Shellfish* 4-70'3.11 Methods of Sanitization -Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical" Sources* 1D Proper,Adequate Handwashing - Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms` Re u1stoty Authorit 3-202.18 Shellstock.Identification Present* 2-301..1.2 Clewutin Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash" 3-201.17 Game Animals* 1.1 Good Hygienic Practices Receiving/Condition 2-401.11 Eating.Drin� Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes.Nose and 3-202.1.5 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301,12 Preventing Contamination When Tasting'` 6 Tags/Records:Shellstock I12 Prevention of Contamination from Hands 3-202,18 Shellstock Identification* 590.004(E) Preventing Contmnination from 3-203.12 Shellstock Identification MaintainedKlEin lovees* 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 Ca acities* 590.0(14(1} Labeling of Ingredients' 5-20411 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance /HACCP Plans Supphsd with Soap and Nand Drying 3-502.11 S ecializod Processing Methods* Devices 3-502.72 Reduced oxygen packaging, criteria* 6-301.11 Handwashin Cleanser,Availabila R-103.12 Confounauce with Approved Procedures'" 6-301.t2 Hand Dryin,Provision *Denotes critical item in the federal 1999 RNA Cate or 105 CNIR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: 7 b fl 'rfLi Date: Page: of .2 , Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item - Verified ' � PLEASE PRINT CLEARLY - <1 nom ' /3 — v ZA? .v 2,2ry 4 /.C/ tG / ✓ o (17U-7L 0 A4WAlad /I 1691-If Idlez P Om / T / a I - j T/YPY" rm� ' ay �✓/ ,mss � fin, _ „/� � .� / / • // W �tnt/ e 670/1/.5e01 o 1,11dn:t Alle.L AaGjAk�r,7_ -rn '—_, V4P c SA ti1'r17-2"/" tI Discussion With Person in Charge: / Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P ❑ Re-inspection Scheduled ❑ Emergency Suspension .comply with all mandates of the Mass/Federal Food Code. I understand that .noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. / /�� ' ❑ Voluntary Disposal ❑ Other: 3-501.1.4(0) PHFs Received at'femperatunn Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 4 'Fl45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives t9 PHF Hot and Cold Holding 3-202.12 o1chtive.0 3-501.16(6 H ) Cold PI Maintained at or below 590.004(1`) 41°/45°F* 3-302.14 Protection from 1 anal C1 aved Additives* 3-501.16(A) Hot PHFs Maintained at w'above IS Poisonous or Toxic Substances 140°F.* 7-101.11 ldlrtainelnfonnatian-C)riginal Containersrs* ;-50t.16(A) Roasts Held at or above 130'F. 20 Time as a Public Health Control 7-102.11 C parari Name St -Working Container,'"- 3.501 19 Time as a Public Health Control" 7-201.1.1 Suarauon-Stojatze" 7-202.11 Restriction-Presence and Use" 590.004(H) VarianceRecuiwment 7-202.12 Conditions of USe* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.C:riteria-Chemicals* POPULATIONS(HSP 7-204.12 Chetnicak for Washing Produce.Criteria* 27. 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drvirw Agents. Criteria* Beverages with W nning Ldabek* 7-205.11 Incid nod Food Contact,Lubricants' 3-801.I1.(B) Use otPastennzedE�s* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.'1I(l)) Raw or Partially Cooked Animal Food and BRaw Seed Sprouts Not Served ` 7-206.12 Rodent alt Stations* 3-801.11(C) Unopened Fond Packa re Not Re-served. 7-2(16.13 ?racking Powders,Pest Control and Monitoring* CONSUMER ADVISORY _ TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw, Undercooked or PRFs Not Otherwise Processed to Eliminate 3-40LI1A{1}(2) Eggs 155'F 15 Sec. Patlic ens r' °"'a,rzooi 1 �s-lmmedi ate Servicc, 145°F15secr 3-302.13 Pasteurized Fags Substitute for Raw Shell 3-40i.11(A)(2) Comminute dFish.Meats&Game g.,>s* Animals- 155'F 15 sec. 3-40L11(B)(1)(2) Pork and Beef Roast- 1.30`F'121min'" SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injcuarl R4caG- 155°F 15 590f009(A)-(D) Violations of Section 590.009(A)-(D)in ec. * 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 Poulny or Ratites-16VF 15 sec. * above if related to foodborne illness 3-401 11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145"F* 590.009 violations relating to good retail 3-40112 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3401.11(A)(1)(b') All Other PHFs-- 1,45'F 15 sec- I4 Reheating far Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3.403.L l(A)8z(D) P11Fs 165'1` 15 sec. * (Items 23-30) 3-403.11(6) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness Inlerventions and riskfactors listed above, can be 3403.11(C) Conunerciall_v processed RTE Food- ,)imnd in the following sections ofthe Food Code and 105 C.MR 14WF* 590.000. 3-403.11(6) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts* _23....... Management and Personnel FC-2 .003 18 Proper Cooling of PHFs -2-4.--- Food and Food Protection FC 3 .004 -- rs 25 E w ment and Utensils FC 4 .005 3-501.14(A) Cooling Cooked PHFs from 140'r to -- --- ' -.006- --""' +, � 26. Water.Plumbing and Waste IFC 5 .006 0'F Within 2 Hours and Front 70`1` 27. Ph stoat Facilii FC 6 A07 1 to 41 W45'F Within 4 Hours. * 28. Poisonous or Tox(c Materials FC-7 .poll 1 3-501.14(6) Cooling PHFs Made From Ambient ?$ Special lwi ulrements _ 009 Temperature fngrodients to 41°F145°F 30. Other Within 4 Flours` SY0`"°""""-2""' 'Denote,critical item in the federal 1999 Food Code or 10i CMR 594000. CITY OF SALEM TBOARD OF HEALTH Establishment Name: u� r K S�o� /�/�'f s /��i Date: /a— Q-n _ Page: I of i Item Code C-critical Item DESCRIPTIONOF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY /vow _S s s v� by / s S / >'� is 0-n lae / I t i . i Discussion W tffPersdn`in=Cha'rge:' "0— j -1WI K Correc#iSe Action Required: ❑ No ❑ Yes ❑ Voluntary Compliance ❑ Employee Restriction/ have read "I'sei 3oolrt, have hadUpejoppogyr ity,.to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of oEmbargo ❑ Emergency Closure ❑ your food permit. /� /� ��C C� - Voluntary Disposal ❑ Other: I er 3-501.14(C)� PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(Items 1.22) (Cont.) 41°F/45`F Within 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Cooling=Methods for PHFs 19 PHF Hot and Cold Holding 1,4 v Food Addifiv Color Additives 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Protection 590004(F) 41`/45° F" 3-3(Y2.14 Protection fromUna> roved Additives" 15 Poisonous or Toxic Substances 3-501.L6(p) Hot PHFs Maintained at or above 140'F. 7-101..11 IdeConaiying Information-Orlginai 3-501.16(A) Roasts Held at or above 130'F. Contuainer,' 7-102.11 C cannon Name-Working Containers* 20 1 Time as a Public Health Control 7-201.1 1 Se aration-Storage,., 3-501.19 Time as a Public Health Control* 004(H) Variance Re 7-202.11 Restriction-Presence and Use* 590. Requirement 7-202.12 Conditions of Use' 7-203.11 Toxic Containers-Prohibitions- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2tk1.1t Sanipzers,Criterra-ChemPOPULATIONS HSP 21 --- 7-204.1.2 Chemicals for washing Produce,Criteria* 21 3-80't.l l(A) UnpasteurizedPre-packagedJuices and 7-204.14 Diving Arents,Criteria' Beverages with Warning labels^ 7-205.11 Incidental Food Contact.Lubricants* 3-801.11(8) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides, Criteria* 3-801.1 1(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. * 7-206,12 Rodent Bak Stations- 3-801,11(C) Unopened Fri Package Not Re-served. 7.206.13 Tracking Powders,Pest Control and Monitorin,* CONSUMER ADVISORY _ TIMEJTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Fonds'I'hat are Raw, Undercooked or PHFs Not Otherwise Processed to Ehininate 3-40'1.11A(1)(2) Eggs- 155'F t5 Sec. Pathogen~ 4 F"""""' E es-lnunedtate Service 145°.F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game Eggs* Animals-155°F 15 sec.'" 3-401.11(11)(1)(2) Pork and Beef Roast-130".F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155'F 1.5 590.009(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 tinder the appropriate sections Poultry or Ratites-165'F 15 sec. * alcove if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F a. 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165''F* Special Requirements. 3-401.11(A)(If la) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1](A)&(1)) PHF,165'F 15 sec. x (Items 23-30) 3.403.11(B) Microwave-165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Times .foodborne,illness unerventions and riskfoctors 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 AAF* 590.000. 3-403.1.1(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 580.000 Roastsx_ 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 3-50114(A) Cooling Cooked PHFs from 140'F to 26. Water,_Plumbin and Waste FC-S 006 _ 70°F Within 2 Hours and From 70'F 27. Physical Facilites FC-6 .007 to 4f'F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ectal R uirements .009 Temperature Ingredients to 41'F/45'F 30. _ Other Within 4 Hours* ssmurnutr,aao� -"Denotes entical item in the i'edeud 1999 Food Code or 105 CNIR 592000. COURT DOCKET NO. CITATION NO. _ . Q CITY OF SALEM PD 11} VIOLATION NOTICE NAME(LAST,FIRST,INITIAL) /WW1 K �{©P rMtLKtT r { gLd STREETADDRESS CITYrrOWN STATE ZIP /d -x61cCRJor+A.6 -344sri ^ e-/9'? 3 LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) STREETADDRESS CITY/TOWN STATE ZIP / /7SA4vGY M,000' ol?70 REGISTRATION NO. STATE EXP.DATE MAKE/TYPE YEAR COLOR DATE OF VIOLATION TIMEA/ DATE CITATION WRITTEN PEUSOrvFL wLWAM �I INJW 6 l' o�I I�UN PM �L"�© ❑YES '2- ❑NO LOCATION OF VIOLATION ENFORCING DEPT. /a 8 •s./4 ;- OFFENSE CHAP. SECT. FINES AR-Sf''&- VraL+FilrJ9V Bad' C SArrr f+ �e OFFICERS mfr Q I.D.NO. TOTALFIN Is @ n �' Csl'o'0�R/Q`JY� DUE C/:5r ae OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ,/-' ©+IN HAND X � �-_ ❑ BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE, MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL ---- t c uan R l pie `l I _--- Door c a- R TCX o CITY OF SALEM, MASSACHUSETTS 3�6 BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 .� TEL. 978-741-1800 ry FAX 978-745-0343 I p JOANNE SCOTT, MPH, RS, CHO o r STANLEY J. USOVICZ, JR. �? �J MAYOR HEALTH AGENT April 12,2004 Kwik Shop Market&Deli 10 Jefferson Avenue Salem,MA 01970 Dear Owner, On March 29,2004 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old male purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Kwik Shop Market&Deli is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes,chewing tobacco, snuff,or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of TWO hundred dollars($200)for the SECOND offense. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$200.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,41h floor,within ten days of receipt of this notice. Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders,and other documentary information in the possession of this Board,and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, oanne Scott Health Agent JS/bas Cc: North Shore Tobacco Control Program Christina Harrington,Board of Health Chairman N2 2177 s� City of Salem - Board of Health Mw m`O Violation Notice - Tobacco Sale to Minors This notice is to inform you that during a tobacco sales compliance check,your establishment violated the Salem Board of Health regulation#24 prohibiting the sale of tobacco products to persons under 18 years of age. i 5h t&P Name of establishment i [) Address 31a51� y: uapM /T/n Date of sale Time of sale Minor's age/gender Minor's ID# I'y1 c�4�1 C5c/v-, i v\,S. Adult supervisors Narrative report of incident and description of seller by adult supervisor who will testify at the Salem Board of Health meeting including a description of the seller: I affirm, under the pains and penalties of perjury, that the above report is true to the best of my knowledge and belief. C om Adult supervisor(Signature) Adult supervisor (Print name) VENDOR STATEMENT: I acknowledge I received this Violation Notice on 19 at AM/PM and I am being given a carbon copy of this notice. I also acknowledge that I have been told that a letter regarding Board of Health follow-up to this violation will be mailed to me at the above address. Owner/Manager/Clerk(Signature) Y L_� i ; Owner/Manager/Clerk(Print name) If vendor refuses this Notice or if Adult Supervisor feels unsafe in delivering it,an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information, contact the North Shore Tobacco Control Program at 978/741-5646. Board of Health-white/NSTCP-yellow/Establishment-pink _ EXPLANATION AMOUNT 53.179/113 QUICK SHOP & DEL( - 10 JEFFERSON AVENUE SALEM,MA 01470 ""-' 4516 (978)740-9955 /Q CHECK PAY DOLLARS AMOUNT DATE TO I HE ORDER OF DESCRIPTION I CHECK NO. 4 7 Eastern Bank L211 u°0045 i6„0 4011300981: 60 0044 2 18,10 .... .�CRTllC(ATUgr.S ClgF ":..TI ON " 5IC: �J I FT CITY OF SALEM, MASSACHUSETTS - '� - BOARD OF HEALTH , • i 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Kwik Shop Market and Deli Address of Establishment: 10 Jefferson Avenue Owner's Name: Elie J. Zeaiter Restrictions: Application Date: 7/15/2004 Permit for Food Establishment 316-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 66-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT t a CITY OF SALEM, MASSACHUSETTS 4y� BOARD OF HEALTH u a 120 WASHINGTON STREET: 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT �TO OPERATE A FOOD ESTABLISHMENT q NAME OF ESTABLISHMENT (■ l' 'I //��J S N 'o P&.�P Q�TEL# (?21 4 3 1 /? 7 ADDRESS OF ESTABLISHMENT /0 eXft"&, H t>� SatPn A o /9 7 0 MAILING ADDRESS (if different) Se� OWNER'S NAME FI j _ ' R TEL# 3 2 /5-7/ ADDRESS � r1/ Sf 3 CITY----f& STATE 41A ZIP o CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON C G/ ;e,7 ZC4;alq HOME TEL# M/ 6-32 /5-?i HOURS OF OPERATION: Mon.0�o. Tue. Wed. -9Thu. 7/o Fri.7-1. Sat.7,/e Sun. 2153— '3 9oa � -0 FEE check TYPE OF ESTABLISHM fM1 b%- Y RETAIL STORE NO less than 1000sq.ft. =$50 1000-10,000sq.ft. more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT,SERVE YY 50 ALL NON-PROFIT(such as church kitchens)ACCO VENDOR 66 u YES NO NO $i5p Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knoIedge nd be)ief, have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number --------------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date �`Y'4 a – to -V—>>" Vkf/60, mmnosemlpl .COURTDOCKET NO - CITATION NO. CITY OF SALEM ° < VIOLATION NOTICE PD 1115 f m NAME(LAST,FIRST,INITIAL) /ICw1 rR'f j 40 to rHAn>4r r f �u STREETADDRESS CITY/1OWN STATE ZIP D /d ��FItCeToN,6E� SA'&M e/97 LICENSE N XP.DATE DATE OF BIRTH _C - _ ao fn m(l QOWNERS NA o r y F a D 00 STREETADDRESS CITY/TOWN STATE ZIP m /$jam}o Ng 1 L r �7co RO ('1&hl�oP a�fi GIY7o O m c Z REGISTRATION NO. STATE EXP.DATE MAKE/TVPE YEAR EN;A O C D _ - D o m IT1 y m r DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSO // IWUflV O C L/� O{QJ❑PM IZ-�..' ]YEOYE f. LOCATION OF VIOLATION EN nORCING DEPT T �' � to ✓E�r'tS 3alf �rlr� /-j •4,/� w O OFFENSE CHAP. SECT. FINES -A m 1p G 5 Arr(f�� r'o � O OFFICER/ I.D.NO. TOTALFINE @ r7 -�• lSr°:pI`�ID/1`JN DUE `V?�SOd O OFFICER CERTIFIES COPY GIVEN TO VIOLATOR O m l r N m !�." '" I�I'l.� HAND X r a v ❑ BV MAIL ry = DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY - o ORDER OR BY CHECK MADE PAYABLE TO: z CITY CLERK CITY HALL 93 WASHINGTON STREET _ - SALEM,MA 01970 TEL.(508)745-9595 X 251 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE _ PAYMENT IN THE AMOUNT OF n 0 $ CASEk x z z 0 O � SIGNATURE cn SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL NVS > P 1 � 0 , 0.) w C O I- �O a O w Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4t' Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tvpe of Operations) Tvpe of Inspection Rwme Jw/t< M*t� as" ❑ Food Service ❑ Routine Address /Q Tf6FASoN Risk IjRetail [ Lrtinspection Telephone Level El Residential Kitchen Previous Inspection 7No - 99ff t44 ❑ Mobile Date: Owner HACCP WN [I Temporary ElPre-operation ,6Ar'J',oMM ZMAIr-&g.- ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) 'Z& Time ❑ Bed& Breakfast ❑ General Complaint CL C4A-4 In: El HACCP Inspector n &r4113,,,1K Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) [:1 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT " El12. Prevention Of Contamination from Hands F] 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ❑ 13. 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 ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE _ ❑ 4. Food and Water from Approved Source TIMErrEMPERATURE 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 [:118. Cooling PROTECTION FROM CONTAMINATION [119. 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) [110. 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 O 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.N- 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(5so.00s) 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)(510.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:590Ms UFmm6-I4.tloc Inspector's Signator Print: A. PIC's Signature: O Print: �� C 7EAl '( Page oft Pages 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 ofResponsibdity� 3-302.II(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTL Foods* 2-103.11 Person in charge-duties Contamination from Raw ingredients 3-302.11(A)12) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other" 2 590M03(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1 i(A) Food Protection" applicants* 3-302.15 Washing Fruit's and Vegetables 590003(F) Responsibility Of'A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant'ro Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Re ortine by Person in Charge* 3-306.14(A)('B) Returned Food and Reservice of Fond* 3 590.003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701,11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fes* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Fond in a Hermetically Seated Container* Sanitization Tem teratures* 3-201,13 Fluid Milkand Milk Products* 4-501.172 Mechanical Warewashing-LlotWater 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.t4 Eggs and Milk Products.Pasteurizedv° 4-501.114 Chemical Samtis2tion-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-1.01.1.1 Drinking Water from an A roved S 'stem` 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean, 590.006(A) Bottled Drinking Waters 4-602.11 Cleaning Frequency of Egniptnent Food- Shellfish Water Meets Standards in 310 CMR 22.0"` Contact Surfaces and Utensils* 5hetpish and Fish From an Approved Source 4-702.11 Frequency of Sanirization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equi memt Shellfish* 4-70311 Methotis of Sanitization-Hot Water anal 3-201.15 Molluscan Shellfish from NSSP Listed ChemicaP Sources' 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Anes' 3-20218 Shellstock Identification Present`" 2-36112 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* I1 Good Hygienic-Practices $ Receiving/Condition 2-401.11 Eating,Drinking or Usin Tobacco"` 3-202.11 PHFs Received at Pro ler Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-202.15 Package Lite cit yr Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.t2 Preventing Contamination When'I'as0ng" 6 TagsiRecords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identitication* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Emplo cgs* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible t 3-402.12 Records.Creation and Retention* 5-20111 Numbers an Ca acides* 590.0040) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accesstbility.Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.1 f _ S eciaiized Processing Methods* - Devices 3-502.12 Reduced ox der packa ging, criteria" 1 6-301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.12 Hund Dryin;Provision *Denotes eriival item in the tedernl 1999 Fwd Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: JW0P ^r— V— lJFLJ Date: 4C 4411W Page: 2i of ez _ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY lJ (.+n O `a CA VdS_ Q f 9 #j 124d iv{r/d 6 i Discussion With Person in Charge: Corrective Action Required: ❑ No : ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or uspension/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 I.aw Cooled to Factors(items 1.22) (Cont.) 4'V. F/45°F Within 4 Howl, PROTECTION FROM CHEMICALS 3-501_15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(13) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 4't°/45°F* 3-30114 Protusion from Unapproved Additives'" 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs* Maintained at or above 140 I. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above '130°F. Containers' 20 Time as a Public Health Control 7-102.11 CommonNamkin^C:ontainers" e-Wor 3-501.1.9 Time as Requic Health Control" 7-201.11 Searation-Slora£e* 7-'202.11 Restriction-Presence and Use" 590.004(H) Variance Rec uirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 'toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitners.Criteria Chenncals 7-204.13 Chenecals for Washing Produce Criteria* 27. 3-801.11(A) Unpasteurized Pre-packaged juices and 7-204.14 DryingAaen[s,Cnteria'% Beverages with Warninn Labels* 3-801.11(B) Use of Pasteurized E-as* 7-205.11 incidental Food Contact,Lubricants* 3-807.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria" Raw Seed Sprouts Not Served.. * 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Packa>e Nix Re-served. 7-206.13 Tracking;Powders, Pest Control and Monitorin " CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw. Undercooked or PHFs Not Otherwise Processed to Eliminate '� E/'eceba r r1Uai 3-401.11A(1)(2) Eer;+- 155°F 15 Sec. Pathogens. 1.c<s-Immediate Service 145'F15sec•x 3-302.13 Pasteurized Eggs Substitute for Raw Shell Egge 3-401.11(A)(2) Comminuted Fish. Meats&Game Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3-40 1.11 Pork and Beet Roast- 130'F 121 1030* ---- 3-401.11(A)(2) R hires,Injected Meats- 155°F IS 590-009(A)-(D) Violations of mobile on 590.0orary and in sec. * catering, mobile f md, temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHK residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165"P15 sec. * above if related to foodborne illness 3-401.1l(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 1659,* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145°F'15 sec. 19 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403,11(A)&(U) P1IFs 165'F 15 sec. * (Items 23-30) 3-403.11(13) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness inlernentions and risk factors listed above, can be 3-403.1.1(C) Commercial ly Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 5.90.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts" 23. Management and Personnel FC-2 .003 _24.___ Food and Food Protection FC-3 .004 1H p 9 25. E ui meat and Utensils _�,FC 4 005 Proper Cooling of PHFs -r- --{ 3-50114(A) Cool mg Cooked PHFs Gotn 140"F to 26. Water,Plumbing and Waste FC 5 70`F Within 2 Hours and Front 70`F 27. Physical Facility FC-6 .007 ' . to 41.°F145°P Within 4 Hours. 2 8. Poisonous or Toxic Materials FC-7 .008 * 3-501.14(B) H Ingredients Frm Cooling From Ambient 30. Otheral Requirements...... Tempera =I=- 009 Within 4 Hours* s:+poro�„wa,zm,� *Uenores critical item in the federal 1999 Food Code or 165 CMR 590.000. I Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Dat Tvpe of ODeration(s) T e.of Ins ection i na�,P eft!!$ r ID6Gf 1 ?+1 e ❑ Food Service p outiR e Address 16 J&FP&49#1 AX Risk EA-lTetail ❑ Re-inspection Telephone Leve,l�{� El Residential Kitchen Previous Inspection r7a� ,9f� ' 1ElMobile Date: El Temporary ElPre-operationOwner 6 MAM &*� HACCP Y/N ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time EJ Bed&Breakfast El General Complaint �� Z� In: ❑ HACCP InspectoradVa&NAO." o ff eff f Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT y _ ,; ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13. _ Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC [114. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE " -- El 15.Toxic Chemicals - TIME/rEMPERATURE CONTROLS Potential) Hazardous Foods ❑ 4. Food and Water from Approved Source (Potentially p, ) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling 7CTIONFROM CONTAMINATION - El 19. Hot and Cold Holding 7Separation/Segregation/Protection El20.Time As a Public Health Control 9 Foo;Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) (q ❑21. Food and Food Preparation for HSP ❑ 10,, Propd}Adequate Handwashing ❑ 113Good 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 Health. 590.000/federal Food Code. This report, when signed below C` by a Board of Health member or its agent constitutes an i 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 4. Food and Food Protection (FC-3)(590.0044)) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 2�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 FR 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 / lrder. 30. Other DATE OF RE-INSPECTION: 6 S 5901nsp Fc m 14,do Prim:IMP '41 PIC'sSignature: ,V �- Print: ' Pagej oil Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Crass-contamination 1 590.003(A)_I As�l-nment of Responsibility" 3-3011I(A)(I) Raw Animal Foods Separated from 590.003(B) DemonshationofKnowledge ' Cooked and RTE Foods* 2-103 I'1Persim in char��e-duties I Contamination from Raw Ingredients 3-30111(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1 1(A) I Food Protection- 3 >ficants* 3-302.1.5 Washing Fruitsand Ve etables 590.003(F) Responsibility Of A Foxd Employee Or An 3-304.11 Food Contact with 13quipment 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* L11590 003(1)) Exclusions and Restrictions* DlsposNonofAdulterated orContaminated 590.003(17) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ Few* 4 Food and Water From Regulated Sources `) Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.11 I. Manual Warcwsshing-Hot Water 3-201.12 Foal in a Hermetically Seated Container* Sanitir,'ctian'Fentt)eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewasting-HotWater 3-202.13 Shell Eggs* Samtizatnora Tem erahres* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,PH, concentration and hardness.' 3-202.16 fee Made From Potable Drinkm Water' 5-1.01.11 - Drinkin>Water&:oin an Approved System* 4-60I_71(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 4 02.1 L Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Sureand Utensils" Shellfish and Fish Froman Approved Source 4-702.11 Frequency of Sanftization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui menu Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11. Clean Condition-Hands and Arms" Pentratow Authodt 3-202.18 Sheilstock.Identification Presen `1 2-301.12 Cleaans,Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1.7 Game Animals* i.t Good Hygienic Practices g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 1-202.11, PHPs Received at Proper Temperatures* 2-001.12 Discharges From the Eyes,Nose and 3-202.15 Packaae'Integrity,- Mouth* 3-101.11 Fund 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* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em lovees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parusfte Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590,004(7) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibnlit O eration and Maintenance lHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3.5{}2,13 Reduced as men nacka rims.criteria* 0301.11 Hanotwashiu CSeanser,AvaifabiliC 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Drying Provision '1)enoies critical Item in the federal 099 Faxl Code or 105 CMR 590,000. CITY OF SALEM BOARD OF HEALTH Establishment Name: /ewiK rMblo *#*4 J46rr f 6d;i. Date: irh-, lay Page: Z of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION _ Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY .. ZN .0 d � rf 3' ,✓� Ps 13 Wuc P q -1L e 2 lAxp !d s ~tj / CY - /ftl cit ! - ("ft f4+U,4f- GNP webl ti r A4.4/to L-& 2 our x_ Ali f1t- 044 VTT- N Sckr M e!✓ 4 !9 6Gc N wtrr t L Si- d- *AS AW "P 4. GA-n s ,�n�� MS r►r ss' he., RA^v5-_ y r"dI&K, Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. / ; �� ,7 i ❑ 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(Hems 1.22) (Cont) 41°745°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Calor Additives 19 PHF Hot and Cold Holding 3-501.16(B) .Cold PHRs Maintained at or below 3-202.12 Addtnvt1* 590.004(F) 11°!45° Fik 3-302.14 Protection fromUnapptoved Additives* 't-501.t6(A) blot PHFs itiiarntained at or above 15 Poisonous or Toxic Substances - 140'F. 7-101..11 Containers* information-Orta riot 3-501.16(A) Roasts Held at or above 130'F. Containers" 7-1.02.1 t Common Name-Work ColContainers* Time as a Public Health Control 7-202.17 Seara6on-Stvra�__ 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 of Use" 7-203.11 Toxic Containers-ProbibitionssREQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 SanitiZets.Criteria-Chemicals' POPULATIONS(NSP) - 7-2(11.12 Chemicals for Washllt 7 Produce,Criteria* 21 3-801.1 I(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels. 7-204.14Dr Ina. guts. Criteria* 3-801,11(B) Use of Faster 7-205.11 incidental Food Contact.Lubricants* 7-206.1 1. Restricted Use Pesticides.Criteria* 3-801.11(0) Raw or Pattiaity Cooked Animal Fuad and Raw Seed Sprouts Not Served. 7-206.12 Rpck,nPBait Sunnixns� 3-801.11(C) UnoenectFoodPucka=eNotRc-served. 7-206.13 Tracking powders,Pest Control and ' CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate Enecn�e vvaom 3-401.1.IA(1)(2) F<bs 155"F 15 Sec. Pathe ens.* L gs Imnedr rte Servie.c 145°F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11.(A)(2) Comminuted Fish,Meats th Game Eggs* Animals- 155'F 15 sea 3-401.11,(B)(1)(2) - Pork andBee_fRoast- 130°F121min* SPECIAL REQUIREMENTS _ 3-401.11(X)(2) Ratites,Injected Meats- 155°F '15 590.(09(X){D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-40 1.11(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited raider the appropriate sections Poultry or Ratites-165'F 15 see. alcove if related to foodborne fthiess 3-401.1 1(C)(3) Whole-muscae, tract Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-- Microwave 165°F* Special Requirements. - 3-401.11(A)(1)(b) All Other PHFs-1.45'F 15 sec. t7 1 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec.e. (Items 23-30) 3403.1 t(B) Microwave- 185'F 2 Minute Standing Critical and nomcritisat violations, which do riot relate m the Time* ,foodborne illness inter venlions and risk fnc'tars listed above, can be 3-403.11(C) Commercially Processed RTE Food- ,found in the following sections cif the Food Code and!05 CMR '140°F* 590.000. 3-403.11(7,) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000-_) Roasts . * 23. Mona ement and Personnel __ _ FC-2 .003 Ig Proper Cooling of PHFs 24. Food and Food Protection __. FC-3 .004 L-L25 _____Equipment and Utensils _ FC-4 .005 3-501.14(A) - Cooling Cooked PRFs from 140'F to 26. Water,Plumbin and Waste FC-5 .006 70'F Within 2 1fours and From 70'F 27. Ph sical Facili ____ FC-6 .007 to 41°Fi45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501 14(B) Cooling Pf Fs Made From Ambient 29. SlDectal Re uirements _ _ .009 Temperature Ingredients to 4117145'F 80 Other Within 4llours" sswo-.,:n.at rm„ "Denoh9 critical item,ii the federal 1994 Food Code or 105 C'MR 590-000. CITY OF SALEM BOARD OF HEALTH Establishment Name: )k"p- syenp ^*#4w r n&-u Date: (#A:! tr Page: of 3 Item Code C-Critical item DESCRIPTION OF VIOLATION i PLAN OF CORRECTION Date No. Reference R-Red Item ` Verified PLEASE PRINT CLEARLY 2S C W P F1fXAT&-,` 14AP Cc—"!NV 0l fMILr '+ry ` P M c) P G Ytil�e�60- C1r1SAw V► 9 Im Ae C "Y- R e mcnP - c r/c r i-tt AtIO lu M 20 &X-ir- /hoot- VIC Tuir&EIRIFis jill AITA5.001M. f440110C tALW P. pls t.4A t-A�049 F 117 12 7A 4= a vlr „1- Discussion With Person in Charge: , _ Corrective Action Required: ❑ No Ll Yes�LCJ: I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled o , Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑, Other: F3-501.16(B) (0) 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 Coolin=. Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding Cold PI1FsMaintained at or tYelow 320212 AdcHtives* F) 41V45°F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) H(rt PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F 7-101.11 Identifying Information-Original 3-501.16(A) Roasts IIeld at or above 730"F. Containers" 7-102.11 Common Name-Working Containers" 20 Time as a Public Health Control 7-201.11 Se enation-3forage* 3-501.19 Time as a Public Health Contra..* 7-202.'11 1 Restriction-Pres`ence and Use' 590.004(1-1) Variance Requirement 7-202.12 Conditions of Use. 7-203.11 Toxic Containers-Proldhitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals` POPULATIONS(HSP) _ 7-204.12 Chemicals for Washing Produce,Criteria"' 21 3-801.1](A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 7-204.14 Dn in"A encs,Criteria'" 3-801.11(B) Use of Pasteurized 7-205.11 Incidental Food Contact, Lubricants* 3.801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides.Criteria* Raw Seed Sprouts Not Served. " �-2606 20�3 � t Bait'Stations* ' ued F«)d Packa ge Not Re-served. ng Powders,Pest Control and oring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods'rhat are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate Pathog ens*Enncnv r vcoa� 3-401.1.IA(i)(2) Eggs- 155 F 15 Sec. Ti ,-Inunedi tc Service 14501715sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2i Comminute{Fish,Mears&Game Eggs* Animals- 155°F 15 sec. * 3-401.11(11)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meat's-155,`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sea * catering, mobile taxi, temporary and 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Contanoruz Fish,Meat, debited under the appropriate sections Poultr=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 Crooked in a practices should be debited under#29- Microwave 165`11* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs -- 145"F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(I-)) PHFs 165°F 15 sec. * (lteirns 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do nor relate to the Time* ,foodborne illness intervetdions and riskfactors listen above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 10.5 CMR l4WF* 590.000. 3-403.11(F.) Remaining Unslwed Portions of Beef Item Good Retail Practie_es _ FC 590.000 Roasts" 23. Mane ement and Personnel_ FC-2 .003 - _ 18 Proper Cooling o4 PHFs 24. Food and Food Protection _ FC--3 O(W 3-50114(A} Cooling Cooked PHFs from 1 25. Equipment and Utensils FC 4 .005 .40"F to _....._.-.-. __._-__. 26 Water,Plumbingand Waste FC 5 .006 70"F Within 2 Hours and From 70"F 27. Ph deal Facility_ TC--6 .007 to 41.°.F/459F Within 4 Hours. * 23. Poisonous or Toxic Materials FC-7 .008 3501.14(3) Cooling PFIFs Made From Ambient 29- Special Requirements __ .009 Temperature Ingredients to 41"F/45°F 30 _ Other _ Within 4 Hoursk ssvora,:,nceaaaoo '"Denotes critical item in the fMeral 1999 Food Cade or 105 CMR 596.000. r COMMERCIAL No. 594 PEST CONTROL P.O. BOX 694 ArEs5 k BEVERLY, MA 01915 978-223-.0.131 NAME, ,„. t'a:+ si .�rs.. ,`"kh+x > a' 1 `'` .tr:- "`�k c 4*KWICKtSHOP�MARKET�, d X740;9955 ADDRESS rN,xa e`�.3t .'^x,?:r,T`i' aa TMsjn 'g+'t_txs'"6`;N ?i''� `+.a^k ,tf>;,.iw' Ns.�`�iu y I FUEFFERSON AVE SALEM�MA� x�' x w`.,'.: SOLD BY� �k.,z.,��j� ''`�:� GASH� {�C O D.'� d❑PAIDOUT L� GFNPMAINT, r, ,..Q CHARGE;'LQ MERCHANDISE RETURNED " NZ t contras blox e a# 2455-79' ;'MET OD- IS LI OID� ,SPRAY c .TAR ET ;IShGENERAL= CRAWLING;JNSE TS F BAI aBLOx?I%BAIT �,.STATIONar a ,.f Me. u 4 r � "ra:yzP di' 3� i *�✓t4. d� 2 y, �, � �� s'�� p�`'sas`,�3,t'3y'S��`�Gti"ss�''',�'�l,�t� '''`i,` �'� � _ � •�t L ,f` � . .i" `��x y pr £Lx x.�a�n3�"`; 4�' w yY M#x N�"'r 1 '''4 t .,7� 4 y.x + x x •� 4�i}�"f�,, k" 4, xq F,Y, l � �•°#:, tt'<zr- Nc , RhXxt'ra Aam" sl$x} e"a,�a:✓M�rtr'"{xt ha7 firrJ. g.kkrtf4 ` ` v� ap' x'. � :i;>R�;1 ', ., ' NC2581 SIGNATURE \ ALL CLAIMS AND RETURNED GOODS. ST BE ACCOMPANIED BY THIS BILL. GENERAL PURPOSE PHODUCT 6540 ® To Reorder 1-800-225-6380 or www.nebs.com .., Fold at(>pto.tipP1;DU-O-VUE®Envelope PATMOR. MECHANICAL tU_ M I G 1175 Master License #12689 4,, Work Order/InVOICC 9-Henrietta Road Peabody, MA 01960 DATED F�ORDER Q HOMETEL. ORb TA BY--- WORKTEL. 1 T Tel:(978) 532-0478 Fax.(978) 532-0946 CSTOMERDRDERND. P+M-MoRK ❑cOHTRACT ❑;EXTRA � c/, srnar c ATE ❑OVERTIME L]OTHER � w JOB NAME/NO. /� 67��soi✓ Mac 1 .. . . JOB LOCATION O al.0 C' , - INVOICED E - JOB TEL. CHECKMARKS DENOTE '`v�` �' "'°" , TERMS - WORK TO BE DONE �5tig �Vv�5 � �xP OQ� COMPLETED 0"O 00 Q.,, U �v+ Z; ;,;,. � , °�, "i.# s"dw;+e wc^" �;�DESCRIRTIONOF WORKg NO HEAT NOWATER �BURSTPIPEIS). THAW PIPE(S)`." INSULATE PIPE(S) BLOCKAGE-WASTFfnrSTEMHRS? KITCHEN _ -BINK !TU`: $ .INSTANTHOT :WATER FILTER +i,,µp 'TiF - ..'.'1,. DISPOSAL v DISHWASHER # . .BATH (1) (2) (3)_ !_+v„; ( uvAToav =. T"T" P:9kHi OALiN ABO I WATCH CLOSET BATHTUB o t Uw SHOWERSTALL/.HEAD WHIRLPOOL/SPATMOTTLE .LAUNDRY k v. zTffu .e` L iY.4ti1i WASHING MACHINE ' L' .. FAUCETS) SILL COOK i ki.' 400 4L ;SUPPLYLINE(S) - TRA%S)FDRAIN(S) A ". RLTER(S) - ��rry� >vY GATE/BALL-VALVES) 'WATER LINES) :WELL/WATERPUMPi,ki 0-61, ; 1 PRESSURETANK _WATER SOPTENERIQDNO Y.. 3u'iTr.. Ru SUMP I EFFLUEN'rPUMP Y� i'}4 "'WATER HEATER :BOILER-STEAM/NOI':WATER xf t "rvz-'�I SAFETYVALVE CIRCULATOR fBj ( WORK ORDERED BV - 'TOTAL ZONEVALVE .MATERIALS hereby acknowledge thesatisfactory completion of the above TOTAL ` BASEBOARO(S)/BADIATOR(S) �, .described work .LABOR ; FURNACE ',.BURNER HEAT PUMP' ,x SIGNATURIJ 0 TAX AIR CONDITIONERPT xrM1'zLa;i +^got d3TMFR.CRORC.FR // J o CITY OF SALEM, MASSACHUSETTS 3" BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT June 22, 2004 Elie Zeaiter, Manager Kwik Shop Market& Deli 10 Jefferson Avenue Salem, MA 01970 Dear Mr. Zeiler: Please be advised that the Salem Board of Health requires food establishment personnel to behave in a professional manner toward Sanitarians at all times. Any reference to physical characteristics of a Sanitarian or specific request for a particular Sanitarian to conduct future inspections will be considered harassment and the Board of Health will prosecute under appropriate laws and statutes. In addition the State Sanitary Code allows the Board of Health to revoke or suspend an establishment's food permit as a result of any interference of an inspector conducting business. This includes that caused by any form of harassment. The Board of Health expects that you will conduct yourself appropriately. Sincerely yours, anne Scott' Health Agent CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOORPm P11t11,iC$8811'h P¢vcnt.Pmmoc. tem. TEL.(978) 741-1800 FAX(978) 745-0343 KIMBERLEY DRISCOLL Iramdin Q,salem.com LARRY RAMIAN,RS/RF�FIS,CHO,CP-FS MAYOR - - - MAI.TI'IAGF:NT This Form will be collected during your next Board of Health inspection. QUESTIONAIRE - GREASE TRAPS 2012 I 1. NAME OF ESTABLISHMENT: ( I �l� o h 2. ADDRESS OF ESTABLISHMENT: 0 '5aLm, 3 DOES YOUR ESTABLISHMENT HAVE A GREASE TRAPS Ti ° 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GIS REMOVED FROM THE TRAP? VRE 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?