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LACOSA NOSTRA - ESTABLISHMENTS J { N&mom L IUPC 10241_ $Mftd co n •'Umb In USA y Inspection of LU,C�SCL. N) QS+CLL Date 0Time Name Address Owner Tel. No. Type of Inspection Inspector ( ' I Remarks and Violations are listed below: a J (101 IV! r-, max �P O • � D h2�n^nvP,+ '�i y�c 2�i v► e mI. 40-v�,Ut� � �y.�rni-{' c�Cpc�.e�r2 W c�s�l►ng Report Received by: m z DESCRIPTION ELECTRICA PLUMBING REMARKS K 4 AMN VOLT BTU$ INLE 1 MOP SINK 2 3 BAY SINK WlDRA1NSOARD 3 HOT PLATE 16,8 206 HARD WIRE 4 CONVECTION OVEN 40 206 914" HARD WIRE 6 ] SALAD UNIT 7 115 ' 13 WORKTOP FREEZER 6 115 NEMA 5-15P 9 2 PANINIGRILL 2115 115 NEMA 5.15P 1 TOASTER 14 115 NEMA 5-15P 11 C . o 'AI , IIS 12 7:7�. ,rl��,�, 1 3 COFFE_MACHINE 206 1 Q WORK TOP REFRIG 12 116 NEMA 5-15P 15 IREFRIG.DISPLAY CASE 12 116 HARDWIRE 16 ?RY DISPLAY CASE 116 HARD WIRE 1 w:NOSINK ` 1 SLICER 5 116 19 20, 21 22 23 _24 25 . DRAWN BY KARPOUZIS&SONS COMMERCIAL REFRIGERATION PROJECT SCALE 203 JEFERSON AVE. 1/ a— SAI EM h% DATE APPROVED BY r O 3��d SNI, 2i�N 8TTVZ4B8OS . 8Z :91 ;OaZ/Zi:'T.O 05/21 /2009 08 : 31 FAX 001/001 ar I 2.9,•--� t 13'5' `A . 'i p i , 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 Date Tvpe of Operation(s) Tvpe of Inspection 1-1Food Service ❑ Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑General Complaint In: ❑HACCP Inspector 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 _ s- ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH >. _. - .rte ,� -" 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 from App ' ' TIM EMPERATURE CONTROLS Potential) Hazardous Foods ❑ 4. Food and Water from Approved Source ( Y -) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION�FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control - ,--_.JO ❑ 9. Food Contact Surfaces Cleaning and Sanitizing. [REQUIREMENTS FOR.HIOHLY SUSCEPTIBLE POPULATIONS_(HSP)' E]21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices .CONSUMER ADVISORY ' ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions 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) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-4)(9590.090.0 044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) 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 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:59 tnspe Fa 14.E Inspector's Signature: Print: 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 8 Cross-contamination 1 590,0 OO Assn TION MANAGEMENT * 3-302.1I(A)(1) Raw Animal Foods Separated from Cooked and RTE Foals* 590.003(B) Demonstration of I{t owled e" Contamination from Raw Ingredients 2-103.11 Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 1 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An * Applicant To Report To The Person In Utensils Contamination from the Consumer Charge* Res 590.003 G) Reporting b Person in Charge* 3-306.14(A)(B) .Returned Food and aced or of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restr ct ons 3-701.11 Discarding or ReconditiZ g Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111, Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.1.3 Shell Eggs* Sanitization Tem eratures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. 3-202.16 Ice Made From Potable Drinking Water* 4-601..11(A) Equipment Food Contact Surfaces and 5-101.11 Drinkingr Water from an Approved d S stem* 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 Contact Surfaces and Utensils* - ShelNish and Fish From an Approved Source 4-702.11 Frequen y of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan - Fool Contact Surfaces of Equipment*p Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* SO Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2--301 11 -Clean Condition-Hands and Arms* Ae u/afoAuihorft 3-202.18 Shellstock identification Present* 2-301.12 CleaningProcedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-001.11 Eating,Drinking or Using Tobacco* 3-202.1.1 PHFs Received at Proper Temperatures* 2-401.1.2 Discharges.From the Eyes,Nose and - 3-202.1.5 Package ince 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 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em plo ees* TaoRecords:'Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11. Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement* 1 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized ProcessingMethods* Devices 3-502.12 Reduced oxygen acka mg,criteria* 6-301.11. Handwashin Cleanser,Availability 8-103.12 Conformance with App.-v_1Procedures* 6-301..1.2 HandDr 'n Provision s Denotes ciitiwl item in the federal 1999 Pond Cate or 105 CMR 590.000. l i Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs t 120 Washington Street,4m Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT ¢ Tel. (978) 741-1800 Fax (978) 745-0343 e Name e Date T of 0 eration(s) Tvoe of Insoectlon ❑ Food Service ❑ Routine y Address f Risk El Retail E] Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone"' ❑ Mobile Date: `. Owner HACCP YIN ❑ Temporary ❑ Pre-operation El caterer El Suspect Illness Person in Charge(PIC) Time ❑ Bed 8 Breakfast ❑ General Complaint In: ❑ HACCP Inspector 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 590.999(E) ❑ 590.009(F) ❑ s action as determined by the Board of Health. .. ,-N- -- - FOOD PROTECTION MANAGEMENT_ v.. �y� _ ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH • m . -�-��. E:113. Handwash Facilities PROTECTION FROM CHEMICALS t • -,x ' ❑ 2. Reporting of Diseases by Food Employee and PIC El `14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded _ _, . i El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source LTIMEnrEMPERATURE 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 ❑ 19. Hot and Cold Holding.. ❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP),, ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices � NSUMER 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. c x P 9 590.000/federal Food Code. This report, when si nedbelow 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-d�(sso.00s) cited in this report may result in suspension or revocation of the food establishment permitand cessation of food 26. Water,Plumbing and Waste (FC-9)(990.009) 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)(590.006) and submitted to the Board of!Health at the above address 29. Special Requirements (990.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: i S.5winspmr 14..e Inspector's Signature: I Print: PIC's Signature: Print: Page_of Pages x. �. Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Crass-contaminaton 1 590.003(A) I Assignment of Rexpansibility' 3-302.11(A)(1.) Raw Animal Foods Separated from Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other" EMPLOYEE HEALTH Contamination from the Environment 2 590.003(0) Responsibility of the person in charge to 3-302.11(.0. Food Protection* require reporting by Mood employees and 3-302.15 Washing Fruits and Vegetables applicants* 3-30411 Food Contact with Equipment and 590.003(F) Responsibility Of A Foul Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) ,Returned Food and Reservice of Food* 59(1.(103(G) Reporting b Person in Charge' 3 590.003(D) Exclusions and Restrictions* Food Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions 3-701,1? Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501..111. Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.11.2 Mechanical Warewashing-Hot Water 3-202.)3 Shell Eggs* Sanitization Tem eratures* 3-202.14 F,ggs and Milk Products,Pasteurized' 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 lee Made From Potable Drinking Water* concentration and hardness. 5401.11 Dri aking Water from an Approved System* 4-601..17(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.0(6(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food - Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment' Shellfish* 4-703.11 Methods of Sanitization-Har Water and 3 201.15 Molluscan Shellfish from NSSP Luted 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 Shellsteek Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201..17 Game Animals* r 11 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges.From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records;Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Fu to ees* Tags/Records;Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-40212 Records,Creation and Retention* 5-203.11. Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5.205.11. Accessibility, Operation and Maintenance iHACCP Plans Supplied wfth 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* 6301..1.2 Hand Drying Provision '* Denotes critical item in the fedcnd 1999 Ford Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,. No. Reference R-Red Nem Vermed PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: ❑ .No ❑ Yes 1 have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of o Embargo ❑ Emergency Closure your food permit. C3 Voluntary Disposal 13 Other: 3-501:14(0) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to_ Factors(ftems 122) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Coolie Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PRFs Maintained at or below 3-202.12 Addirives* 590.004(F) 410/450 F* 3-302_14_ Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140°F. * 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers* Held Time as a Public Health Control 7-102.11. Common moemon -WorkingRestriction Containers* 3-501.19 Time as a Public Heai@t Control* 7-202.11 7-201.11 -SSttora e* - 590.004 H) Variance Requirement , - 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizes.Criteria-Chemicals* POPULATIONS HSP 7-204:12 Chemicals for WashingProduce:Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 7-204.14 encs,Criteria* 3-801 .11(8 Use of Pasteurized E * 7-205.11 Incidental Food Contact,,urticants* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or PartiallyCooked Animal Food and 7-2Raw Seed Sprouts Na Served,*06.12 Rodent Bait Stations* 3-801-II(C) Unopened Food Package Not Re-served. " 7-206.13 Tracking Powders,Pest Control and Mottitorin * CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 - Proper Cooking Temperatures for Ani trial Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate -- palb0 ens.*EReeOve I/vr 1 EM-Immediate Service 145°FlSsec* � 3 40i.11A{1)(2) Eggs- F 15 Sec. 3-302.13 Pasteurized E Substitute for Raw Shell 33-401.11(A)(2)o1.i1(A)(2) CotnminutedFish-Meats&Game Eggs* .. Animals-155°F 15 sec. * 3.401,I1(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 foal, temporary and 3-401.11(A)(3) Poultry,Wild Game,Smf3'ed PHFs, residential kitchen operations should be Stuffing Containing Fish,A4eat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* above if related to foodborne illness 3-401.1.103) 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 165F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs-145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3.403AI(A)&(1)) PHFs 165OF 15 sec.* (Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Tithe* foodborne illness ince ventions and risk factors listed above, can'be 3-903.11(C) Commercially Processed RTE Food- found in the follondng sections of the Food Code and 105 CMR 140°F* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef Item I Good Retail Practices FC 590,000 Roasts" 23. Management and Personnel -FC-2 .003 .i 18 Proper Cooling of PRFs - 24. Food and Food Protection - FC-3 .004 1 25. Equipment and Utensils I FC-4 _005 3-501.14(A) Cooling Cooked PRFs from 140°F to 26. Water Plumbing and Waste I FC-5 .006 70°F Within 2 Hous and From 70°F - 27. - Physical Fac[N : FC-6. .007 to 41°17/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials I FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29 Special Requirements 009 Temperature Ingredients to 41°F/45°F 34. Other _ Within 4 Hours* s:suotonnwtze, *Venotes critical item in the federal 1999 Foci Code n, 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,No. Reference R-Red Item Verified PLEASE PRINT CLEARLY 4 t 1 S C Discussion With Person in Charge: Corrective Action Required: ❑ .No ❑ Yes 1 have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures - Violations Related to Foodborne lltness Interventions and Risk According to Law Cooled to Factors{helm 1-22) (Cont.) 41°F/45017 Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Coohn 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(1' 41°145°F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 140°F. * 7-101.11 Identifying Information-Original 3501.16(A) Roasts Held at or above 130°F. Containers* Time as a Public Health Control 7-102.11. Common Name-WorkingContainers* 20 7-201.11 Separation-Stora 3-501.t9 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* 7-204.12 Chemicals for Washing Produce,Criteria* 21. 3-801AI(A) Unpasteutuzd Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beveratzes with Warning Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized E mss* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Amoral Food and Raw Seed Sprouts Not Served,* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 - Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3401.1IA(1)(2) Eggs- l55`F 15 See. Pathogens.'E"rnrmot E -Immediate Service 145°Fl5sec* 3-302.t3 Pasteurized Eggs Substitute for Raw.Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game Eges Animals-155°F 1.5 sec. * SPECIAL REQUIREMENTS__ 3401.11(B)(1)(2) Pork and Beef Roast-.130`F 121 min* 3401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec * catering, mobile food, temporary and 3-401.1I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or.Ratites-I65°F 15 sec. " above if related to foodborne illtless 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401:11(A)(1)(6) All Other PHFs-145°F 15 see. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec. * (item 23-30) 3403.11(B) Microwave- 165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness inten,entions and risk factors listed above, can be 3.403.11(C) Commercially Processed RTE Foal- found in the following sections of the Food Code mrd 105 CMR 140°F* 590.000. 3403.11(E) Retraining Unsiiced Portions of Beef Hem Good Retail Practices JFC 590.000 1 Roasts" 23. Manantiment and Personnel I FC-2 .003 .I 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Equipment and Utensils I FC-4 _ .005_ 3-501.14(A) Cooling Cooked PHFsfront 140°F to 26. Water.Plumbing and Waste ' FC-5 .006 f 70°F Within 2 Hours and From 707 27. Physical Facility FC-6 .007 to 41017/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements - .009 Temperature Ingredients to 41OFl45°F 30 I Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Cale or 105 CMR 590.000. Massachusetts Department of Public Health Salem Board of Health `Division of Food and Drugs 120 Washington Street,0 Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name n 1^� Date T e of O eratlon s Tvoe of Inspection ��2 � Food Service ❑ Routine Address G 5 Risk Retail Re-inspection Level ❑ Residential Kitchen Previous Jns9 action Telephone q� C ❑ Mobile Date: 14l////a OwnerHACCP YIN 11 Temporary ElPre-operationcs'I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑General Complaint In: El HACCP Inspector �(O Out: Permit No. ❑Other Each violation ch ed req fres 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 El12. Prevention of Contamination from Hands 1. PIC Assigned/Knowledgeable/Duties _ ____ ❑ 13. Handwash Facilities EMPLOYEE HEALTH a ° ' J PROTECTION FROM CHEMICALS ....:: - �. M. t y..,.t.. ❑ 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 TIME/rEMPERATURE CONTROLS(Potemlally Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. 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_S_USCEPTIBLEPOPULATIONS.(P El 10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP 0-11. 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)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3)(sso.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 r::r, 28. Poisonous or Toxic Materials (FC-7)(590:008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:59JIrrepxfFomKi4.Ex Inspector's Signature, Print G PIC's Signature: Print:Ze r 61 Page of a Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION $ Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibilit * Cooked and RTE Foods* 590.003(6) Demonstration of Knowledge" Contamination from Raw Ingredients 2-103.11. Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* - require reporting by food employees and 3-302.15 Washing Fruits and Ve etables applicants* 3-304.11 Food Contact with Equipment and 590 003(F) Responsibility Of A Foal Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Foal and Reservice of Food* 590.003(G) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* Food DispositionofAduReratedorContaminated 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 Foci Law* 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Temperatures 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13Shell 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.* 4-601.11(A) Equipment Food Contact Surfaces and 5-L01.1:1 DrinkingWater from an Approved System* - Utensils Clean* 590.006(A) Bottled Drinking Water* 4602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.04` ShefHish and Fish From an Approved Source Contact Surfaces and Utensils'' 4-70111 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-Ha Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re u/ato AuthorN 2-301.11 - Clean Condition-Hands and Arms* 3-202.1.8 Sbellstoek Identification Present* 2-301..1.2 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* 3-202.1.1 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* 12 37301.12 PreventingContamination When Tasting* 6 Tags/Records:Shellstock Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Em plo ees* Tags/Records:'Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3=402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(1) labeling of Ingredients' 5-204.11 Loc tion and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance' 7 - /HACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11. Specialized Processing Methods* 6.301.11 Handwashin Cleanser, Availability 3-502.12 Reduced Ox aen packaging,criteria* 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision 'Denotes critical item in the federid 1999 Food Code or 105 CMR 590A00. Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 04/09/2012 ESTABLISHMENT NAME: La Cosa Nostra File Number:BHF-2012-000016 293 Jefferson Avenue SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2012-0422 Apr 9,2012 Dec 31,2012 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES December 31, 2012 Board of Health This Permit is not transferable and must be reissued upon change of ownership 0r location.The permit mus[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 Calzones Dinners •Veggie•Ricotta&Mozzarella $7.99 FREE •Manacotti $8.99 w/meatballs $9.99 •Cheese•Ricotta&Mozzarella&Provolone $7.00 SLICE PIZZA •Chicken Broccoli alfredo $9.99 •Italian • Ricotta, Provolone&Mozzarella $8.75 with coupon Chicken Primavera $9.99 •Pepperoni•Ricotta&Mozzarella $8.50 P Chicken Marsala $9.99 •Ham• Ricotta, Mozzarella&Swiss $8.75 Sausage primo $9.99 •Steak• Provolone&Mozzarella $8.99 ■ ■ ■ ■ ■ ■ ■ ■ ■ Shrimp Scampi $10.99 •Steak bomb•Provolone&Mozzarella $9.25 Eggplant Parm $8.99 •Chicken and broccoli • Alfredo&Parm $9.25 .p 300 OFF w/meatballs $9.99 • Buffalo chicken•Swiss&Mozzarella, •Ziti and meatballs $6.99 wt side of blue cheese $9.25 $25.00 Order Ziti w/sauce $4.99 •Cordon Bleu Chicken•Ham, bacon, With coupon Chicken Stirfry over rice $9.99 swiss&mozzarella $9.75 • Italian meat loaf $9.99 CREAT YOUR OWN CALZONE ■ ■ ■ ■ ■ ■ ■ ■ ■ mashed or rice w/veggie 6 Tappings Ifti ings$11.99 • Extra cheese$1.00 Baked Haddock $10.99 $5 00 mashed or rice w/veggie Pizza OFF •Shrimp Fra Diavlo $10.99 Slices $1.00 $40.00 Order Cheese $6.99 with coupon Ask about our Homemade Soups 1 Topping $8.25 Subs Toppings $9.50 ■ ■ ■ ■ ■ ■ ■ ■ ■ Subs 3 Toppings $10.75 The works(any 6 Toppings) $12.99 BUY 4 -Turkey $s.so Club Roast Beef,Turkey,Ham $6.75 Gourmet Pizzas DINNERS •Roast Beef $6.50 La Cosa Nostra $9.50 GET 5TH •Pastrami $7.00 Shrimp Scampi $14.99 •Ham and Cheese $5.99 Philly Cheese Steak $10.75 FREE •Meatball $6.50 Buffalo chicken $10.50 with coupon Steak&Cheese $6.50 Meat Toppings •Steak Bomb $6.75 ■ ■ • ■ ■ • • ■ ■ Sausage, Pepper and Onions $6.50 Pepperoni,sausage, meatball, •Italian $6.50 hamburg, bacon,salami, ham, •Tuna $6 99 anchovies,steak,chicken ANY SUB Chicken Salad $6.99 Chicken Stirfry $6.50 Veggie Toppings $5•00 Pepper,onions&mushrooms onions,pepper, mushrooms,tomatoes, With coupon Hot Dog $3.25 blackolives, broccoli, spinach,jalapeno. • � Salads Feta cheese $1.50 ■ ■ ■ • ■ • • • ■ Create your own pizza 6 toppings $12.9 All come with lettuce,tomatoes,onions cucumber ' BUY 4 Tropical Shakes •Chef Salad $6.99 ll .. „�,• CALZONES •Grilled Chicken $6.99 •Tropical Blend y GET 5TH •Buffalo Chicken $6.99 • Banana Heaven `` •Steak $7.99 •Strawberry Wow FREE •Tuna $6.99 Drinks Wltn COUpOn •Chicken Salad $6.99 Antipasto $7.25 •Coke-Diet Coke „. Ham,salami,pepper,provolone,onions •Dasani � •Chicken Caesar $6.99 -Mello Yellow •Greek $6.99 •Fanta Orange , •Garden $4.99 •Bargs Root Beer Y Tomatoes,onions,Cucumbers •Sprites - `.,,fit OF _ g •Supreme Garden $5.99 •Powerade Tomatoes,onions,olives,cheese, •Vitamin Water peppers,cucumbers •Monster WE 11A VE PIES, If you or anyone in your parry has food allergies, �. `. CAKES AND PASTRIES! please let us know before your order. TAKE OUT- DINE IN WE DELIVER 978 745 4400 r •. y ;\ ASK ABOUT OUR SPECIALS ` 'WE ALSO SERVE BREAKFAST" 7:OOAM TILL 11:00 AM -" 293 Jefferson Ave, Salem MA FusaRostra FREE SLICE PIZZA with coupon ITALIAN KITCKEN E • ■ ■ • • • • - Breakfast Breakfast Sandwiches $ OFF $255.0.0 0 Order •3 Eggs,toast, HF,3 Bacon, 3 Sausage $8.99 • Bacon, Egg and Cheese $3.50 with coupon Hash 1 Pancake •Sausage, Egg and Cheese $3.50 •2 Eggs,Toast, HF, 2 Bacon, 2 Sausage $7.99 Ham,Bacon,Sausage •2 Eggs,toast+ HF, 2 Bacon or 2 Sausage $5.99 • Ham, Egg and Cheese $3.50 $5 00 OFF •2 Eggs, Toast+ HF $4.79 •Egg and Cheese $2.50 $40.00 Order • 1 Egg,Toast+ HF $2,69 Add HF $1.00 Add Bagel or English $0.50 with coupon On white or Wheat w/1 Sausage or Bacon$3.25 2 Pieces$4.00 ��a �� • • ■ • • ■ • • • C5;L NJ k BUY4 � DINNERS Omelettes Pancakes & French Toast GET 5TH All omeletts comes with your choice of toast 8 home tries Pancakes French Toast FREE •Johnny's Special $7.99 -3 Pancakes $4.00 Order $4.00 with coupon Ham,Bacon,Sausage, pepper,onions, 2 pancakes $3.00 1/2 Order $2.25 mushroom • • • • • • • • ■ • 1 Pancakes $2.00 w/Powdered sugar • Leyca's Special $7.50 and cinamon Ham,Bacon,Sausage Add fruit$0.75 ANY SUB Cu of Fruit $2.75 Add fruit $0.75 $5.00 • Denver $6.59 P W Pepper,Onion,Ham • Bowl of Fruit $3.75 with coupon •Western $6.59 Breakfast Sides Onion and Ham Qty ■ ■ ■ ■ ■ ■ ■ ■ ■ • Spanish $6.59 3 Ham $2.25 Pepper, Onions, Salsa 3 Sausage $2.25 BUY 4 •Vegetarian $7.25 3 Bacon $2.25 CALZONES Spinach,Pepper,Onions,Mushroom, Corned Beef Hash $2.75 GET 5TH Broccoli,Cheese Home Fries $1.99 • Plain $5.00 Bagel $2.00 FREE • w/Cheese $5.50 w/cream cheese $2.50 witn coupon •Tomato $6.00 Egg $0.99 • Onions $6.00 Muffins $1.69 • Mushroom $6.00 • Broccoli $6.00 Drinks • Spinach $6.00 • Coffee •Tea Add more than one Veggies for$0.50 • Orange Juice •Apple Juice • Ham $6.25 • Milk • Sausage $6.25 • Ruby Red Grape fruit • Bacon $6.25 Pineapple, Mango, Strawberry, Kiwi Add another meat foriust $1.00 Veggies$0.50 Ifyou or anyone in your parry has food allergies,please let us know before your order. WE DELIVER 978 745 4400 293 Jefferson Ave, Salem MA BUSINESS HOURS Mon to Thrs 7:00 am -9:00 pm I Frid and Sat. 7:00 am -10:00 pm I Sunday 7:00am -8:00pm 05/21/2009 08:31 FAX U001/001 IL� � 2 R © O J y n 13'8" 8 I � EQUIPMENT LIST m z DESCRIPTION ELECTRICAL, PLUMB NG REMARKS AMP VOLT STUS IINLEI 1 MOP SINK 2 3 BAY BINK W4IRAINBOARD 3 HOT PLATE 18,B 206 HARD WIRE 4 CONVECTION OVEN 49 206 914" HARDWIRE 5G TABLE 8 71 ISALAD UNIT T 115 1 ' 8 WORKTOPFRMUR 6 115 NEMA 5-15P I 9 2 PANINIGRILL 2175 115 Z NEMA 5-15P 10 TOASTER 14 116 NEMA 615P 11 12 1 COFFEE MACHINE 20 206 14 WORK TOP REFRIG 12 716 NEMA 5-15P 151 REFRIG.OISPLAY CASE 12 115 ! . HARD WIRE T6 CRY DISPLAY CASE 116 JHARDWIRE rl 5 116 ' DMWN BY KARPOU21Sd501SIS - _ COMMERCIAL REFRIGERATION PROJECT SCALE 293 JEFERSON AVE. 1l4"-4' SA EM MA DATE APPROVER BY - �3f Z0 39VJ - - .`OIJI 2YJN�� - ' 8IT4Z/-6605 . 8Z:9T 500ZiZL/L0 CI1"I' OF SALEM, lu MASSACHUSE,'rs ftc ®V ArblicHealth Bonaool Henl,'n-I � 120 WnSI IIN( um S rti:e'r,4'"'Fl.00a MQR /j AD KIb1BERLEY DRISCOLL TLiL.(978)741-1800 Fnx(978)745-03 � �hr V� Y RANIDIN,RS/RLI IS,CI lo,CP-FS MAYOR tram esalenn.com 6QARZ)OFSAL6 1-11 Ai:ni AGL:N7' OF HFA H Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: 2) Establishment Address: &v v1r 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: 5) Applicant Name&Title: Ltqrakk WsaA-4vove b 4 -,4 6) Applicant Address: 66p/ i�1&641 Sf 0242o& 44 04vv — 7) Applicant Telephone No:7824 Hour Emergency No: Email: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership, give name,title and home address of officers or partner. An association / Name Title Home Address A corporation`// An individual A partnership Other legal entity 12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: Address: ( C/ V41k of? r Telephone No: 781^ Q Fax: Email: Emergency Telephone No: 7$ -63;t " 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: r Check#: 173/ Date: Amount: AM _--� li � � �yi\�'t�i +•; ' ��%L[�<�AJI :Ifl � I 4Ir Qf�I:I_� :� . • -_— .. 1 is ►_ �� a 6 . -i c —_— PER la 1 laimi�,1GK➢il1�[v�l�� 1 �•��liij •' • ��_ • I . r�Y *-Y Lr-.ry..' Y n ♦• "^."r r.SN . .n..r:r��..I'r.,..�� .._._... .•. ,y♦.v♦"t^.f'�n r1 , .-.•}. .c „ .r r. -. 3-501.14(C) ' PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Feetors(items t-22) (Cant.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives#, 3-50I J6(B) Cold PRFs Maintained'at or below 590,004(F) 410/45'F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 140'F. * Containers*7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1300F. 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 1 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* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLYSUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSPS 7-204.1_2 Chemicals for WashingProduce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning labels* 7-204.14 Restricted Drying encs.Criteria*d Use Pesticides,Criteria*Food Contact,Lubricants* 3-801.11(B Use of Pasteurized E=* 7-206.11 R 7-205.11 Incidental 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.12 Raw Seed S rts Not Served.* 2 R en tattoos 1 t Bait er S 3-801.11(C) Unopened Food Packer Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEIf EMPERATURE 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 340i.IIA(1)(2) Eggs- 155°F 15 See. Pathogens.'eaaere"t Eggs-Immediate Service 145'F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3d01.11(A)(2) Comminuted Fish.Meats&Game E 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)-(DI Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PRFs, residential kitchen operations should be Stuffing 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. 3-4011 l l(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3.403AI(A)&(D) PHFs 165-F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Nem Good Retail Practices FC 540.o Roasts"` 23. Management and Personnel FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection I FC-3 .004 3-501.14(A) Conlin Cooked PHFs from 140°F to 25. Equipment and Utensils FC-4 .005 Cooling 26. Water Plumbinci and Waste FC-5 .006 11 70'F Within 2 Hours and From 70'F 27. P cal Facia FC-6 007 to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC=7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .004 Temperature Ingredients to 41°F/4.5'F 30. 1 Other _ Within 4 Hours* s:sro; ovz me "Denotes critical Teem in the federal 1999 Food Code or 105 CMR 590.000. l Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4s' Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 NameLa co7sp_ Dat T e of O eration s T e f Ins action CL I Food Service Routine Address ci3Risk ❑ Retail El Re-inspection " Level ElResidential Kitchen Previous Inspection Telephone 97 '11L}S_LiL)OO ❑ Mobile Date: OwnerHACCP Y/N ElTemporary 0 Pre-operation Cjnf' CtSs t' vl ❑ Caterer ❑Suspect Illness Person in Charge(PIC) 5Ct(h42_ Time ❑ Bed&Breakfast ❑ General Complaint Inspector In i Permit No. ElO herr- Out: Each violation ch ed 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 E1. PIC Assigned/Knowledgeable/Duties El13. Handwash Facilities EEMPLO l*HEALTH -_ _ - - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives ❑ 15.Toxic Chemicals -FOOD FROM APPROVED SOURCE, ❑ 4. Food and Water from Approved Source 71ME/rEMPERA7URE CONTROLS(Potentlally Hazardous Foo_ds)J ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing I REOUIREMENTS FOR HIGHLY_SUSCEPTIBLE POPULATIONS_(HSP), ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER-ADVISORY - _ _ _ _ - ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions 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 x 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-a)(sso.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 r:H 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S.501nap F.n 14.l _$W] Inspector's Signature' _ Prin 2CZRqh - PIC's Signature: ` Print: a Pagel ofPages Violations Related to Foodborne Illness Interventions and Risk Factors(Hems 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590,003(A) Assig meat of Responsibility* 3-302.11(A)(1) Raw Animal Foods Separated from • a -- ----- Cooked and RTE Foals* 2-103.11 Demonstration a Kube Knowledge"` Contamination from Raw ingredients 2-103.11 Person in charge-duties 3-3011.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 1 Washing Fruits and Vegetables applicants* 3-304.11. - Food Contact with Equipment and 590.003(F) Responsibility Of A Foal Employee Or An * Applicant To Report To The Person In Utensils Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting b Person in Charge* 3 590.003(D) Exclusionsand Restrictions* Disposdiono/AduUeratedorContaminated Food 590.003(E) Removal of Exclusions and Restrict ons 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 3-201.1.2 Food in a Hermeticall y Sealed Container* Sanitization Tent eratures* 3-201.13 Fluid Milk and Milk Products* - 4-501.112 Mechanical Warewashing-Hot Water 3-202.13Shell Eggs* Sanitization Tem eratures* 3-202.14 Eggs and Milk Products-Pasteurized* 4501.114 Chemical Sanitization-temp.;pH; 3-202.16 lee Made From Potable Drinking Water* concentration and hardness.* 4-601.,11(A) Equipment Food Contact Surfaces and 5-101.II DrinkingWater from an Approved System* 590,006(A) Bottled Drinkin Utensils Clean* Water* 4.602.11 Utensils Frequency ofEquipmentFoiod 590.006(.B) Water Meets Standards in 310 CMR 22.0"' y Sheldish and Fish From an Approved Source Contact Surfaces and Utensils* 1' • 4-702.11. Frequency of Sanitization of Utensils and 3-291.14 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* t0 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301,11 Clean Condition-Hands and Arms* 3-202.18 Shellstoek 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 Eating,Drinking or Using Tobacco* 3-202.1.1 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and r, 3-202.1.5 Package Inte it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Togs/Records:Shetistock 12 Prevention of Contamination from Hands 3-202.18 Sheilstock Identification" 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* - Employees* Tags/Records:'Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conventenity Located and Accessible 3-402.12Records,Creation and Retention* 5-203.11 . Numbers and Capacities* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11. Accessibility, Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced Ox gen acka"ng,criteria* 6-301.11 Handwashing Cleanser,Availability 6-301.12 Hand Drying 8-103.12 Conformance with A roved Procedures* Provision *Denotes critical item in the Weral 1999 FoM1 Cade or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Lam- ca t N a t, R Date: tt I Page: a of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY -o it �cfi ce i < an :Yo noq Qn c6 v Heel t� Gc vl ri Gede RLAC'CApgs�Lv lAs r r 't ` c ;51 L rAobe- Acp -iro s Use Witt lie, C'nM:Lr t '50 `t tln 'H--= y `e 1 111 cX vY 1 1 nef ozK u rc3 i vK X2'1 r, q+ - , t Discussion With Person in Charge: Corrective Action Required: ❑ No O Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to obse a all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Feder Food Code. I underst nd that noncompliance may result in daily fines of t my-fi e d ars or us ension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 13Other: t 3-501.14(C) PHFs Received at Temperatures i Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to Factors(Harris 1-22) (Cont.) 41'F/45*F Within 4 Holum PROTECTION FROM CHEMICALS3-501..15 Cooling Methods forPHFs g4 Food or Color Additives 19 Mile Not and Gold Holding 3-50IA6(B) Cold P13Fs Maintained at or below 3-30 Ye na roved Ad 590.004(F) 41°/45'F* . s* r ditives`e 3-202.12 Additives*, _-Z.la Protection 3-50IA6(A) Hot PHFs Maintained at or above on from I 15 Poisonous or Toxic Substances 140°F. * 7-101,11 ldentitying Information-Original 3-501.16(A) Roasts Held at or above 130°F. " Containers* Time as a Public Health Control 7-102.11, Common Name-Working Containers* 20 7-201.11 Se ation-Stora * - 3-501:19 Time as a Public Health Control* 7-202.21 .Restriction-PresenceandUse* - 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* 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and .Beverages with Warning Labels* 7-204A4 Drying Agents.Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205:11 Incidental Food Contact,Lubricants* 3-80LI1(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sproxits 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 TIMEf6EMPERATURE CONTROLS Animal 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHF% Pathogens.'eas onrnroi 3-401.11A(1)(2) Eggs- 155`F 15 See. Eggs-Immediate Service 145'Fl5sec+ 3-302.13 Paste*urized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* 3-401.I1(A)(2) Ratites,Injected Meats-15i`F 15 590.009(A)-(D) Violations of Section 590.1109(A)-(D)in SM, catering,.mobile food,temporary and -1401.1I(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,lamer Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to goal retail ` 3-401.12 Raw Anima)Fo coki Cooked in a practices should be debited under#39- Microwave 1657* Special Requirements. 3401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PR4C77CES 3-403A I(A)&(D) PHFs 165°F 15 sec. ' (Items 23-30) 3-403.11(B) Microwave 265'F 2 Minute Standing Criticaland non-critical violations, which do not relate to the Time* n - foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sectioru.of the Food Code and 105 CMR 1400F* 590.000. 3403.1I(E) - Remaining Unsliced Portions of Beef em I Good Retail Practices .FC 590.004 Roasts* 23. 1 Man4gement and Personnel -FC-2 .003 1 lg Proper Cooling of PHFs 24.. Todd and Food Protection FC-3 OOd 3-501.14(A) CoolingCooked PHFs from 140`F to 25' Equipment mem and Utensils FC-4 .005 26. Water.Plumbing and Waste FC-5 .006 70`F Within 2 Hours and From 70'F 27. Ph cal Facili FC-6 007 to 41'F/45'F Within 4 Hours.* i 28. Pasorxws or Toxic Materials FG=7 .008 1 3-501.10,.B) Cooling P14Fs 29. Special Requirements .009 Temperature Ingredients to 41'F/45°F 30 i Ottler _ Within 4 Hours* ssw:r,ww.c • 'Dente caticat iwin in the federal 1999 Focal Cade or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: L"al CYoisy- Nie Date: 1� ( Page: of— Item Code C-Crltleai Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dete. fdo. Reference R-Red Item PLEASE PRINT CLEARLY Verified tt Ct �� Q � of i t Ck tLi �. - F e i O 4X U u c( cc 44 � -—"pf rou 0 u 1 I l ill e &IJ02LE&nt� V,11t vl� i SS( r - til key, 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 obse all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Feder ood Code. I uncle t nd that noncompliance may result in daily fines oft my-fi doll s or ension/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 Iaw Cooled to Factors films 1-22) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501..15 Coohn Methods for PHFs ;4 Food or Color Additives 19 THF Hot and Card Holding 3-50r.i6(B) Cold PHFs Maintained at or below 3-202.12 Additives*^_ 590.004(F) 4101450 F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. * 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* 20 Time as a Public Health Control 7-102.11. Common Nana-WorkingContainers. 3-501.19 3-SD1:19 Tias a Public Health Control* 7-201.11 Separation-Storage* - 7-202.11 Restriction-Presence and Use* 590.604(H) Variance Requirement -202.12 Conditions of Use* 7REQUIREMENTS FOR HIGHLY SUSCEPTIBLE ' 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washing Produce,Criteria" 21 3-801.tl(A) Unpasteurized Pre-packaged luices and 7-204.14 m . encs.Criteria* :Beverages with Warms Labels* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 incidental Food Contact,Lubricants* 3-801.1 I(D) Raw or Partially Cooked Animal Food and 7-206.11 -Restricted Use Pesticides,Criteria* Raw Seed S . rts Not Served.* 7-306.12 - Rodent:Bait Stations* 3-801.11(C) Unopened Food Packalte Not Re-served. 7-206.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of TIMEtFEMPERATURE ;6 Proper CONTROLS CooldnS Temperatures for Animal Foods That are Raw.Undercooked or PNot Otherwise Processed to Eliminate Patho•ens.* 3-401,IIA(1)(2) Eggs- 155°F IS Sec. Eggs-Immediate Service 145°Fl5sec* 3-302.13 1 Pasteuti2ed Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game 1 Animals-155°F 15 sec. * SPECIAL REQUIREMENTS _ 3.401.118)(1x2) Pork and Beef Roast-130°F 121 min* 3-461.11{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 3-001.11(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 see. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other ' 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs- 135°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(1)) PHFs 165-F 15 sec.* (Items 23-30) - 3-403.11(B) Microwave-165`F 2 Minute Standing Critical,mrd non-critical violations,which do not relate to the Tithe* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE.Food- found in the following sections of the Food Code and 105 ChM 140°F* 590.000. 3-403.1I(E) Remaining Unsliced Portions of Beef _ r item ! Good Retail Practices I FC 590.000 I Roosts* 23. Management and Personnel FC-2 CO3. - .1 18 Proper Cooling of PHF9 1 24.. Foci and Food Protection FC-3 .0040 3-50L14(A) CoolingCooked PRFs from 340°F to 25. Equipment tandUtensils FC-4 .00.5 Pltimbino and Waste FC-5 .006 70°F Within 2 Hours and From 70'F '27, 1 Pti icai Facility i FC-8 to 41°F/45'17 Within 4 Hours. * i 28. Poisonous or Toxic Materials ' FC=7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ecis)Requirements 1 .009 �t Temperature Ingredients to 41°F/45°F 30 1 Other ' Within 4 Hours* "Denoas critical imm in the federal 1999 Food Cale a1W C:MR 590.000. i CITY OF SALEM -- BOARD OF HEALTH /I Establishment Name: !� cc5cu N)O-&(a Date:--4/ (! ( 5, Page: u of Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date.: No. Reference R-Red Item Verifled PLEASE PRINT CLEARLY (F 1 Ik-7fr,16 a t e tke I ft?i lC Vvy) holz 'ii "( t all l u - . c l 2. l -cd 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 obsery all conditions as describe , and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federa ood Code. nderst at noncompliance may result in daily fines of my-fi e d rs or su pe sion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 1 ❑ Voluntary Disposal ❑ Other: l 3-501,14(C) PHFsReceived atTemperatures 'i Violations Re)aded to Foodborne lltness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 4i'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PRFs 14 Food or Color Additives - 19 CHF Hot and Cold Holding 3-501,16(B) Cold PRFs Maintained at or below 3_202_12 _`Additives* 590.004(F) 4101450 F* 3-302.14 Protection from Unapproved Additives" -•-• 3-SUl.lfi(A) Hot PHFsMaintained oforabove 15 Poisonous or Toxic Substances id0°F. 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11, Common Name-Working Containers'° 20 Time as a Public Health Contra] 7-201.11 Separation-Stora * 3-501.19 Time as a Public Health Contr(il* fi 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* 7-204.11 Sanitizens,Criteria-Chemicals* POPULATIONS HSP 7-204.i2 Chemicals for WashingProduce,Criteria° 21 3-801.11(A) Unpasteurized Pre-packaged Juices and ;i Bevera>es with Warr»noLabels* 7-204.14 n encs•Criteria' "r 3-801.11(B) Use of Pasteurized B * i, 7-205.11 Incidental Fwd Contact, ;Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food mid 7-206.11 -Restricted Use Pesticides;Criteria* Raw Seed Sprimas 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 TIMEI6EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of ` 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or Not Otherwise Processed to Eliminate PHFB *SIWI.I/Yf2IX11 3-401A IA(1)(2) Eggs- 155'F 15 Sec. Eggs-Smmediate Senic�e 145'F15sec* 3-302.13, Pasteur d Eggs Substitute for Raw Shell t - Eggs* t 3401.1 i(A)(2} Comminuted Fish.Meats&Came Animals-155'F 15 sec.* SPECIAL REQUIREMENTS 3401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3401.11(A)(2) Ratites,Injected Meats-155'F 15 sec.* catering, mobile food,temporan and 3401.11(A)(3) Poultry,Wi1d Game,Staffed PHFB, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail 3-401.12 Raw Animal Fads Cooked in a practices should be debited under#29- i Microwave 1650F* Special Requirements. i 3-40LI I(A)(1)(b) All Other PRFs- 145'F 15 sec.° 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3-403.1l(A)&(D) PHFB 165-F 15 see. * (Items 23-30) 3-403.11(B) Microwave--165`F 2 Minute Standing -Critical,and non-critical violations,which do not relate to the - Time* foodborne illness interventions and risk factors listed above,can be 3-403,11(C) Commercially Processed RTE Food- found in the fallowing sectionsof the Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Min I Good Retail Practices i .FC 540.000 Roasts* 23. 1 Management and Personnel 1 FC-2 .003 1g Proper Cooling of PHFB 24. Food and Food Protection FC-3 .004 25. Equipment and Utensils 1 FC-4 .005 3-501.14(A) Cooling Cooked PHFB from 140'F to 26, Water.Plumbing and Waste - 5 .006 700F Within 2 Hours and From 70'F 27. -Physical Facilityi FC-6 .007 c to 41`F/45'F Within 4 Hours. * 126. Poisonous or Toxic Materials FC--7 .008 3-501.14(.B) Cooling PHFB Made From Ambient 29. Special Re quirements 009 Temperature ingredients to 41'F/45'F 30' Ott --i- Within 4 Hours* "Denotes cziticat hero in the federal 1999 Foal Cale or 105 CMR 590.000. -' Ca' IlaWaste'Services - - 295 Forest Street ' r .Peabody,MA:01960 Service:Agreement - (800).950 9293 Fax(978)535-6937 r j Account Number El is' E]IDS E)§X - ❑Bp- Effective Service Start Date.L {"Cl)./r r-) ❑FC E3SIS ❑SDS [3PRICE ❑CL ❑OC EI IF[ . 0 M 0 C ❑VOL Delivery Date Els ❑PIR CUSTOMER INFORMATION ! - BILLING INFORMATION: 'SERVICE INFORMATION Company Name: Company Name: bN Address. Address' County:, // County: . -Phone Number: ^� .:�� (.,ryJ,s—..--�t"'{�� ' :Phone Number: Fax Number: Fax Number: Tax I.D.#/SS#: Email Contact Name: Contact Name`.` NEW SERVICEINFORMATION Container Container _:.Service Disposal Extra Pickup Monthly Type :Rental Haul Disposal -Rate Per Feel Service'. .QTY (FL,RL Ro) -Size Frequency, ` MateriafType " Rate Rate site Codes Ton Delivery Fee. ({.Fee` FL I RL Container Delivery Charge Its . $50 00 -r Route Days MSW M T W Th F Sat TOTAL Route Days Recycling M , T W Th ` Sat Sun PREVIOUS SERVICE INFORMATION Container ., Disposal Extra Pickup Monthly.. lWe Container Service 'Rental ' ' Haul Disposal ".'Rate Per 1 Feel Service. QTY )FL,RL,RO) Size Frequency, Material Type ,Rate J Rate SiteCode. Ton Delivery Fee Fee Y z. SIC Code-Industry Weight Estimate I-Wcu.yd Agreed Upon Term Months,- SPECIAL onthsSPECIAL COMMENTS r ' fT 1 hay,, read and understand the terms and conditions on the"reverse side Customer Authofice Signal re Ca Casella Waste Authorized LSignature Print Name aisle Print Name and Ttle (J Date ! Dater^, Branch Manager Sig nature ^ Date: \I_L_....r '..-- /ir/pest Control Service Agreement B & B PEST CONTROL 09871 271 Westem Avenue, Suite 203 LYNN, MASSACHUSETTS 01904 (781) 599-4317 CUSTOMER SERVICE LOCATION LGk Co5ci rG 1�r 3 t Fr-vso J� i STREET D �� 2rsc �rnE� V i�Ss CM70 CITY.STATE and ZIP rr PERSON TO BE CONTACTED SERVICE PHONE SLi�ty. 1�1GS Q�y 7 CG�rn PHONE TYPE OF PROPERTY TO BE SERVICED L� [' DATE SERVICE BEGINS EXPIRATION DATERENE'NAL 5ERV1 OBE PERFORMED L)-5- ❑ ONTHLY ❑QUARTERLY ❑OTHER PESTS TO BE CONTROLLED' - Rc��nLSI. _Rcticl 5r 5�;c(iryr c�r�S_ - fSPECIAL INSTRUCTIONS: U�.LZ TERMS AND CONDITIONS: SERVICE GUARANTEE: We agree to apply chemicals to control above-named pests in accordance with terms and conditions of this Service Agreement. All labor and materials will be furnished to provide the most efficient pest control and maximum safety required by federal,state and city regulations. L— SERVICE RENEWAL:This agreement shall be for an initial period of one year, and will renew itself annually unless either party cancels �— this agreement by giving thirty days written notice before any expiration date. ANNUAL AGREEMENTCHARGE $ BY COMPANYPIGNU DATE INITIAL SERVICE CHARGE $ -77S C UTH MONTHLY/QUARTERLY PAYMENTS $ ?S -(:,L) EOR CUSTOMER ADATE __ $ IMPORTANT MESSAGE I FOR DATE /l��/'�- TIME M OFa(� OCJ�'� /� PHONE Phi 'NR �/ A A CODE NU ENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL ` TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE Iona SIGNED FORM 4009 MARE IN LLS. NOTES Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: f Required as of 101112001 in accordance with 105 CMR 590.003(A) i-P CO14 I Ia0,A1,e;V 19) Person Trained in Anti-Choking Procedures( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑ Caterer Permanent Structure ❑ Food Service—( Seats) ❑ Frozen Dessert Manufacturer Mobile QFood Service—Takeout ❑ Residential Kitchen for Retail Sale ❑Food Service—Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments------------------------ (check one) RETAIL STORE R STAURANT Annual ❑ Less than 1000sq.ft. $ 70 ALess than 25 seats $140 Seasonal/Dates: ❑ 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 ❑25-99 seats $280 ❑ More than 99 seats $420 Temporary/DatesMme: -------------------------------------------------------------- - ---------------------------------------------------------------------- ❑ Bed&Breakfast/Childcare Services/Nursing Home $100 --------------------------------------------------------------------------------- ------------------------------------------------------- ADDITIONAL PERMITS 0 MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (including, church kitchens, state funded childcare 8 private clubs 23) Food Operations: Deffnitions: PHF-potentially ha;ardous food(timeltemperature controls required) Non-PHFs-non-po entially hazardous food(no timeltemperature controls required) (check all that apply): RTE-ready-to-eat ods(Ex.sandwiches,salads, muffins which need no further processing Sale of Commercially PHF Cooked to OrderHot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service _ Sale of Commercially Preparation of PHFs For Hot And I PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service 14 Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. pp� 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: OIl�._5U 26) Signature of Individual or Corporate Name: IMP®RTAIMT MESSAGE FOR DATE 1 TIME--4 P.Ips M .1.A n/� (r�l .�C, `1 4 1,5 3 GI/I-e OF l�G'� F1SDli NO11�nCG nn�''n1ct�J.SGFFCriq ,G PHONE �W �n�e7� v10 N ARE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE.CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE.YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE 1 MIAL U b i P G �,lct; fry S?S SIGNED *NIVERSAL- 4ROO57 UE IN U.S.A. NOTES - CITY OF SALEM, MASSACHUSETTS LICENSING HOARD 0,�Zv EM,12owASHiNGTONSTREET' WFLOOR SALMA 01970 ROBERT M.Sr.PIEML CHAIRMAN TEL. 97&745-9595 EXT.5648 JOHN H.CASEY FAX 978-744.6775 or 978-7449846 RICHARD C.LEE KIMBERLEY DRLWOLL MAYOR MELISSA PAGUARO, CLERK OF THE BOARD HEATH DEPARTMENT NOTIFICATION FORM IF YOUR APPLICATION INCLUDES THE SERVING OF FOOD YOU MUST HAVE THIS FORM SIGNED BY THE HEALTH DEPARTMENT PRIOR TO SUBMITTING YOUR APPLICATION TO THE LICENSING BOARD. (this form MUST be signed and returned with your application). NAME OF BUSINESS Z4 CDSfE AIOSyq Corporate name: d/b/a: LOCATION: K-73 l yQst f J( TELE.# - A6+-�"q6 � TYPE OF LICENSE APPLICANTS INFQRMATIN Name: L06 'CA Q t155L4NPalU Home address: GL �l�0aS City: j.. NN State: M& Zip: Home Tele.# HEALTH AGENT/INSPECTOR'S 4OMM,E,N�-TS:n _��-(,Ta...� `�ua,; lAR•cf� � '1�fi7 �• 1 i:�- 17it.rsc,e�-� DATE Health A ent health dept.nuhC Furth 2.09 CITY OF SALEM, MASSACHUSETTS BOARD OF HEAL:rI-1: 120 WASHINGTON STREET,4"'FLOOR YJMB RLEY F MAYOR ISCOId RECEIVED MAR FAA(978) 745-03430 LARRY RANIDIN,RS/REHS,CHO,CP-FS 23 2512 lramdin&salcm.covi HEALTH AGENT . CITY OF SALEM BOARD OF HEALTH Fees:New Establishment:$180.00 Remodel:$90.00 Make Checks payable to:The City of Salem No cash is accepted FOOD ESTABLISHMENT PLAN REVIEW APPLICATION NEW REMODEL CONVERSIONj(t IC n4 Ud,l OU"!SL? Date: Name of Establishment: L CoSA vs Category: Restaurant_, Institution , Daycare_, Retail Market Other { Address: a� � QQsp]� ` nem MA Phone if available: Name of Owner: qqn/ cq6 AS Mailing Address: (Y1 SaVem �r gl - 3 Bio Telephone: Applicant's Name: ��r��QASSQIUQIN Title (owner, manager, architect, etc.): C)LVA)e 2 Mailing Address: Lp/t41' tokclol `�q//V a p 190 Telephone: 7 ll( - (j3 a" q0y I have submitted plans/applications to the following authorities on the following dates: Licensing Board Plumbing Zoning Electric Planning Police Building Fire Conservation Other ( ) Hours of Operation: Sun 7— 0 ThursI— Mon— Fri -7 - /O Tues Sat 7- n wed7j_ Number of Seats: a D Number of Staff: 3 (Maximum per shift) Total Square Feet of Facility: Number of Floors on which operations are conducted Maximum Meals to be Served: Breakfast (approximate number) Lunch 5O Dinner Projected 7� Projected Date for Start of Project: /! Projected Date for Completion of Project: Type of Service: Sit Down M is (check all that apply) Take Out Caterer Mobile Vendor Other AA-�QP7 Please enclose the following documents: Proposed Menu (including seasonal, off-site and banquet menus) Manufacturer Specification sheets for each piece of equipment shown on the plan Site plan showing location of business in building; location of building on site including alleys, streets; and location of any outside equipment (dumpsters, well, septic system- if applicable) Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services and mechanical ventilation Equipment schedule B. INSECT AND RODENT CONTROL APPLICANT: Please check appropriate boxes. YE N N S O A 1. Will all outside doors be self-closing and rodent proof? ( ( ) ( ) 2. Are screen doors provided on all entrances left open to the outside? ( ) ( ) 3. Do all openable windows have a minimum#16 mesh screening? 4. Is the placement of electrocution devices identified on the plan? O ( ) 5. Will all pipes & electrical conduit chases be sealed; ventilation systems exhaust and intakes protected? 6. Is area around building clear of unnecessary brush, litter, boxes and other harborage? O ( ) 7. Will air curtains be used?If yes, where? C. GARBAGE AND REFUSE Inside 8. Do all containers have lids? NA O ( ) 9. Will refuse be stored inside? ( ) ( ) ( ) If so, where? 10. Is there an area designated for garbage can or floor mat cleaning? ( ) ( ) Outside 11. Will a dumpster be used? ( ) } Number I Size JA411 Frequency of pickup WPB Contractor 12. Will a compactor be used? 4/0 Number Size Frequency of pick up O ( ) Contractor 13. Will garbage cans be stored outside? l 14. Describe surface and location where dumpster/compactor/garbage cans are to be stored nut- vap- 15. Describe location of grease storage receptacle r ' a &T 16. Is there an area to store recycled containers? ( } O ( ) ues Indicate what materials are required to be recycled; k Glass I�AMetal N Paper pQ Cardboard j Plastic 17. Is there any area to store returnable damaged goods? /es D. PLUMBING CONNECTIONS AIR AIR *INTEGRAL *"P" VACUUM CONDENSATE GAI` i BREAK TRAP TRAP BREAKER PUMP 18. Toilet 19. Urinals 20. Dishwasher 21. Garbage Grinder 22. Ice machines 23. Ice storage bin 24. Sinks a. Mop b. Janitor c. Hand wash d. 3 Compartment e. 2 Compartment f. 1 Compartment g. Water Station 25. Steam tables 26. Dipper wells 27. Refrigeration condensate/ drain lines 28. Hose connection 29. Potato peeler 30. Beverage Dispenser w/carbonator 31. Other 10. Will the facility be serving food to a highly susceptible populations O If yes, how will the temperature of foods is maintained while being transferred between the kitchen and service area? A. FINISH SCHEDULE Applicant must indicate which materials (quarry tile, stainless steel, 4" plastic coved molding, etc.) will be used in the following areas. Kitchen FLOOR COVING WALLS CEILING Bar Food Storage Other Storage Toilet Rooms Dressing Rooms Garbage & Refuse Storage Mop Service Basin Area Ware washing Area Walk-in Refrigerators and Freezers 5. How will cooking equipment, cutting boards, counter tops and other food contact surfaces which cannot be submerged in sinks or put through a dishwasher be sanitized? Chemical Type: gleach Concentration: O O Test Kit: YES /NO 6. Will ingredients for cold ready-to-eat foods such as tuna, mayon ise and eggs for salads and sandwiches be pre-chilled before being mixed and/or assembled0 If not, how will ready-to-eat foods be cooled to 41'F? v 7. Will all produce be washed on-site prior to use?L y/NO Is there a planned location used for washing produce. YES NO Describe_ S itye If not, describe the procedure for cleaning and sanitizing multiple use sinks between uses. 8. Describe the procedure used for minimizing the length of time PHF's will be kept in the temperature danger zone (41'F - 140°F) during preparation. 0r Tape 9. Provide a HACCP plan for specialized processing methods such as vacuum packaged food items prepared on-site or otherwise required by the regulatory authority. REHEATING: 1. How will PHF's that are cooked, cooled, and reheated for hot holding be reheated so that all parts of the food reach a temperature of at least 165°F for 15 seconds. Indicate type and number of units used for reheating foods. 2. How will reheating food to 165°F for hot holding be done rapidly and within 2 hours? d t m) / M I C10" a No+'g k PREPARATION: 1. Please list categories of foods prepared more than 12 hours in advance of service. pi!AMAlks. SDV 0nth k 2. Will food employees be trained in good food sanitation practices? ES /NO Method of training: Sed✓� 5eh also ak 4S M-6 Number(s) of employees Dates of completion: , / 9 3. Will disposable gl and/or utensils and/or food grade paper be used to prevent handling of ready-to-eat foods? ES NO 4. Is there a written policy to exclude or restrict food workers who are sick or have infected cuts and lesions?YES /NO Please describe briefly: Will employees have paid sick leave?Y r® 2. List types of cooking equipment. CpUVA7eoo)(L Dyol, flo+ 'cpovt/��e, �I,Z7_4 OV91 J HOT/COLD HOLDING: 1. How will hot PHF's be maintained at 140°F (60°C) or above during holding for service? Indicate type and number of hot holding units. Sova ty4,��,� 2. How will cold PHF's be maintained at 41'F (5°C) or below during holding for service? Indicate type and number of cold holding units. pc iq oR q COOLING: Please indicate by checking the appropriate boxes how PHF's will be cooled to 417 (5°C) within 6 hours (140°F to 70°F in 2 hours and 70°F to 41°F in 4 hours). Also, indicate where the cooling will take place. COOLING THICK THIN THIN THICK RICE/ METHOD MEATS MEATS SOUPS/ SOUPS/ NOODL S GRAVY GRAVY Shallow Pans Ice Baths Reduce Volume or Size Rapid Chill Other (describe) THAWING FROZEN POTENTIALLY HAZARDOUS FOOD: Please indicate by checking the appropriate boxes how frozen potentially hazardous foods (PHF's) in each category will be thawed. More than one method may apply. Also, indicate where thawing will take place. Thawing Method *THICK FROZEN *THIN FROZEN FOODS FOODS Refrigeration Running Water Less than 70°F(21°C) Microwave (as part of cooking process) Cooked from Frozen state Other(describe' *Frozen foods: approximately one inch or less =thin, and more than an inch=thick. COOKING: 1. Will PQQ product thermometers be used to measure final cooking/reheating temperatures of PHF's?YE /NO What type of temperature measuring device: �C dL YP P g ��0'mE Minimum Cooking time and temperatures of product utilizing convection and conduction heating equipment: beef roasts 130°F (121 min) solid seafood pieces 145°F (15 sec) other PHF's 145°F (15 sec) eggs: Immediate service 145°F (15 sec) pooled* 155°F (15 sec) (*pasteurized eggs must be served to a highly susceptible population) pork 145°F (15 sec) comminuted meats/fish 155°F (15 sec) poultry 1657 (15 sec) reheated PHF's 165°F (15 sec) F. SEWAGE DISPOSAL 40. Is building connected to a municipal sewer?YES)o NO ( 41. If no, is private disposal system approved. YES ( )NO ( ) PENDING ( ) Please attach copy of written approval and/or permit. 42. Are grease traps provided? ES )NO If so, where? '( ry,jAl �+��I�j Provide schedule for cleaning & maintenance G. DRESSING ROOMS 43. Are dressing rooms provided? YES NNO ( ) 44. Describe storage facilities for employees'personal belongings (i.e., purse, coats,boots, umbrellas, etc.) .LR H. GENERAL 45. Are insecticides/rodenticides stored separately from cleaning & sanitizing agents? YES (XI NO ( ) Indicate location: gaSww 46. Are all toxics for use on the premise or for retail sale (this includes personal medications), stored away from food preparation and storage areas? YES 0 NO ( ) 47. Are all containers of toxics including sanitizing spray bottles clearly labeled? YES)<NO( ) 48. Will linens be laundered on site?YES ( )NOK If yes, what will be laundered and where? If no, how will linens be cleaned? I AIN COM 10"t t 49. Is a laundry dryer available?YES ( )NO� 50. Location of clean linen storage: r✓1 PLEASE CIRCLE/ANSWER THE FOLLOWING QUESTIONS FOOD SUPPLIES: 1. Are all food supplies from inspected and approved sources? 191 NO 2. What are the projected frequencies of deliveries for froze foods, Refrigerated foods !q/QQ1�1y and Dry goods 3. Provide information on the amount of space(in cubic feet) allocated for: Dry storage V-00 Refrigerated Storage and Frozen storage ] 4. How will dry goods be stored off the floor? COLD ST GE: 1. Is adequate and approved freezer and refrigeratio vailable to store frozen foods frozen and refrigerated foods at 41'F (5°C) and below? ES NO Provide the method used to calculate cold storage uirements. 2. Will raw meats, poultry and seafoo e stored in the same refrigerators and freezers with cooked/ready-to-eat foods?YES NO If yes, how will cross-contamination be prevented? 3. Does each refrigerator/freezer have a thermometer?(E/NO Number of refrigeration units: Number of freezer units: 114 4. Is there a bulk ice machine available. YES /NO K. HANDWASHING/TOILET FACILITIES 65. Is there a hand washing sink in each food preparation and ware washing area? YES >�NO 66. Do all hand washing sinks, including those in the restrooms, have a mixing valve or combination faucet?YES^)aNO ( ) 67. Do self-closing metering faucets provide a flow of water for at least 15 seconds without the need to reactivate the faucet? YES ( )NO( ) 68. Is hand cleanser available at all hand washing sinks? YESXNO( ) t 69. Are hand d ing facilities (paper towels, air blowers, etc.) available at all hand washing sinks?YESNO ( ) 70. Are covered waste receptacles available in each restroom?YES KNO ( ) 71. Is hot and cold running water under pressure available at each hand washing sink?YES NO ( ) 72. Are all toilet room doors self-closing?YES ( )NO ( ) 73. Are all toilet rooms equipped with adequate ventilation?YES (N NO( ) 74. Is a hand washing sign posted in each employee restroom?YES�q NO( ) L. SMALL EQUIPMENT REQUIREMENTS 75. Please specify the number, location, and types of each of the following: Slicers I 7/p,Q/C fahJe Cutting boards Can openers Mixers 1 A �e Floor mats k Vok Other J. DISHWASHING FACILITIES 57. Will sinks or a dishwasher be used for ware washing? Dishwasher ( ) Two compartment sink ( Three compartment sink 58. Dishwasher Type of sanitization used: Hot water(temp. provided) Booster heater Chemical type Is ventilation provided?YES O'QNO ( ) 59. Do all dish machines have templates with operating instructions?YES ( NO ( ) 60. Do all dish machines have temperature/pressure gauges as required that are accurately working?YES ( )NO ( ) 61. Does the largest pot and pan fit into each compartment of the pot sink?YES XNO ( ) If no, what is the procedure for manual cleaning and sanitizing? 62. Are there drain boards on both ends of the pot sink? YES NO ( ) 63. What type of sanitizer is used? Chlorine )� ( Iodine ) Quaternary (� ammonium ) Hot Water Other ) ( 64. Are test papers and/or kits available for checking sanitizer concentration?YES ( ) NO 51. Location of dirty linen storage: &1&.j✓y 52. Are containers constructed of safe materials to store bulk food products?YES 6NO ( ) Indicate type: kh QQ ap Qeez4S 53. Indicate all areas where exhaust hoods are installed: LOCATION FILTERS SQUARE FIRE AIR AIR &/OR FEET PROTECTION CAPACITY MAKEUP EXTRACTION CFM CFM DEVICES 54. How is each listed ventilation hood system cleaned? L SINKS 55. Is a mop sink present?YES4NO ( ) If no, please describe facility for cleaning of mops and other equipment: 56. If the menu dictates, is a food preparation sink present?YES, NO ( ) * TRAP: A fitting or device,which provides a liquid seal to prevent the emission of sewer gases without materially affecting the flow of sewage or waste water through it. An integral trap is one that is built directly into the fixture, e.g., a toilet fixture. A?P?trap is a fixture trap that provides a liquid seal in the shape of the letter?P.? Full ?S?traps are prohibited. 32. Are floor drains provided & easily cleanable, if so, indicate location: E. WATER SUPPLY 33. Is water supply public Xor private ( )? 34. If private, has source been approved?YES O NO ( ) PENDING ( ) Please attach copy of written approval and/or permit. 35. Is ice made on premises or purchased commercially( )? If made on premise, are specifications for the ice machine provided?YES (gyp NO ( ) C�eA Describe provision for ice scoop storage: Provide location of ice maker or bagging operationKtctcheA) 36. What is the capacity of the hot water generator? 37. Is the hot water generator sufficient for the needs of the establishment? Provide calculations for necessary hot water(see Part 5 &Part 9 Under Section III in this manual) 38. Is there a water treatment device?YES ( )NOX If yes, how will the device be inspected & serviced? 39. How are backflow prevention devices inspected &serviced? l 1 1 (c) At a distance of 75 cm(30 inches) above the floor in areas used for hand washing, ware washing, and equipment and utensil storage, and in toilet rooms; and (3) At least 540 lux (50 foot candles) at a surface where a food employee is working with food or working with utensils or equipment such as knives, slicers, grinders, or saws where employee safety is a factor. e. Food Equipment schedule to include make and model numbers and listing of equipment that is certified or classified for sanitation by an ANSI accredited certification program(when applicable). f. Source of water supply and method of sewage disposal. Provide the location of these facilities and submit evidence that state and local regulations are complied with; g. A color coded flow chart demonstrating flow patterns for: -food (receiving, storage, preparation, service); -food and dishes (portioning, transport, service); -dishes (clean, soiled, cleaning, storage); -utensil (storage, use, cleaning); -trash and garbage (service area, holding, storage); h. Ventilation schedule for each room; i. A mop sink or curbed cleaning facility with facilities for hanging wet mops; j. Garbage can washing area/facility; k. Cabinets for storing toxic chemicals; 1. Dressing rooms, locker areas, employee rest areas, and/or coat rack as required; m. Completed Section 1; n. Site plan (plot plan) FOOD PREPARATION REVIEW Check categories of Potentially Hazardous Foods (PHF's) to be handled, prepared and served. CATEGORY* YES (NO) 1. Thin meats, poultry, fish, eggs (hamburger; sliced meats; fillets) V ( ) 2. Thick meats, whole poultry(roast beef; whole turkey, chickens, hams) 3. Cold processed foods (salads, sandwiches, vegetables) 4. Hot processed foods (soups, stews, rice/noodles, gravy, chowders, casseroles) 5. Bakery goods (pies, custards, cream fillings &toppings) >e ( ) 6. Other * A generic HACCP plan for each category of food may be available from the regulatory authority for reference. STATEMENT: I hereby certify that the above information is correct, and I fully understand that any eviation from te above without prior permission from the Salem Board of Health m nullify final a roval. Signature(s) owner(s) or responsible representative(s) Date: ************ Approval of these plans and specifications by the Salem Board of Health does not indicate compliance with any other code, law or regulation that may be required--federal, state, or local. It further does not constitute endorsement or acceptance of the completed establishment (structure or equipment). A preopening inspection of the establishment with equipment in place & operational will be necessary to determine if it complies with the local and state laws governing food service establishments. , I'I K EXAM FORM NO. 4501 EMM "(B CERTIFICATE NO. 6737650 I 59,09VSaffiso s e w r LEYCAR.LA, CAS,TILL�O- for successfully completing the standards set forth for the ServSafea Food Protection Manager Certification Examination, j which is accredited by the American National Standards Institute (ANSI)—Conference for Food Protection (CFP). i 10/27/2009 DATE OF EXAMINATION 10/27/2014 DATE OF EXPIRATION Local laws apply.Check with your local regulatory agency for recertification requirements. { I NATI O ACCREDITED PROGRAM RESTAURANT f David Gilbert Arne,ican National Standards Institute ASS `-'lATAON® Chief Operating Officer, National Restaurant Association l #0655 Executive Director, National Restaurant Association Solutions 02009 National Restaurant Association Educational Foundation.All rights reserved.SemSefe and the ServSafe logo are registered trademarks of the National Restaurant Association Educational Fcundabon, l and used under license by National Restaurant Association Solutions,LLC,a wholly owned subsidiary of the National Restaurant Association. This due ani cannot be reproduced or altered. - 08121102 v.608 Nil SO Mi CERTIFICATE OF ALLERCaEN AWARENESS TRAINING- Name of Recipient:,Leycarla Hassanein �j Certificate Number:,Cw7553, , Date of Completion:,;03/21/2012 �7 Date of Exp11 iration: 03/20/2017 to Issued By: �t The above-named person is hereby issued this cert ficate for completing an allergen awareness training program COt11pUWorks recognized by the Massachusetts Department of Public Health CompuWorks Systems,Inc. in accordance with 105 CMR 590.009(G)(3)(a). 591 North Avenue,Door 2 Wakefield,MA 01880 P:781-224-1113 Ibis certificate will be valid for fie(5)years from date of completion. F:781-224-0504 7f� w• .compuworks.com (�4