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LAFAYETTE MARKEY - ESTABLISHMENTS LArAYETTE "MARKET 183 LAFAYETTE STREET r 0 Commonwealth of Massachusetts ` e City of Salem Board of Health Kimberley Driscoll $ty 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/14/2011 ESTABLISHMENT NAME: Lafayette Market File Number BHF-2004-000005 183A Lafayette Street Salem MA 01970 LOCATED AT: 183A LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2012-0017 Jan 1,2012 Dec 31,2012 $70.00 TOBACCO VENDOR BHP-2012-0025 Jan 1,2012 Dec 31,2012 $135.00 Total Fees: $205.00 PERMIT EXPIRES ecember 31,2012 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 � � . CITY OF SALEM, MASSACHUSETTS i! B0ARD OF HE.A,LFH �� 120 WASHINGTON STREET,4"'FLOUR TEL (978) 741-1800 I IN[BCRLEY DRISCOLL F-\x(978) 745-0343 MAYOR tramdin@salcm.c(,m LARRY IL;A�tUIN;125/Rlil IS,CI IO,CP-ISS - ' 201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT I NAME OF ESTABLISHMENT �}FAy TTT I ''RRKE ' TFL it 7 5 — 2 2— ADDRESS OF ESTABLISHMENT 3 A I-AFAyE7 vrT FAX# MAILING ADDRESS(if different) EMAIL- Business': Website: OWNER'S NAMEUL a: .. /L_0_h#f?t tfl9 TEL# !�� 6�0 fU/ ADDRESS R 17Rrq dbl? M Avc WaDvlzm MA rel801 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food its prepared) _. 91L- / p EMERGENCY RESPONSE PERSON )nt c-, ,[�1 LQ D149�1/4 HOME TEL# ']'S1 DAYS OF OPERATION Monday - -Tuesday Wednesday, d Thursday;',' Friday': Saturday - Sunda HOURS OF OPERATION p Please write in time dday 'IPrh 9'!r>"-I(pM QAC - (>� lAn - �� P"� . lll„- nnr� �� ✓t, q f ��. (For example llam-llpm TYPE OF ESTABLISHMENTFEE (check oniv) RETAIL STORE YES NO less than 1000sq.ft. _ 70 1000-10,000sq.ft. more than 10,000sq.ft. =$420 RESTAURANT_ --- '.' --------------- YES NO less than 25 seats =$140 (Outdo.., Etat ona.i y ,.�Z5d�ac,�z r 0) 25-99 seats =$280 more than 99 seats =$420 '------ - ---------- ------ ---------------------- BED/BREAKFAST/ YES $100 CHILDCARE SERVICES/NURSING HOME--------------------------------------------- ADDITIONAL PERMITS ------------------------- --------------- - ------------ -- MAKE ----------- -- MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES gD $25 TOBACCO VENDOR <ZEN0 135 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all slate tax returns paid all slate taxes required under the law. Sr t Date Social Security or Federal Identification Number Updated 523/11 FOODAP201 Ladm Check#& Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Lafayette Market File Number:BHF-2004-000005 183A Lafayette Street Salem MA 01970 LOCATED AT: 183A LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0027 Jan 1,2011 Dec 31,2011 $70.00 TOBACCO VENDOR BHP-2011-0026 Jan 1,2011 Dec 31,2011 $135.00 Total Fees: $205.00 PERMIT EXPIRES IDecember 31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH f' 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR Ixaael:.-Nl;AU,',I u)SAI.cnt.COM DAVID GREENBAum,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT At4FA YC-rrE TEL# Vag- 114S' 2022 ADDRESS OF ESTABLISHMENT—/X?A- LaA y�,r <S� FAX# MAILING ADDRESS(if different) EMAIL- Business': n Website: // / OWNER'S NAME /� r� It 01) 1A TEL# -19I hx [x,3 1 ADDRESS L R yGJ/� �� 1G NL1� 62/9 7O STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON /tl - ✓ • 131 date` yq HOME TEL# -71 ' 6094' 1 f S1 sDAYS:OF'OPERATION ,. Monday. ::` < Tuesda r `s+Wednesday, „i Thursday;f ; p...,Fndzy% ;Saturday . , '{.Sunday; HOURS OF OPERATION Please write in time of day. For example Ilam-11 pin) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ------------------------------------------------------------ ------ ---------------------------------------------less-------than-------2-5---s-eat-- ---------------=----14---0--- RESTAURANT YES NO s $ (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 -------------------- -- --------- ----------------------------- --------------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME - ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES <Q $25 TOBACCO VENDOR Co> NO $135 ALL NON-PROFIT(such as church kitchens) YES $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all stale tax returns and p id all stale taxes required under the law. Signatur Date Social Security or Federal Identification Number Revised ionli 1 FOODAP201 Ladm Check#&Date // $ _'v 1 1 't Commonwealth of Massachusetts r City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/11/2010 ESTABLISHMENT NAME: Lafayette Market File Number:BHF-2004-000005 183A Lafayette Street Salem MA 01970 LOCATED AT: 183A LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0239 Jan 4,2010 Dec 31,2010 $70.00 TOBACCO VENDOR BHP-2010-0238 Jan 4,2010 Dec 31,2010 $135.00 Total Fees: $205.00 PERMIT EXPIRES (December 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 / CITY OF SALEM, MASSACHUSETTS + BOARD OF HEALTH 120 WASHINGTON STREET,4"t FLOOR TEL. (978) 741-1800 K AMERLEY DRISCOLL F x(978) 745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT J WhYCrl : /-0,q,9Kr7" TEL# ADDRESS OF ESTABLISHMENT J41a FAX# MAILING ADDRESS(if different) EMAIL-Business': /ALYQYIYA lnait'• Ce)M Website: OWNER'SNAME )VLT A//,0bI9RJyA TEL# 99'1-6i0dP-113/ ADDRESS A2 (Ol.OAlil 1)QIVe 49 Atibaa MA 01310 STREET - CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON f7• t� �/ HOME TEL# '7<91-608L 608 1131 D"A.YSOF OPERA7IONsIMo tday� luesda'% Wednes ay '�Thu sday ��,Fntlay� ayk i `_ `;SatufdSuq�ay HOURS OF OPERATION # I Please write in time of day. / i (For example 11 am-11 pm) 1 !/IM'llpnl; ?40A-11Jp 1 1,64 Ij-•• TYPE OF ESTABLISHMENT FEE check only) RETAIL STORE YES NO lessthan 1000sq. . 7 1000-10,00 sq. . - 280 more than 10,000sq.ft. =$420 ----------------------------------------------------------------------------------------------------------------ie-s's-------------------------------------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES CQ) $2 TOBACCO VENDOR ES NO 135 ALL NON-PROFIT(such as church kitchens) YES NO *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have fled all state tax returns anclLpaid all state totes required under the law. ?Y n ) /2LO /0 F �2D-S� 46.2,Z Sipatrrre _ J _ Date Social Security or Federal Identification Number. --------------------------- ----------- --- ------ Revised 4/24/07 424/07 FOODAP2008.adm Check#&Date S t I 183A Lafayette Street Lafayette Market City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: '' 8 g PROTECTION FROM CONTAMINATION 745 2022] p " $, SJ Handwash Facilities FAIL Critical RED 'iIi Comment: Bathroom handwash sink missing paper towels.Provide paper towels at all hand sinks at all times. Rahul Jashvant Bilodanya+ 1 Violations Related to Good Retail Practices (Blue Items) PIC " p �� ,,, Food and Food Protection FAIL Critical BLUE a Kiran MIs$ra}_ w:;,;F Comment:The following items were removed outdated: IDSpeCfOr: `` 1 cracker barrel cheese 4 - "-� P . _) 4 bags cheez it snack mix Elizabeth Salandrea 1 bottle wish bone dressing e Date InspectedCorrect By. 1 bag TGI Friday cheese fries 1 bag caramel bugles 5/12/2009 > 1 package royal gelatin Risk Level: 2 betty Crocker muffin mix 1 package sugar free puddings _ 1 can chef boyardee Permit Number ti ; 1 can chunky soup .BHP-2009-0100 '�.'' " , ;* 6 cans diet mountain dew Status: Owner to closely monitor all expiration dates. SIGNED OFF of Critical Violations Some drinks stored on floor in basement.Store all drinks 6-8"off the floor. r'^ g 2 Some price labels covering expiration dates(baby food,pasta sauce).Do not cover expiration dates with price labels. [rTime IN � " Time OUT * '8:? Equipment and Utensils FAIL Non-Critical BLUE " Comment: Ice cream freezer needs general cleaning. Urgency Descnpti -... I BLUE:' Milk fridge needs general cleaning. Violations Related to. 00 Retail Practices (Critical Small beer cooler in back corner needs general cleaning. Evilations must be corrected¢'. imediately or withiria0 Please forward last 3 months' extermination invoices to the Board of Health within one week. ys)(Non-criticalt bviolations muse corrected irni bdiately or within 90rdays) r City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 28,2009 ) Page 1 oft I� Item Status Violation Critical Urgency RED {Vlolations,Related to-9 (Foodborne Illness Interventions nand Risk Factors (Require immediate corrective action)__. City of Salem Board of Health 120 Washington Street,4th Floor.SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 28,2009 ) Page 2 oft IMPORTANT MESSAGE FOR S2f4 ` DATE TIME M OF PHONE AREA CODE NUMBER EXTENSION ❑ FAX ❑ MOBILE AREA COOE NUMBER TIME TO CALL I TELEPHONED All PLEASE CALL CAME TO SEE YOU . WILL CALL AGAIN WANTS M SEE YOU RUSH RENRNED YOUR CALL WILL FAX TO YOU . _. G ^Q MESSAGE Ibf, Ab . SIGNED MAAOE IN U.S ..A NUTS Tvio Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'" Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tvoe of Operations) Type of Inspection LAJJ) Yr)A�Lc ' r-)-)\0'a t' ❑ Food Service ® Routine Address Risk ® Retail ❑ Re-inspection 1 k 3 R Sal- to v z Sr Level ❑ Residential Kitchen Previous Inspection Telephone g7 g 1 y S 20 L L ❑ Mobile Date: Owner HACCP YIN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ❑ HACCP Inspector ) xt�ify+� 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',;"."" u�,��m „®,m,�,e 2 El 12. Prevention of Contamination from Hands E] 1 PIC Assigned/Knowledgeable/Duties [113. Handwash Facilities EMPLOYEE HEALTH iPROTECTION FROM CHEMICALS%77 ❑ 2. Reporting of Diseases by Food Employee and PIC sa a�• ro� :*` �- _ _ _ iG a .. �m�= Ll14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded m ❑ 15 Toxic Chemicals FOOD FROMAFVROVED9OURC�li4"1�:3�u„,'w'„�� ��U��.�„�� 1 TIME/TEMPERATURE CONTROLS Potentialf Hazardous foods `�"""„I ❑ 4. Food and Water from Approved Source _ _ ( Y ) �.. .. _a ❑ 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 El8. Separation/Segregation/Protection El 20.Time As a Public Health Control El9. Food Contact Surfaces Cleaning and Sanitizing ':"REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)j` ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices [CONSUMEf3ADVi60RY„ ❑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 Q immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of I 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 r 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:sso�nspecrFomis-ra ooc � A Inspector's Signat e((V �, Print: ., V - T)Av� PIC's Signa ure: Print: �� \�0 ,A( � yG Page 11 of Pages Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT r S Cross-contamination 1 590.003(A) Assignment ofResponsibihty* 3-302.1.1(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Foods* 2-103.11 Person in charge--duties Contamination from Raw Ingredients 3-302.1 1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590:003(,C) ,Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1.1(A) Food Protection* a flicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11. Food Contact with Equipment and - Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(6) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reserviee of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501..1.1 I. Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem eratures* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 MechanitalWarewashing-HotWater 3-202.13Shell Eggs* Sanitization Temperatures* Eggs 3-202.14 E >s and Milk Products.Pasteurized* 4-501..11.4 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-101..1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 5)(1.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment ood- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils Shellfish and Fish Froman Approved Source- 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contad Surfaces of E ui ment* Shellfish- 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Regulatory Authorit Game and Wild Mushrooms Approved by 2.301.11 Clean Condition-Hands and Arms* R 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* ll Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 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* - ees* Tags/Records: Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 3-402.4( Records,Creation and Retention* i-204 11 Location and Placement* 590.004(.1) Labeling of Ingredients' 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying -3-502.11 Special Methods* 630111 Devices 3:502.73 Redued oxygen x gen packaging,criteria* - Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Dm.Provision s Denotes critical item in the federal 1999 Ptxxl Code ur 105 CMR 590.060. t CITY OF SALEM t BOARD OF HEALTH Establishment Name: -�r�y� i 'r nYhoa2lL�t Date: Ll -1b -o F Page: of �- Item Code C-Critical Item ff DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date Reference R-Red Item Verified No. i PLEASE PRINT CLEARLY -- �- Pkv A, 1Cz c_ ens r L �.z. 1 nor ns r� y ta�ttov�l i 1� �cra Ivy l„ . S 7cSves ftoT O'z�Sc.wn-Znay 1 Ql � W-t c -zvv 9-1 7n^cS i - '4 r 2`\ C -• T1-1�. 1-c��.v v'��.r li I S'�.r� S R :c•,"o�� o�� 75���.•'�� '-a - G��ooas r�r-v�� r.�� � -L • �nLfdN�� i3c�;` s � - A,(�.. J 3 - 1\C INLu V0.pr 1 - Sa�� �,t SZ LN ,PS n170 3 - otic s S �vY Z s a- Uil 1 p s v\l, • � • Aa�a�.c-+�o tioo �c>�- qc,�s -ZS��n Oa r SC,��, ova�v-�, Sv lws�eh �-�-oa�+r1•o,- a�v� tix�i rA-e�ire� 7f�18,. t yvti7.. v �jrOVf4 nda� 01' 1'r� � � a+�Z\t t-_1 rA�. 'Jiver � .-� 1-�cA1bTn�L L�i(�i�oC'i Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ "Yes it f 9 I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction / Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. pug J r� ❑ Voluntary Disposal ❑ Other: r i it 114(C`) MIR Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Lai,,Cooled to Factors(items 1-22) (Cont) 4VF/45"F Within 4 Hcqas. Coolia�,,Melho&for PHR PROTECTION FROM CHEMICALS 14 Food or Color Additives E19 PHF Hot and Cold Holding ---T------- 3-,$01.16(1l� Cold PHFs Maintained at or below 3-2a J2 A("rive,r ,590.00I(F) 4 1 V45'F* , 3-302,14 Protection fronk 1.1trappruved Addibees' —A 3-50 L I6;A) Hot PHIS Maintained at or above 15 Poisonous olsonous or Toxic Substances 140"1". - Roasts Hold at or those 130°F.I(TI 11 nnotyme Tnuoi —0i iglruj 3 Coluainers" - Time as a Public Health Control 7-102.11 colmoon Name- WorlkillLc tit,Llllsr�� L��O --- 7-204.174e3-501 19 Time as a Public Ilealth Cono2L--i -aLu(n-7-so A�ae 5901004(11) varianT 7-201 R��,Arictnari -PrescRw andhxea- 7-202.12 Corrhtions of ljso -T,- -CC-0-ni—at"o-E,--pr'ehibinom, 7-203,11 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7.204.11 Sjmii7��c,,(tire I r.ia-C I h I e I in I iols* POPULATIONS HSP) 7-204J2 Cheillicais for Wushing Ilioduce,c6teiral- 21 T-801.1 I(A) Unpatcuriyed Pa,paekagcd Inoncs and 7-204,1 Bcv"a,�es with Warni")i LsJb 1 0 S ±— 3-801.11(8) lja�of Parteuri7�d E S' 7-205,11 Incidental Food Coraact�lAibricants* iE2 3-801 11(D) Raw or PartialIv Cooked Xm�n�a Food wal 7-206.f I Restricted 1 s peucides'clitelia* Raw stta[S 7-206.12 Roclent 13nit siafions� - .4 E38�( I,I I(C l Unopened N [Not Re-seac4lz 7-206.13 'franking Powders,Pest Control and Nlonitorin"4 Z--- CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS -22 3-601,11 Consumer�Vtvisozv Posted for Corvanalptilln(It Animal Foo&Thai are Raw. Underawked or 6 Proper Cooking Temperatures For Not 00tv'(wise Pr(wwqseati to E'lirainate PHFS 'W"" 3-e401. F,i, Padur"enn* go- ITiF F5 7Sc Irmon.diawServict, 1 45F I 5sec, 4-30-3.13 Pasteurizod Substitute fea Rmv Shell 9-401.11(02) Coulliankned FM-Meats&Gaint —4K-I(B)(I)( ) Amer ds SPECIAL REQUIREMENTS 1 2 Polk and Beef Roast - 130 F 121 min* 3-401.1 (6) 1 violations 0 Section in I(A)(2� Raotes,Injeclod M,us 155 F 15 catering. mobilo food,teniporari,and F-461JI(A)Tj llouilry'Wild G)allre' 5ulffej€'l-IFS, residen'1W kitchen operations should be Fi%h, Meat, w debited corder the appropriate sections Poultry�or Ratites-165°F`J5 sec. above if related to fbodborric illness 3-401 Whole-nals"le,lrtacTkcf Slowks intetventions aud risk factors, Other W5'F* - -- 590.009 violations s relarin v to pood retail 3 401.12 Raw ArritWiFoods Calked ol 11 practices should be debited under#29 - Microwave 105'F spccuil Requircrilmits. -All Omer 11.I I Fn-- 145,2F 15 sec. 17 Reheating for Hot Holding -VIOLATIONSRELATED TO GOOD RETAIL PRACTICES 3403J](A)&(D) PHFa 165°F 15 see,, (Itents 23-30) 7'�-4031 1(8)� Microwave- 165" 2 Minnie Standire, Criiiral and non-e rilical viinalb#*, which do nor relive 4e itir --lirce foodborne tuners imet ventions and rLkjattors aided atove, (ani be t-403.11(C) Commercially Processed RTF Rind- Jound in the Folid Code dead 105 0,11? 140°F" J90.0()O' �E s90 m 401 1 I(F�i Reatunon, Unshced Portions of&ef ��tem::- Roasl*I* 23, 1 Management and Personnel N3 T�f I r24 F�po;ieotio'n 18 Proper Cooling of PHFS 7 5 LEguip Utensils FC--4 �005 3 01,14A) Cooliaiz Cooked PHFs from 140'F to 26 V Watei,Pitantamiand Waste 7017 Within 214ours and From 70"F 19 Physical Facility_ FC-6 .007 w 4j 'F/45�F WitinnA Houu. 1 �41 28 Poisonous or Toyjc Malerials FC-7 '008 p —---– ------- -- ----- - 1.14(B) Cooling PHRIMadc Frour Ambient Temperain 30, her r�-501.14 0 re InLredicinq n,41"F/451' -LOL Within 4 Ilkiurs item in lhr jolend 1999 Foal(*'Aeer joS CMR 590000' .. ' '' wr. -50�.+*3 ��` 4', A��> i v=,�� .my�� � +^;i!psk-.�+�+x�t i .nm•.swr r �*a -.r �8. Commonwealth of Massachusetts • City of Salem Board of Health Kknbedey DdScoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/14/2008 ESTABLISHMENT NAME: Lafayette Market File Numbu:BHF-2004-000005 183A Lafayette Street Salem MA 01970 LOCATED AT: 183A LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0356 Jan 14,2008 Dec 31,2008 $70.00 TOBACCO VENDOR BHP-2008-0357 Jan 14,2008 Dec 31,2008 $135.00 Total Fees: $205.00 PERMIT EXPIRES iDecember3l, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in, a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1 QTY OF SALEM, MASSACHUSETTS BOARD OF HEALTH r. 120 WASHINGTON STREET,4" FLOOR TEL.(978) 741-1800 KINMERLEY DRISCOLL FAX(978) 745-0343 MAYOR 1SCOTFOSALEM.COM JOANNE SOOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1--AFA4C�[C MR12VE7_ TEL# c;-78— 74s"2D2z_ ADDRESS OF ESTABLISHMENT ��`� A k4 rAYu-17�6 S7 FAX# MAILING ADDRESS(if different) II EMAIL-Business': b t L 0 d CLL 1 `G�(P QYVICI.t l 03)7l, Website: -181 OWNER'SNAME TEL# - 608- 113 ADDRESS S 1)0Ni�-OQTH Af,5 W01R\fQf3 M © 1801 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON R A kA U U Q�\ t_b0 tie\y/a. HOME TEL# DAYS OF OPERATION Monda Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION 1c9 Please write in time of day. 1 (For example l lam-11pm) QJh 01 QM M A M� ` 4d4gh .AM �M 1" —1lAA TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. more than 10,000sq.ft. =$420 ------------------------ ---------------------. . RESTAURANT YES NO less than 25 seats........ --- =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ..-----'----'----.. YES NO ..----- -----------------------------------'-----$1---0-0..---- . BED/BREAKFAST/ CHILDCARE SEEVICES---._-----_-,..._ _._- ..... ................ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE �NO $25 TOBACCO VENDOR 135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paidall state taxes required under the(law. / Sib ature Date Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008.adm CheckN&Date S Commonwealth of Massachusetts ` e City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: Lafayette Market File Number:BHF-2004-000005 183A Lafayette Street Salem MA 01970 LOCATED AT: 183A LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0100 Dec 23,2008 Dec 31,2009 $70.00 TOBACCO VENDOR BHP-2009-0101 Dec 23,2008 Dec 31,2009 $135.00 Total Fees: $205.00 PERMIT EXPIRES IDecember 31,2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS ' t BOARD OF HEALTH 120 WASHINGTON STREET,4"-�FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR ID10NNr SALFNi.COA4 JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT LA FAY 15'n7E- M 1)R kE 1- TEL#9) 71IL57'2022. ADDRESS OF ESTABLISHMENT 123AgjjgefrE ST FAX# MAILING ADDRESS(if different) EMAIL-Business`. bi, darIy�� QM6114I �Qit Website: OWNER'SNAME RAI-tUL T 21LLDAelYA TEL# i'f/'- -09-1/-1 ADDRESS 9 bMFO -M AUENVE h,JXt&A) I - 0/yo/ STREET CITY SPATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON Yo t T kr( L_ HOME TEL# 02),6 -6 '/'70 DAYSOFOPERATION.' I '.: Monday Tuesda Wedhesda ' Thursda > P = `Edda Saturday- Sunda HOURS OF OPERATION p� ® p Please write in time of day. 0PN RPM' �ar ��'�11n grµ-���/t( 04t ��� d -�� M Arm � �p� (For example 1 lam-11 pm) P P g TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YE NO less than 1000sq.ft. _$ 70 1000-10,000sq.ft. 280 more than 10,000sq.ft. =$420 ------------------------------------------------------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 mora ti a 1 99 Jews -WYLv BED/BREAKFAST/ YES NO - $100 CHILDCARE SERVICES - - ADDITIONAL PERMITS � MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE Y $25 TOBACCO VENDOR `YEP NQ < 135 ALL NON-PROFIT(such as church kitchens) S O $25 *Please pay total with one check payable to the City of al M. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date �Tj A L f l`f7e d $ j CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 Fax 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor .JOANNE SCOTT, MPH, IRS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT L AFR\1 E i T E M P q-V e TEL# 9a - `lU -- 2022_ ADDRESS OF ESTABLISHMENT 1%% A L.APpyCTTE: 5r FAX# MAILING ADDRESS (if different) tt EMAIL--Business': �11 A airl t/A MgMa0 .CAK-,, Owners: OWNER'S NAME QA"QL_ �M !\ PAYT TEL# ADDRESS ( S � ET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) - EMERGENCY RESPONSE PERSON HOME TEL# OAYSOFOPENATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS Of OPERATION �1 1 Please writeinumealaay : 7� - INA IRR,-�0PNI If4u 1( I`& 'Am,-N)k �Aµ . 1'Qyt I/[A -I� �� `IAµ _I�p�l IFar example Liam-11pmi TYPE OF ESTABLISHMENT FEE (check onyJ----,, RETAIL STORE ( YES NO less than 1000sq.ft. 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES O less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 ------- _ --- __----------- -- -....._ BED/8REAKFAST YES NO $100 - ---------------- ---...-- - _.-... - - --- .._-....._._.. . ......._. .......--............. .. ...._... .--- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YESaNO TOBACCO VENDOR YES ALL NON-PROFIT(such as church kitchens) YES $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, i have filed a0 state tax returns and paid all state taxes required under the law. I _�� t 44 _ Q2,n277W62 Signa ure Date Social Security or Federal Identification Number ---- --- - - ----- --------- ---- - - - - - - - -r1 ------------ - --------------------------- - Revised 11113/06 FOODAP'L007.adm Check#&Date s /� Commonwealth of Massachusetts'i��, x aq .+a;r J s' ir�+ -*,P's k4"s" r-rmae „ k o� YrCs rr M. Y v' �+{r T F ++aa•' �w�', S�,�t'�,5�" Aub �} }\ W � �J _4 711 iq++. �'t A. $ + i+. s ,a Y�.ak+!fie a YE -, qµS') �'S,C��{`u�'8ax � ,T3�`�•R YC� � r iq. a �` IGm ey�Dnscoll- �� «�Y "�` , G ri to 120 Washington Sheet,4th Floor * a�¢ Ma)FOr� �a f { ,,:r s}y^M J-a y ✓, v+. z Yti;.�,-.',c ,;,,,i n ,e ,,.:: r+ +m`.'.+.+ r,�.�:' . :"'h E .,. "y^. =M'9"�t SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 03/01/2007 ESTABLISHMENT NAME: Lafayette Market, Inc. File Number:BHF-2004-000005 183A Lafayette Street Salem MA 01970 LOCATED AT: 183A LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0418 Mar 1,2007 Dec 31,2007 $100.00 TOBACCO VENDOR BHP-2007-0419 Mar 1,2007 Dec 31;2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1 183A Lafayette Street Lafayette Market City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 745-2022 PIC Assigned/Knowledgeable/Duties PASS RED Owner: Non-compliance with: Rahul Jashvant Bilodariya Anti-Choking PASS PIC: Thiennga Nguyen Tobacco PASS Inspector: David Greenbaum ' EMPLOYEE HEALTH Date d re tbauCorrect By: Reporting of Diseases by Food Employee and PIC PASS RED 3/9/2007 Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS 0 RED BHP-2007-0418 Receiving/Condition PASS 0 RED Status: SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS 0 RED #Of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 09,2007 ) Page 1 of 1 Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS 91 RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS ❑v RED immediate corrective action) Proper Adequate Handwashing PASS 0 RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS RED Handwash Facilities PASS RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS 0 RED Toxic Chemicals PASS 0 RED TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS 0 RED Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 09,2007 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: All unfinished wood shelving must be made impervious before the next routine inspection. In accordance with the Federal Food Code and the State Sanitary Code all requirements to operate a food establishment have been met. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Mar 09,2007 ) Page 3 of Inspection of Date✓-/ - 4 7 Time Name Address 4 75 1����7z fr Owner yy11 / y / Tel. No. / Type of Inspection l�il d / f"M1�-{-- Inspector —1 - ?7 ( ' Remarks and Violations are listed below: Orl 1) n ` 6G1J+1 Pa S�i d Jr) - ,1,P n r /,r / 5 l' nn,LJc' -SLP d /-7 1 h 2 !I f1h j/10 y /n //a 41;-A .S rny 5� h✓ (7,ry Iiw 000IP0 IIAJ- / a. h0,,, 14 AJ- r - 1 � ., sGtd rine 1)n ln1 /3111I �"J-J C/' Z4 f In fht (, ,aik on-w, �G/f1 �,•,,/ ff I , CO ✓✓an + 1u W ✓/✓Ne /P� S .en 5Ia '/ (inf / 7i1 r ru v� �ir f1l�n.t� crr, -c f w #000 of At- -ryJP Yu I/21� / �! I I � IlS/� A IL4 M 7/? _ r S0PIM vw/ VP iia / alre ,r M f �r) ` -h-p liv,e,,f 4 At-�� -- D A�z1 _ / (I n�ia ,n.4 Iu D✓ ✓ovtii�,. � L_ 1 CK Ji. 5/?2✓f5 1/l l lam V6-4111L i9-n 4// es h jF m A� kw 1 - ke, `JIIQ' ") ��/�{1.Q✓� {?.C,t .� - Jv! C,f _J /7t.v 5�/ /✓1 t/�5�/�OYt1 0K VF�7✓fc., 0l Q -F)h1, .! llGcr /l�/ 1.a/// 4�x� �� �P.,Z/ --7 Ir7 �� Report Received by: Inspection of Date Time Name Address Owner Tel. No. Type of Inspection Inspector ( � 1 Remarks and Violations are listed below: Report Received by: Inspection of Date Time Name Address Owner Tel. No. Type of Inspection Inspector ( � 1 Remarks and Violations are listed below: Report Received by: inspection of Date Time Name Address Owner Tel. No. Type of Inspection Inspector ( ' ) Remarks and Violations are listed below: Report Received by: r f Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, Division of Food and Drugs Salem, MA 01970-35230 Floor FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Type of Operations) �Ipe of Inspection ❑ Food Service ❑ Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner HACCP VM El ElPre-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. rFOOD PROTECTION MANAGEMENT; �, ,�'; •, ,," .y�"- ",o�",k ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH r PROTECTION FROM CHEMICALS�y, , ) e.......a gym,.,,. ,..,,-..,..�.�.•.,as�s�, ,e„�,: ❑ 2. Reporting of Diseases by Food Employee and PICa�.I-• --m ��I + �, �h ��. • � ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded � r ❑ 15.Toxic Chemicals g FOOD FROM APPROVED SOURCE-'�T,=u,a ��' 4�A7„�•�" m , a1'� +rTiME/TEMPERATURE CONTROLS(Potentially Hazardous Footls)'r •' ' ❑ 4. Food and Water from Approved Source '- ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling f PROTECTION FROM CONTAMINATION11 '; " ` �, I70 ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and SanitizingREQUIREMENTS FOR HIGHLY SUSGEP, TIBLE PO-PULATIONS(HSPj ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices L-:CONS UM ER ADVISORY,•„.,,, ��"s",,� .k"G .�.! iw"�""" in„Iwf,.7 �,a+��,'I ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)590.0 4) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(5cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(s90.00 )o.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) 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:50IMpe FOm 14,dX Inspector's Signature: Print: PIC's Signature: Print: Page_of Pages Violations Related to Foodb6me'Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 59(1.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw Ingredients - 3-3011.1(A)(2) Raw Anitual Foals Separated from Each EMPLOYEE HEALTH Other" 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) - Food Protection* applicants* 3-302.15 Washin Fruits and Vegetables 590.003(F) Responsibility Of A Foal Employee Or An 3-304.11 Foal Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE 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 1 3-201.12 Food in a Hermetical) Sy caled Container* Sanifization Te eratures* - 3-201.13 Fluid Milk and Milk Products* 4-501.11.2 Mechanical Warewashing-HotWater Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.1.0. Eggs and Milk Products.Pasteurized* 3-202.16 Ice Made From Potable D nk ng Water* concentration and hardness, 5-'101.11 DrinkingWater from an Approved System* 4-60 L 17(A) Equipment Ct Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* - 1. Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Surfaces and Utensils*ce 4-702,11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed SChemical* Sources* 10 Proper,Adequate Game and Wild Mushrooms Approved by Hand Re ulato Author' 2-301.11 Clean Condition-Handscashing and Anes"' 3-202.18 Shellsta;k 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 Receiving/Condition 2401.11 Eating,Drinkin or Using Tobacco* - 3-202.11 PHFs Received at Proper Temperatures* 7401.12 Discharges From the Eyes, Nose and 3-202.15 Package Inte it * Mouth* 3-101.11 Food Safe and Unadulterated* , 3-301..12 Preventing Contamination When Tasting* 6 TagstRecords:Shellstock L12 0 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-20.3.12 ShellstockIdentification Maintained" r Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* _ Conveniently Located and Accessible 5-203.11. Numbers and Capacities* Labeling of Ingredients' 3-402.12 RecoLabel s,Creation and Retention* 5-204,11 Location and Placement* 590.004Q) 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance- 1HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices Reduced oxen rackang;criteria* 6-301.II Handwashin Cleanser, Availability 3-502.12 6.301 l2 8-103.12 Conformance with Approved Procedures* Hand Dr ,'n*Provision Denotes crillical item in the federal 1999 Foal Cate of 105 CMR 590.000. - - ii 1• _- / P ' . `�f .7k,� a'� Massachusetts CF e: a5 S mentr�of) PubIi6 H0alth t d Salem Board of Health si e n = 11 l : a+ a(ji E, i a 'y t-. 120 Was)tmgton Street,4"Floor Division of Food and Drugs 1 1 �i Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date TVDe of Operation(sl Tvpe of Inspection ❑ Food Service ❑ Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ) r $ y, ❑ Mobile Date: El Temporary,✓ ElPre-operationOwner ) " HACCP YM t0 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. 1 FOOD PROTECTION higryAdEMENT m a ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH-,, .e.„.„,.,.„.M ('„,-PROTECTIEIN FROM CHEMICALS II a ❑ 2. Reporting of Diseases by Food Employee and PIC U- •*s ❑ 14.Approved Food or Color Additives V ❑ 3. Personnel with Infections Restricted/Excluded t ❑ 15.Toxic Chemicals 2 `FOOD FROM APPROVED ❑,4. Food and Water from Approved Source "i 1,TIMMEMPERATURE CONTROLS(Pgtentlally Hazardous Foods) , kr3a El 5. Receiving/Condition El16. Cooking Temperatures 4 t , E] 6. 1,T Reheating 6. Tags/Records/Accuracy of Ingredient Statements - � g ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling r � , «+ ❑ 19. Hot and^Cold Holdin PROTECTION FROM CONTAMINATION 9 , El 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control t ❑ 9. Food.Contact Surfaces Cleaning and Sanitizing \ C,REOUIREM 1 T6 FOR HIGHLY Sus.CEPTIBLE POPULATIONS(HSP) ED 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11: Good Hygienic Practices ' v sCONSUMERADVISORY>' ❑22. Posting of Consumer Advisories `.Violations'Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected `" I' To Faodborne Illnesses Interventions immediately orwithin 10 days as determined by the Board and Risk Factors(Items 1-22) s of Health. Nori-critical,(N)violations must be corrected + Y Official Orderfor'Correction: Based on an inspection ,immediately or within 90 days,as determined by the Boafd today,'the items checked indicate violation`s,"of 105 CMR of Health. j / 590.000/federal Food'Code. This report, when signed below cC by a Board of Health-member or its agent constitutes an - \ 23. Management and Personnel (FC-2)(590.003) x order of the Board of Health. Failure to correct violations , 241 Food and Food Protection (Fc-3)(590.004) cited in this report may result.in suspension or revocation of 25:°Equipment and Utensils (FC-4)(590.005) the food"establishment permit And cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) 1 ' „ 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,,501Wu IFmm 14x f; Inspector's'Signature: Print: PIC's Signature: f Print: Page_of_Pages ' s ✓ Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Gross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(1.) Raw Animal Foods Separated lrom 590.003(B) 1 Demonstration of Knowledge* Cooked and RTE Foods* 2-]03.11 Person in dnarge-duties Contamination from Raw ingredients 3-302.1.l(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by foal employees and 3-302.11(A) I Food Protection* applicants" 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char*e* Contamination from the Consumer 590.003(0) Reporting by Person in Charge' 3-306.14(A)(.B) Returned Food and Resetvice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrict ans Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Frwd"` 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Cam fiance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tem eratures* - 3-201.t3 Fluid Milk and Milk Products* 4-501.1 t2 Mechanical Warewashing-Hot Water 3-202.1.3 Shell Eggs* Sanitization Temperatures* 3-202.1.4 Eggs and Milk Products,Pasteurized* 4-50L114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water' concentration and hardness. 5-101,11 DrinkingWater from an A roved S stem* 4-60 L 11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinkin Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils' Sheiltish and Fish From an Approved Source 4-702.11. Frequency of Sanitization of Utensils and 3-201.44 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by e to Author' 2-301.1.1. Clean Condition-Hands and Atrnns* Rula 3-202.18 Shellstock 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 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes,Nose and 3-202.15 Package Ince it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 t Preventfn Contamination When Tasting* 6 TagslRecords:Shellstock 12 - Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Emplo ees* TagalRecords: 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(7) Labeling of Ingredients' _ 5-204.11 Location and Placement* 9 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Special ized Processing Methods* Devices 3-502.1.2 Reduced ox en packaging,criteria* 6-301.11. Hindwashing Cleanser, Availabilit g 8-103.12 Conformance with A. roved Procedures* 6-301.12 Hand Drying Provision '�Denotes critical item in the federal 1999 Foal Cade or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH f t o`l t�inR Name of Establishment: Lafayette Marke} Address: 183A Lafayette Street 3 Owner(s): RJ Bilodari Phone: 781-608-1131 November 13, 2006 The proposed new owner of this establishment presented plans for this establishment for review in accordance with the State Sanitary Code. ITEMS FOR SALE All food items displayed and offered to the public must be from a source permitted as a Wholesaler from the Mass Department of Public Health. There will be no food preparation at this establishment. FLOOR PLAN All surfaces must be intact, impervious and easily cleanable. All refrigeration units must have accurate internal thermometers. Refrigerated food must be held at 41 degrees Fahrenheit or lower, freezers at 0 degrees Fahrenheit or lower. EXPIRATION DATES All expiration dates on products must be clearly visible. Out dated items must be promptly removed from display. HAND WASHING The hand sink must have a wail hung soap and paper towel dispenser, stocked at all times. TRASH Trash barrels stored in the rear of the property will be used. These must remain closed and the area kept clean and sanitary at all times. EXTERMINATION Monthly services of a Licensed Pest Control Operator are required. Please keep receipts for inspections. An opening inspection will be conducted in ear Itj P Iroeow'f DKL�.c<: Lt.,!/ �'tt:i_i 1 ' Fl r/u ' 'f/7 1 % .f `. Joanne Scott Date Health Agent 1 t 1,3 0 b RJ Bilo ariga Date . .. ...._.- ..... __ CITY OF SALEM, MASSACHUSETTS RECEIVED BOARD OF HEALTH q 120 WASHINGTON STREET, 4TH FLOOR DEC — 4 2006 SALEM, MA 01970 CITY OF SALEM TEL 978-741-1800 BOARD OF HEALTH FAx 978-745-0343 Kimberley Driscoll www.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT_ Nict, PAT-yy,- TEL# 179 7 4 S 2d` 2 ZADDRESS OF ESTABLISHMENT �'� � S 19101A. RA- 0%N70 FAX# MAILING ADDRESS (if different) EIVLAIL--Business': ��{{ 'j p( gOwner's:_ ll OWNER'S NAME ILP a kt- � Y/OAA10 jb f� s,, ur o �A TEL# rj7-2 77t{ Z70 b ADDRESS Itl iRUJ60n1 DL c' P-X e.v", MA}-- OIC170 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially+hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL O) DAYS Of OPERATION Monday Tuesday Wednesday Thursday Friday _I Saturday Sunday HOURS Of � 0NPA1 PM PM f #Mwtmay. 7 11 P 7 #t� 11 pM tPor examalg 11am-ttemt i TYPE OF ESTABLISHMENT FEE (Check only) RETAIL STORE E NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. 100 more than 10,000sq.ft. _$ ......... --- -YES N-----i4O. _ - _ _ -....--.... ..... -- --.. ..-..... - -...- le- - RESTAURANT ss than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 _._.. ....._.... - -- - ._..... _.... - ... - -- - - , -- - ------ ------- -- ---....--- BEDIBREAKFAST YES NO $100 -- ... --- - ----- - -.... -..----- -- .. . ......_... - ....... ................ . ... . ----------- --.....-._... ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief. have filed Ali state tax returns and paid all state taxes required under the law. _ 1242 106 0 D0 _ Signature Date Social Security or Federal Identification Number - -------------------- --------------- ---------n---o--,-q--.----- ------ - ------------------------------------------------- --------------- Revised 11/13/06 FOODAP2007.adm Check#&Date— =-6�—/ 0 �_ s —1 op.0-0 mmb1M" et *CoonwealthotMas'sachusetts, � �Cof9atem It.; «'yam{ r.Nf P z r ioard of ea .BHlth -^` } . .i., 120 Washington Street,4th Floor l�ml>e�ey DnSooll Y r r t s{ ;" Mayor SALEM,MA 01970 . Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: Lafayette Market, Inc. File Number:BHF-2004-000005 183A Lafayette Street Salem MA 01970 LOCATED AT: 183A LAFAYETTE STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0005 Dec 19,2006 Dec 31,2007 $100.00 TOBACCO VENDOR BHP-2007-0047 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES !December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 15 of 29 va y rv:£ L4"�vaL' 9h-•c+L` a-"�-.c'kf'yx+ ,+ :..�.°�+^tW'�`§�'a+xaw .+_. xtFs,�..r ��"�§e`q mow.$ �t`�z q"">f'�;, +� } 'r � ♦ y°�' +,�rt^ ,°�r1y ...,., ,wnw- .a.?r_..;.: .i+' '3�,� F... r;n.w...�._,.s,. ...a...L A- -.r. - _• Mw. 'Si4rY 'f CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741.1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Lafayette Market, Inc. Address of Establishment: 183A Lafayette Street Owner's Name: Thiennga Nguyen Restrictions: Application Date: 12/2/2004 Permit for Food Establishment 147-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 36-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, - In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH _ 120 WASHINGTON STREET, 4TH FLOOR c SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT LAfA IFTTT MRRIcC T, ry(, TEL# `I7Y 74SZti ZL ADDRESS OF ESTABLISHMENT S)- S•c Pte+^ MA 0161 70 MAILING ADDRESS (if different) QUI. OWNER=S-NAME Tl1iry Y�c c n/ n f1 TEL# 'I 7S 7 402 3 ADDRESS CITY in(c✓vw STATE ik� A' ZIP I i70 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON I.emery.^ UtJLtnHOME TEL# 1 Vf '74 C Z el rl a HOURS OF OPERATION: Mon. 7-111 Tue. 7-11 Wed. 7 -II Thu. '7-11 Fri. 7 ll Sat. /-] Sun. 7-iI TYPE OF ESTABLISHMENT FEE check only RETAIL STORE n YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100— more than 10,000s .ft. =$250 q RESTAURANT YES NO / less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR �� YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signatur Date Social Security or Federal Identification Number -------7.0a_ --------------------------------------------------- 'I------------------------------------ Revised 11/03/03 FOODAP2.adm Check#&Date o2.III 11 Jo�.4 I0'i 183A Lafayette Street Lafayette Market, Inc. City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-2022 Handwash Facilities FAIL Critical ❑d RED Owner: Comment:The front hand wash sink found obstructed. Keep hand wash sink clear and accessible at all times. Thiennga Nguyen PIC: Thiennga Nguyen , GENERAL COMMENTS: Inspector: David Greenbaum 669:AII other violations cited in the 6/6/06 inspection report have been corrected. Date Inspected:Correct By: 6/20/2006 J Risk Level: i Permit Number: BHP-2006-0129 _ Status: SIGNED OFF # of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 21,2006 ) Page 1 oft y,- Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 21,2006 ) Page 2 oft 183A Lafayette Street Lafayette Market, Inc. City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-2022 Handwash Facilities FAIL Critical ❑d RED Owner: �-Comment:The front hand wash sink found obstructed. Keep hand wash sink clear and accessible at all times. Thiennga Nguyen PIC: The front hand wash has no hot water. Provide hot water at the hand wash sink at all times. The front hand wash sink missing paper towels. Provide disposable paper towels at the hand wash sink at all times. Inspector: The bathroom missing paper towels. Provide disposable paper towels in the bathroom at all times. David Greenbaum Date Inspected:Correct By: Violations Related to Good Retail Practices (Blue Items) 616/2006 Food and Food Protection FAIL Critical BLUE Risk Level: Comment:The following items found outdated: 2-wheat thins mayo _ � ' 4-BBQ sauce Permit Number: V e-corn BHP-2006-0129 4-corn muffin mix '� 2-pork and beans Status: Closely monitoor all expiration dates. VIOLATION Physical Facility FAIL Non-Critical BLUE #of Critical Violations: Comment:The walk in has unfinished floors,walls and ceiling. The walk in flows,walls and ceiling must be made impervious and 2 easily cleanable. Time IN: Time OUT: \ The bathroom found cluttered. Keep bathroom free and clear of all clutter. Urgency Description(s): \\v The bathroom light needs a protective cover. BLUE: Violations Related to Good \J There are broken floor tiles near the front door. Replace all broken floor tiles. Retail Practices (Critical they-See Notes FAIL Non-Critical BLUE violations must be corrected immediately or within 10 Comment:The establishment is in need of a thorough cleaning and dusting. days)(Non-critical violations GENERAL COMMENTS: must be corrected immediately or within 90 days) 647:Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 07,2006 ) Page I oft • Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) II City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 07,2006 ) Page 2 oft iE Commonwealth of Massachusetts Board of Health. 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/27/2005 WHO'S PLACE OF BUSINESS IS: Lafayette Market, Inc. File Number:BHF-2004-0005 183A Lafayette Street - Salem MA 01970 LOCATED AT: 183A LAFAYETTE STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0129 Jan 3,2006 Dec 31,2006 $100.00 Total Fees: $100.00 PERMIT EXPIRES IDecember3l, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 3 of 9 CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH s 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 �� ,/ '{O STANLEY J. USOVICZ, JR. FAX 978-745-0343 c, [(V// MAYOR Www.SALEM.COM �Q r ;, JOANNE SCOTT, MPH, RS, CHO A�� �F C HEALTH AGENT 1i 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT ry NAME OF ESTABLISHMENT LkEhJ F j T H!tLET• TEL# 179 740 2� 1 3 •. ADDRESS OF ESTABLISHMENT I g '1 � �� S fi. S K HA- O j q:7_D MAILING ADDRESS (if different) Q,�nr &,,f_GVVgE-R`S'NAMET Itl G N N( F4 N� i/�} F A/ TEL# 97y ADDRESS CITY SSTATE f-�k ZIP Iq 7O CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentiallyhazardous food is prepared.) EMERGENCY RESPONSE PERSON 1 Le Vi 5n c- NG�-� HOME TEL# G17S 7 2 HOURS OF OPERATION: Mon.]_:: Tue. LI VGed. 4, Thu. 7•-1I Fri. -7-11 Sat. -7- Sun. TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than I000sq.ft. =$ 50 1000-10,000sq.ft. =$100•-- more than 10,000sq.ft. =$250 ----- ------------ ------------------ --------- --------------------------------------------- '"'""-""----n"',------ ---= "'"'-------------- .............--- - -----------_......---- ---------- RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more / v more than 99 seats =$200 ----------------------------------------------------------------------------------$---10------------------- BED/BREAKFAST YES NO 0 .. ---------- ------------ -------- -- -------- ------..I --............. . ............... ............. --....... ....... ...... ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM,YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. q o 9 Signature Date Social Security or Federal Identification Number --- --------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date .2.G 1 '3 7 /0�_ Ufa � 183A Lafayette Street Lafayette Market, Inc. City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ .Telephone: -.. Item Status Violation Critical Urgency Nature of problem or correction 745-2022 Non-compliance with: Not Done Owner: Anti-Choking PASS ❑ z Thien iga Nguyen _ Tobacco PASS ❑ Thiennga Nguyen„ ^" FOOD PROTECTION MANAGEMENT Not Done Inspector: "- PIC Aselyned/Knuwludyuublu/Duoec PASSd❑ itLu David Greenbaum °" EMPLUYEE HEAL IH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS [] RED .6/15/2005. Personnel with Infections Restricted/Excluded PASSd❑ RED Risk Level- ° M % FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASS 0 RED 1311 P-2605-022G Rocoiving/Condition PACS ❑r RCD Status: Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED SIGNED OFF Conformance with Approved Procedures/HACCP PASS ❑d RED #of Critical Violations Plans 1 PROTECTION FROM CONTAMINATION Not Done Time IN:, Time OUT: SPparatinn/SegrPoatinn/PrntPrtinn PASS 0 RED Notes: Food Contact Surfaces Cleaning and Sanitizing PASS 0 RED 209 Proper Adequate Handwashing PASS ❑d RED a •• Urg " a u ency'Description(s) Good Hygienic Practices PASS ❑J RED :BLUE: , " Prevention of Contamination from Hands PASS ❑d. RED Violations Related to Good Retail Practices (Critical Handwash Facilities FAIL Critical RED Front handwash sink missing paper violations must be Corrected_ towels. Provide disposable paper towels at immediately or.within r10-. '101 ,' the handwash sink at all times. days)(Non-critical violations GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Jun 15,2005 ) Page 1 of 183A Lafayette Street Lafayette Market, Inc. must be Corrected Immediately ". PROTECTION FROM CHEMICALS Not Done or within 90 days)„_ Approved Food or Color Additives PASS RED RED: Violations Related to Tuxiu Chemiuels PASS ] RED Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASS Q RED immediate Corrective action) m Reheating PASS RED Cooling PASSJ❑ RED Hot and Cold Holding PASS RED Time As a Public Health Control PASSJ❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE 32 items found outdated at time of inspection. Owner must closely monitor expiration dates to insure that product on the shelves has not expired. There is food stored directly on the Floor in th basement. All food must be stored at least 6-8 inched off the floor. Equipment and Utensils FAIL Non-Critical ❑ BLUE True cooling unit in front missing a thermometer. Provide a visible accurate thermometer in the unit. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non-Critical ❑ BLUE All shelving is need of a thorough cleaning. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Jun 15,2005 ) Page 2 of 183A Lafayette Street Lafayette Market, Inc. GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Jun 15,2005 ) Page 3 of p CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR o SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Lafayette Market, Inc. Address of Establishment: 183A Lafayette Street Owner's Name: Thiennga Nguyen Restrictions: Application Date: 12/2/2003 Permit for Food Establishment 82-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 18-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS �1 " �qq�,�yy BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 NOV 18 2003 • TEL. 978-741-1800 FAX 978-745-0343 G! 1-Y OF SALEM STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH 'MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT LkFYETT MFrRKt/ � TEL# q7!P 71FSX22 ADDRESS OF ESTABLISHMENT 183 A- S Gwt M4-01g7o MAILING ADDRESS (if different) OWNER'SNAME t� p PLFi�IXorU TEL# 97b� 74t� 2 ` '73, ADDRESS W th V 6no,- CITY `OL'C'r STATE tom- ZIP p 1 J 70 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Tiyeyih gg I R N je4y HOME TEL# 7/�0-z X13 q7 p/A b% pN o-✓ pM 8*1 p�. " 111 6M /M �M ffi HOURS OF OPERATION: Mon. BH_i(Tue.7 it Wed.7-11 Thu?�Fri.7-11 Sat.-J -1/ Sun. 7 /1 TYPE OF ESTABLISH M T FEE check only RETAIL STORE E NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. 100 S2 d� more than 10,000sq.ft. RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR 8�� ES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have fled all state tax returns and paid all state taxes re uired under the law. II / rs /v-3 043 - 56 S9- q09 Signatur D to Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4`" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Type of Operation(s) Tvpe of Inspection Z47LLut,/�Q `7"YkiR/ Q�"'-jr✓G- �/-/$"-0� iFood Service ❑ Routine Address f Risk Retail ❑ Re-inspection Telephone Level ❑ Residential Kitchen Previous Inspection WS' 4 0 y ❑ Mobile Date:y_ F- p Owner HACCP Y/N El Temporary [-] Pre-operation G Ale/ d /q -L/P/n ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) / Time ❑ Bed&Breakfast ❑ General Complaint Sf7 r- T-7� In: ❑ HACCP Inspector rt�a0� r ,l /. YY'f[, CdPia Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands'- [-] 1. PIC Assigned/Knowledgeable/Duties _ ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC E] 3. Personnel with Infections Restricted/Excluded El 14. Approved Food or Color Additives FOOD FROM APPROVED SOURCEEl 15.Toxic Chemicals. - ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)`:,,: ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling .PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20. Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY.SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY _ [:122. 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 ofCealNth. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste `(FC-5)(590.006) the food establishment permit and cessation of food 1. 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:5900 WFo, a 14.. I ctor's' igna r : - NeE N Print: PIC's Signature: r'1 Print: a .��U/ �n vt �� Pagel Of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination ] 590.003(A) Assignment of Responsibility* 3-302.11(A)(1) Raw Amoral Foods Separated from 590.003(B) Demonstration of Knowledge* �� Cooked and I2TP Foods- 2-103A I oods-2-10311 Person in charge-duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated front Each EMPLOYEE HEALTH Other" 2 590.003(0) Responsibility of the person in charge to Contamination from the.Environment require reporting by fool employees and 3-302,1.1(A) I Food Protection* applicants* 3-302.15 Washing I'miksand Vegetables . 590.003(F) Responsibility Of A Food Employee Gr An 3-304.11 Food Contact with Equipment and Applicant To ReportTo The Person]it Utensils* Charge* Contamination from the Consumer 590.003(G) Re ordn b Person in Char e* 3-306,14(A)(B) Returned Food and Reservice of Food* 3 590.003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe F_O.OD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources g Food Contact Surfaces 590.004(A-B) Conalaliance with Food Law* 4-501.11 I Manual Warew tshing-Ikst Water 3-20L12 Food in a Hermetically Sealed Container* Sanitization-Yam-eraatres* 3?01.1.3 Fluid Milk and Milk Products* 4-501.'112 Mechanical Warewashina Plot Water 3-202.13 Shell Euog* Sanitization Temperatures* 3-202.14 Saes and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. " 3-202.16 ice Made From Potable Drinking Water* 5-101.11 Drinkin Water from an Approved System'" 4-601.11(A) Equipment Fuad Contact Surfaces and Utensils Clean' 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Cauglt Molluscan Food Comaar Snrtiaces of F ui Item* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.,15 Molluscan Shellfish from NSSP Listed Chemical* Sources* LO Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulato Author 2-301.11 C9ean Condition--Hands and Arens" 3-202,18 Shellstock Identification Present* 2-301.12 Cleaning Proedme* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* .. 3-201.17 Game Animals* 11 Good Hygienic Practices 2-401.11 Faun , Drinking, r Using Tobacco* S Receiving/Condition .-,..... .... _�.. �o..__v....., -. 3-202.11 PLIFs Received at Proper Temperatures* 2-401.12 Dkeharges From the Eyes.Nose and 3-202.15 Package Inte it.x, Mouth* 3-101.11 Food Safe and Unadulterated'% 3-301.12 Preventing Contamination When Tasting* b1 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 ShellsWek Identification Maintained'" Ent kivees* Tags/Records:Fish Products ]3 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and.Ca acities* 590.004(.1) Labeling of Ingredients' 5-204.11 Location and Placement" ry Conformance with Approved Procedures 5-205.11 Aceessibilit Q eration and Maintenance fHACCP Plans Supplied with Soap and Hand Drying 3-502.1.1 Specialized Processing Methods* Devices 3-502.12 Reduced ox en 2ackagging,criteria* 6-301.1.1 Etandwashin*Cleanser.Availability 8-103.12 Conformance with A xoved Yroceddres" 6-301.12 Hand Dryin,,Provision "Denote,,critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: LyAfq $9T I_iC eAtA ae 40- Date:�f /1��n 4 Page: 2 of '2 Item Code C-Critical Rem - DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY , O t£� L t/� AJ_t-- owt-6*4— ILL LL- 2 O e ! /Nr C d ✓15X- rt,er nr 3 `V?L r Discussion With Person in Charge: Corrective Action Required: U No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure J your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(0) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Iaw Cooled to Factors(items 9-22) (Cont.) 41°Fl45°F Within 4 tiours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 I Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives` 3-501..16(13) Cold PIIFs Maintained at of below 590.004(F) 4P145"F" 3-302.14 Protection tram Una s roved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous ar Toxic Substances 7-101.11 kient(tying 7nformatfon-Grigins( t40° " Containers* 3-501.1 Ci(A) RoasF.ts Held at or above 130°F. 7-102.11 Common NamContainers*e-Workinn 20 Time as a Public Health Control 7-201.11 Se auation-Stm urge^` 3-501.19 Time as a Public Health Control* 7-2(}2.1 I Restriction-Presence and Use, 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohiberions'r REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Saritizers,Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce. Criteria* 21 3-s0'I.11(A) LJnpasteudzed Pre-packaged Juices and Beverages with Warning Iiibels* 7-204.14 Dr'in eats,Criteria* 3-801,11(B) Use of Pasteurized'Eggs* 7-20511 Incidental Food Contact.Lubricants* 3-80L l I(D) Raw or Partially Conked Animal Food and 7-2061 t Restricted Use Pesticide-s. Criteria* Raw Seed Sprouts Not Served. 'r 7-206.12 Rodent Bait Stations* 3_801.I I(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitorina* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 401L1A(1)(2) Fbgs- 155 F 15 Sec. Pathogens.* '�=n,. r "1 Eggs-immediate Service 145°Fl5see* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game Eggs* Animals-155°F 15 sec.'r 3-401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 nun* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D) in� sec.* catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFr, residential kitchen operations should he Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°P 15 sec. * above if related to foodborne illness 3-401.11.(C)(3) Whole-muscle,huact Beef Steaks interventions and risk factors. Other 1450F T 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under f#29- Microwave 165°F* Special Requirements. 3-40111(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(.A)&(D) PHFs 165°F 15 sec.* (Items 23.30) 3-403.118) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, ohich do not relate to the Time" foodborne illness interventions and risk factors listed above, can be 3-403.t (C) Commercially Processed RTE Food- found in the fallowing sections of the Food Code and 105 CMR 140 IF, 590.000. 3-403.t 1(13) Remaining Unsliced Portions oP,Beef item Good Retail Practices inc 59t1.000 ------ -- 00 Roasts* 23. Management and Personnel FC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC--3 .004 25. Equipment and Utensils FC-T--.005 3-50'114(A) Cool b Ing PHFs from 140°F to --- --- _--__- 26. Water,Plumbin and Waste FC 5 .006 70-17 Within 2 Hours and.From 70°F 27. Physical Facility FC-6 .007 to 41°Fl45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC_-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ectal Re ulrements .009 Temperature htgredienis to 41 OF145°F 30. Other Within 4 Hours:' ssmr�,„m„�-z.:xK 4 Denotes 0 RlLal item in the foiMll 1999 Food Cud,,or 105 CMR 590000. Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'" Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Type of ODeration(sl T e of Inspection L"1124 T l/e- -Old LJ/Food Service Routine Address' / ® Retail Risk S�` ❑ Re-inspection Telephone / Level ❑ Residential Kitchen Previous Inspection Z2 ❑ Mobile Date: OwnerHACCP Y/N ElTemporary ElPre-operation N / u 4j_&1_1 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: El HACCP Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions) 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 " ' ' _. ❑ 1 . Prevention of Contamination from Hands E] 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities EMPLOYEE HEALTH ' - '' ' : ' ` , ,c., ., .... PROTECTION FROM CHEMICALS ` ❑ 2. Re ortin of Diseas p g es by Food Employee and PIC , El3. Personnel with Infections Restricted/Excluded El 14. Approved Food or Color Additives FOOD FROM APPROVED SOURCE -' ' El 15.Toxic Chemicals , ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION19. Hot and Cold Holding ❑ 8. Separation/Segregation/Proro tection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing :. REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 10. Proper Adequate Handwashing Cl 21. Food and Food Preparation for HSP ❑ ❑ 11. Good Hygienic Practices ' CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions 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 ofCeaNh. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations /95. Equipment and Utensils cited in this report may result in suspension or revocation of (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of thisprder. 30. Other DATE OF RE-INSPECTION: 7 1/y S.5901nsP�'Fomr6-14.Ooc !l '2 ector' rgna e: Print: 2 PI 'sSignature: - int: i N C NNG(� '��JLl /I/, Page US Pages e- Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(A) Assignment of Responsibility' 3-302.11(A)(1) Raw Animal Tools Separated from 5911003(B) Demonstration of Knowledge" Cooked and RTE Foods* 2-103.11 Poison in charge-duties Contamination from Raw Ingredients 3-3021I(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection'` a tlictutts* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Egaiptnent and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590,003(C) Re)ortind b Person in Char,-e 3-306.141A}(13) Returned foodand Rcsetvice of Food" 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F.) Removal of Exclusions and Restrictions Food 3-701-11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCEFood" 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) CtnniliancewithFoodLaw* 4-501.111 Manual Warewashing-HotWitter 3-201.12 Food in a Hermeticaliv Sealed Container* Sanitization Temperatures' 3-201.13 Fluid Milk and Milk Products* 4-501.112 Meelt nical Warewastun;-Hot Water 3-202.13Shell E� 's* Sanitizadon Temperatures* 3-202.14 Eggs and Milk Pn)ducts.Pasteurized* 4-501.-1 i4 Chemical concentration hardtion-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* Equipment and hardness. �r 5-1.01..11 Drinkin Water from an Approved System- 4-601_1 I(A) Equipment.Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* 1ils Clem' 4-602.11 Cleaning Frequency of Equipment Food- 590.Opb(B) Water Meets Standards in CMR 22.0* Contact Surfaces and Utensils`" Shellfish and Fish From an Approved Sourcece 4-702.1 L Frequency of Sanitization of Utensils and 3-201.14 Fish arta Recreationally Caught Molluscan Food Contact Surfaces oP ui went* Shellfish" 4-703-11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1p Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-rands and Arms" Regulatory Authority 3-202.18 Shellstock Identification Present* 2-30L12 Cleanfm=Procedare* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game.Animals* 1] Good Hygienic Practices Receiving/Condition 2-401.17 Eatim , nking*or Usrn�Tobaccos`Dri 3-202.11 PHFs Received at Pro ter Tent eratures* 2-101.12 Discharges From the Eyes. Nose and 3-202-15 Package InLit x* Mouth" 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventin=Contamination When Tastim," 6 Togs/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(H) Preventing Contamination from 3-201.12 Shellstock Identification Maintained* Em h)vees* Tags/Records:Fish Products I3 Handwash Facilities 3--902.11 Parasite Destruction" Conveniently Located and Accessible - 3-402.12 Records,Creation and Retention` 5-203.11 Numbers and Ca euro t* 590.004Cq Labeling of Ingredients' S-20411 Ac1xicesion and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibilit O pe�ation and Maintenance lHACCP Plans Supplied with Snap and Hand[Drying 3-502.11 Specialized Processing Methods'* Devices 3-502.72 Reduced oxygen packaging, criteria* 6-301.11 Handwashing Cleanser, Availability 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Drying Provision ..1Denors eri6cal item in the federal 1999 Pond Code lir 105 Cpl 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: f Date:�� -�� Page: _�a of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item. Verified PLEASE PRINT CLEARLY zAg Z / �� / 7` h 2.f di a- s / /XSO rrs y — R, i y— L N011-7 6(P P/Z CPI O /1 GS c �z Sou 1 i b c S c/ z Discussion With Person in Charge: Corrective Action Requiredr ❑ :No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins P LI Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure ' your food permit. �e f ❑ Voluntary Disposal ❑ Other: 3-501.14(0) PHFs Received at Temperatures - Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(Items 1-22) (Cont) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives l9 PHF Hot and Cold Holding 3-202.12 Additives" 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 41.'/45°F* 3-302.14 Protection from Una roved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above s 7-101.11 Identifying Information-Origi3-501.16(A) Roasts Roasts ts Held at or above 130'F. Containers* 7-102.11. Common Narne-Working Containers'" 20 Time as a Public Health Control 7-201.11 Separation-Stora e* 3-501.19 Time as a Public Health Control" 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use, 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sauieizers. Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washin>Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* 3-80 with Warning Labels* 7-205.11 Incidental Food Contact,Lubrican3-801.11.(B) Use of Pasteurized Eggs* ts* 7-206.11 Restdeted Use Pesticides,Criteria" 3-80t.'11(D} Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 7-20612 Rodent Bait Stations* 3-801.11(C) Unopened Food Park Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMElTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for _PHFs Not Otherwise Processed to Eliminate FneceLe ra;2on� 3-4(11.1.1A(1)(2) Eggs- 155'F 15 See. Pathogens.* E,-s-immedite.Service 145'F15sec* 3-302.1.3 1 Pasteurized Eggs Substitute for Raw Shell 3-401.I I(A)(2) Comminuted Fish.Meats&Game E >s* Animals-155'F 15 sec. SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 12't turn* 5 - 3-40 Ll I(A)(2) Ratites,Injected Meats- 155'F 15 90.009(A)-(D) Violations of Section 590.009(A)-(ll)in sec. * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk Factors. (Other 145'F* 590.009 violations relating to good retail 3-40112 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(Ul,b) Atl Other PHFs- 145'F 15 sec. 17 - Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PPIFs 165'F 15 sec. * (Items 23.30) 3-403.1,1(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 3-403.1.1(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3-403.1 l(E) Remaining Unslieed Portions of Beef Item Good Retail Practices FC 590.000 Roasts* 23. Management and Personnel FC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25. Equipment and Utensils FC-4_ _.005 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. Water,Plumbing and Waste FC-5 006 70'F Within 2 Hours and From 70'F 27. -Physical Facility FC-6 .007 to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41'F/45'F 30. Other Within 4 Hours* *Denotes critical item in thefederal 1999 Fard Codear 105 CMI2590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: 1_-OF�t L/r'/7 Date: Page: 3 of 3 Item` Code C-Critical Item DESCRIPTION'.OF VIOLATION/PLAN OF.CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY " / 3 A P r p } � /� 'r All / 1 Al 42 f� t ,[ Discussion With Person in Charge: Corrective.Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Emersion violations before the next ins �t p ❑ Re-inspection Scheduled ❑ Emergency Suspension i 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. I � X"_'" ❑ Voluntary Disposal ❑ Other: R III 3-501.14((Kc) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According it)Law Cowled to Factors(items 1-22) (Cont.) 4'1"F145'F Within 4 Hours. PROTECTION_FROM CHEMICALS 3-501.15 CoolivaMethods for PIlFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PRFs Maintained at or below 590.004(F') 41'/45'F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at to above 140"F. * 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above '130'F. Containers* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.1.1 Separation-Storage' 3-501.19 Time as a Public Health Control" 7-20111 Restriction-Presence and Use* 590.004(H) Variance Rc'c uirement 7-202.12 Conditions of Use* 7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals i'or Washing Produce-Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Wanting Lribels* 3-801.11(13) Use ofPasteutizedE Eggs* 7-205.11 Incidental Food Contact, ,Crites i3O 3-801.11(D) Raw of Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served. * 7-206.1.2 Rodent Bait Stations"` 3-901.11(C) Unopened Food Parka=c Not Re-served. 7-206.13 Tracking Powders,Pest Control and M"nitoring CONSUMER ADVISORY TIMElTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of j( Proper Cooking Temperatures for Animal Foods That are Raw,Undenc oked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs 1557 15 Sec. Pathogens.* ".-s` ,.'oo� 1 E s-immediate Service 145'Fl5sec* 3-302.1.3 Pasteurized Eggs Substitute for Raw Shell 3 40L11(A)(2) Comminuted Fish.Meats&Game Eggs' Animals- 155"F 15 sec. 3-401.11(B)(1)(2) Pot kandBeef Roast- 1.30°F121. min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 1.55'F 15 590.009(A)-(D) Violations ofSection 590.009(A)-(p)in sec. * catering, mobile food, temporary and 3-40 1.11(A)(3) Poulvy,Wild Game,StutYed PHFs- residential kitchen operations should be Sturirng l:onfaining Fish,Meat, u_Jnw ,andel'the -,, o"i_u: awi.�aa Poultry or Ratites-165'F 15 sec. ` above if related to foodborne illness 3-401.1.1(0)(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 tinder#29- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-145'F 15 see. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-4011.1(A)&(D) PHFs 165'F 15 sec. * (Items 23-30) 3-403.11(11) Microwave-165'F 2 Minute Standing Critical and tion-critical violations, which do root relate to the Time* foodborne illness interventions and risk facktrs,listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the follovibig sections of the Wood Code.and 105 CMR 14W[co 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef item Good Retail Practices ^'-FC 590.000 Roasts* 23. Management and Personnel FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection I FC-3 .004 L-L25. Equipment and Utensils _ 1..FC 4 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. Water.Plumbing and Waste FC 5 006 70'F Within 2 Howl and From 70'F 27. Physical Facility FC-6 .007 to 41'F145°F Within 4 Hoary. * 28._ Poisonous or Toxic Materials IFC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Sectal Requirements -- _i-_ .009 Temperature Ingredients to 41°FI45°F 30. Other � _,_,_-__,_____,_,_l Within 4 Hours'" ssmn.w„rir-zmm Denwcs Critical item in the tedrnd 1999 Food Code or 105 CNIR 590.000. o CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 3 w 120 WASHINGTON STREET, 4TH FLOOR ` SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS. CHO MAYOR HEALTH AGENT r COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to : Owner' s Name : Lafayette Market, Inc . Name of Establishment : Lafayette Market, Inc . Address of Establishment : 183A Lafayette Street Type of Establishment : RETAIL FOOD Application Date : 12/10/2002 Restrictions: Permit for Food Establishment 43-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 7-03 These Permits Expire December 31, 2003 Thisermit is not transferable and must be reissued upon change of P P 4 ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT �o CITY OF SALEM, MASSACHUSETTS D BOARD OF HEALTH �l� 3 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 DEC D.. 2002 TEL. 978-741-1800 FAX 978-745-0343 LI i ' ` j_ FAX STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT t-A pA V ET T 6- T TEL# 1 78 7(pS 20 Z Z ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME L,6rP y T I f TEL# g V 7 G J Zo 2 el- ADDRESS ADDRESS I?j 6 w2� x sfi" S _ 1N01-o l x970 CITY go4yy4, STATE H4- ZIP Bfct 70 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON I ", � HOMETEL# VY 7W 7-gy'3 HOURS OF OPERATION: Mon.7-I2Tue._Z:y_Wed. 7_I( Thu. 7-11 Fri.7-// Sat. 7-tl Sun. A--JV TYPE OF ESTABLISHMENT- FEE check only RETAIL STOREES NO less than 1000sq.ft. =$ 0 -3 1000-10,000sq.ft. =600 � l� more than 10,000sq.ft. =$250 RESTAURANT YES !Nd less than 25 seats =$100 �/ 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES DO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE NO 3 $5 TOBACCO VENDOR /� YES NO ��� Ea ALL OF"11 1 I'Suc as CIurc1, kitclNO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. '2 l l gC/ I 2, 0 4 35,6 S q 07 SigiiatureP Date Social Security or Federal Identification Number --------- ---------------------------------------------------- Revised 11/25/02 FOODAP2.adm Chedc#&Date