CINDYS PLANET PIZZA & GRILL IN OOND(pt City of Salem, Massachusetts
lui
Board of Health
120 Washington Street, 4th Floor, Salem, MA 01970
a Tel. (978) 741-1800 Fax. (978) 745-0343 PlubhCHealth
lramdin@salem.com Prcvcnt. Promotc.,Protcct.
Kimberley Driscoll Larry Ramdin, MPH, REHS, CHO
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Fstablishment)
2016
Permit Number: FM-16.248
Permit Type: Food Establishment< 25 seats
Goods &Services: Food Service: 0- 24 seats
Name of License Holder: Cindy's Planet/ Cindy Yen
Name of Food Establishment Cindy's Planet Pizza &Grill
Address of Food Establishment 177 Fort Avenue Salem MA 01970
Restrictions:
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2016 unless sooner suspended or revoked.
Permit Fee: $140.00
Effective: 3/15/2016
v
t City of Salem, Massachusetts
Board of Health �i
PublicHealth
120 Washington Street, 4th Floor, Salem, MA 01970 �«•<e,.P«mo,<.">,«,•
Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin, MPH, REHS, CHO
Mayor Iramdin@salem.com Health Agent
FROZEN DESSERT PERMIT
Permit# License For : Frozen Dessert
FD-16-8
Date of Print Granted To: Cindy's Planet/ Cindy Yen
3/15/2016
Permit Issued Address: 7 Oak Street Apt. A Boston MA 02111
3/15/2016
Location of Establishment: 171 FORT AVENUE
Permit Expires
12/31/2016
Permit Fee Restrictions: Cindy's Planet Pizza & Grill
$25.00
Late Fee Notes:
$0.00
This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2016 , unless
sooner revoked or suspended.
CITY OF. SALEM,
MASSACHUSETTS 1�blicHealth
.BOARD OF HEALTH n.....r..m...r.......
120 WASHINGTON STREET,4-FLOOR
KIMBERLEY DRISCOLL TEL.(978)741-1800 FAx(978)745-0343
MAYOR Iramdin((Osalem.com LARRY RAMDIN,RS/RENS,CHO,CP-FS
HEALTHAGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
.1) Establishment Name: ( t 411
2) Establishment Address: �/.' / I Q
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: — INV
5) Applicant Name&rifle: _ _ OCA)
6) Applicant Address`,
,�f( I
A Qz
7) Applicant Telephone No: 24 Hour Emergency No: �JCflij�e a Email: Q( (tQf
8) Owner Name&Title(If different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An association Name Title Home Address
Cori
or ratio 1 AAndioviduann0
A partnership
Other legal entity
12 Person Directly Responsible For Daily Operations Owner Person in Charge, Supervisor, Manager,etc.
Name&Title:
Address:
Telephone No: Fax: Email:
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
r
Check#: 1/l 1!D D Date:_,,�/22
Amount: /
C
Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: (If applicable)
16) Days and Hours of Operation: N 17) No.of Food Employees: Z '
18) Name of Person in Charge Certified In Food Protection Management:
Required as o/10/12001 in accordance with 105 CMR 590.003(A) k`DI ✓l Q
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ YesNo
20) Location: 22) Establishment Type(check all that apply)
(check one) / ❑Retail( Sq. Ft) ❑Caterer
Permanent Structure ✓ ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer
Mobile GYPood Service-Takeout ❑Residential Kitchen for Retail Sale
❑ Food Service-Institution ❑Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑Residential Kitchen for Bed and
21) Length Of Permit: Brgakfagt Establishments......................
(check one) RETAIL STORE REBTA RANT
Annual ❑Less than 1000sq.ft. $70 ess than 25 seats
Seasonat/Dates: ❑1000-10,000sq.ft. $280 ❑Residential Kitchens $140
❑More than 10,000sq.ft. $420 ❑25.99 seats $280
40 if
_
❑More than 99 seats $420
Te nporary/Dates/Time: m.--••.........................................................
❑Bed& BreakfasUChildcare Services/Nursing Hoe $100
I — m ......................................•-----------------•--------------------...........................-.
ADDITIONAL PERMITS
RI'MAKE ICE CREAM, YOGURT/SOFT SERVE
❑PASTURIZATION $25
❑ALL NON-PROFIT' $25
*Including, church kitchens state funded childcare&private club
23) Food Operations: Definitions: PHF-potentially hazardous rood(fime/tempereture controls required)
Non-PHFs-non-potentially hazardous rood(no tim&lemperature controls required)
(check all that apply): RTE-read toeat foods Ex.sandwichesi salads muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs ✓ for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board ofHealth
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
/� Payment Is due with application
I,the undersigned,attest to the accuracy of E Information provided In this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all othe7,/
licable law I habee nstructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C,sec.49A, I certify and the nalties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state to es required under law.
25) Social Security Number or Federal ID: 04 - 33 2-SO I y
26) Signature of Individual or Corporate Name: 0 1 ND Yi� ?CA-0e-(- I
Massachusetts Department of Public Health Salem Board of Health
Division of Food and Drugs 120 Washington Street,4a'Floor
Salem,MA 01970-3523
�/
Tel. (978)741-1800 Fax (978) 745-0343
City/Town of 5 , Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
Name /'• r Dat Type ofOperation(s) Type of Inspection
G h S 6f,"(1 m Food Service ❑Routine
Address Risk ❑ Retail [jRe-Inspection
Telephone Level L] Residential Kitchen Previous Inspection
Tele
P 7$ 7u l _I egeT ❑ Mobile Date:
Owner HACCP YIN ❑ Temporary ®Preoperation
a ❑ Caterer ❑Suspect Illness
Person-In-Charge(PIC) Time ❑ Bed 8 Breakfast ❑General Complaint
In: ❑HACCP
Inspector Out: Permit No. ❑Other
Each violation checkbd 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 Factor%(Red
Items) Aml-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
Allergen Awareness 590.009(G) ❑
corrective 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
❑ ❑ 14.Approved Food or Color Additives
3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source TIMEREMPERATURE CONTROLS(Potentially Hazardous Foods)
❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements El 17.Reheating
❑ 7. Conformance with Approved Prooedures(HACCP Plans [118.Cooling
PROTECTION FROM CONTAMINATION ❑ 19.Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑ 20.Time as a Public Health Control
❑ 9.Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY-SUSCEPTIBLE-POPULATIONS(HSP)
❑ 10. Proper Adequate Handwashing ❑21.Food and Food Preparation for HSP
❑ 11.Good Hygienic Practices CONSUMER ADVISORY
❑ 22.Posting of Consumer Advisories
Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction:Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
C r N r 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 (Fca)(s9o.004) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FCE)(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: r.,mc
Inspector's Signature• Print:
PTCs Signature: Print: Pnge of a Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors (Items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.1](A)(]) Raw Animal Foods Separated from
1 590.003(A) Assi j uncnt of Responsibility* Cooked and Rlli Foods*
590.003 Demonstration of Knowledge* Contamination tram Raw Ingredients
2.10.1 113 Persson in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
Other'
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3-302.1](A) Food Protection'
require reposing by food employees and 3-302.15 N'ashine Fruits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590.003(n Responsibility Of A Food Employee Or An Utensils*
Applicant To RLpori To'Ihe Person In Contamination from the Consumer
Charge* 3-306.14(A)(13) Returned Food and Reservice of Food'
590,003(G) RL riming b•Person in Charge* Disposition of Adulterated or Contaminated
3 590.003(D) Exclusions and Restrictions* Food
590.003(1: Removal of Exclusions and Restrictions 3-701.1 I Discarding or Reconditioning Unsafe
Food'
FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces
4 Food and Water From Regulated Sources 4-501.111 Manual Warewashing-I lot Water
590.004(A-13) Compliance with Food Law* Sanitization Temperatures*
3-201.12 Food in a I lermetically Scaled Container' 4-501.112 Mechanical Warewashing-Hol Water
3-201.13 fluid Milk and Milk Products* Sanilizalion Tent ratures'
3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH,
concentration and hardness.`
3-202.14 Eggs and Milk Products, Pasteurized* 4-601.11(A) Equipment Foal Contact Surfaces and
3.202.16 Ice Made Front potable DrinkingWater* Utensils Clean'
5-101.11 Drinking Water from an Approved Sysscm• 4-6,02.11 Cleaning Frequency of Equipment Food-
590.006(A) Bouled Drinking Water` Contact Surfaces and Ute sits•
590.006(13) Water Meets Standards in 310 CMR 22.0• 4-702.1 I Frequency of Sanitization of Utensils and
Shellfish and Fish From an Approved Source Food Contact Surfaces of Equipment*
menta
3-201.14 Fish and Recreationally Caught Molluscan 4-703.1 I Methods of Sanitization-Hot Water and
Shellfish* Chemical*
3-201.15 Molluscan Shellfish from NSSP Listed 10 Proper,Adequate Handwashing
Sources* 2-301,11 Clean Condition-Hands and Arms*
Game and Wild Mushrooms Approved by
Regulatory Authority2-301.14 2-301.12 Cleaning Procedure*When to Wash*
3-202.18 Shellslock Identification Present* shsh
590.004(C) Wild Mushrooms' 11 Good Hygienic Practices
3-201.17 Game Animals' 2-401.11 Eating, Drinking or UsingTobacco*
S Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and
3-202.11 PRFs Received at Pro r Tem ralures• Mouth*
3-202.15 package Inle grit ' 3-301.12 Prevenline Contamination N9tcn Tasting'
3-101.11 Food Safe and Unadulteralcd• 12 Prevention of Contamination from Hands
6 Tags/Records: Shellstock 590.004(E) Prevenline Conumtinalion front
3-202.18 Shellslock Identification
I:nt to gees•
3-203.12 Shellslock Identification Maintained' 13 Handwash Facilities
Tags/Records: Fish ProductsConveniently Located and Accessible
3402.11 Parasile Destruction' 5-203.11 Numbers and Capacities*
3402.12 Records.Creation and Retention• 5-204.11 Location and placement'
590.004(1) Labeling of Ingredients* 5-205.1 I Accessibility,Operation and Maintenance
7 Conformance with Approved Procedures Supplied with Soap and Hand Drying
Devices
IHACP Plans (6..330011.11 2I Ilandwashing Cleanser,Availability
-502.11 Eland Drying provision3
3-502.12 Reduced oxygen packaging,criteria•
8-103.12 Conformance with Approved Procedures•
•
Denotes critical item in the federal 1999 Food Code ut 105 CMR 590.000.
t
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: GV1 (S 1✓�Mip l')Pt�� Date: 3ta8t(-6 Page: a of a.
Item code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION DateNo. Reference R-Red Item PLEASE PRINT CLEARLY Vivified
�- l �ct
,
�� fStl
� I
E
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑, yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction
violations before the next inspection, to observe all conditions as described, and to Exclusion
P ❑ Re-inspection Scheduled O Emergency Suspension
comply with all mandates of the Mass/Federal ood Code. I understand that
noncompliance may result in daily fines of �nty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other.
`4
Violations Related to Foodborne Illness Interventions and Risk
Factors(Items 1-22) (Cont.) 3-501.15 Cooling Methods for PI 11's
' 19 PHF Hot and Cold Holding
g PROTECTION FROM CHEMICALS 3.501.16(13) Cold Pill's Maintained at or below
& 14 Food or Color Additives 590.004(17) 419/450 F'
3-202.12 Additives* 3-501.16(A) Hot PRFs Maintained at or above
¢, 3.302.14 Protection from Unapproved Additives* 14001:
f 15 Poisonous or Toxic Substances
.� 3-501.16(A) I Roasts Held at or above 1309'.
Si 7-101.11 Identifying Information-Original 20 Time as a Public Health Control
t Containers*
p7.102.11 Common Name-WorkingContainers' 3-501.19 Time aa Public Health Control'
7-201.11 Separation-Storage* S90.004(H Variance R uirenent
7-202.11 Restriction-Presence and Use' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-202.12 Conditions of Use* POPULATIONS HSP
7-203.11 Toxic Containers-prohibitions* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.11 Sanitizers,Criteria-Chemicals* Beverages with Wanting Labels*
7.204.12 Chemicals for Washing Produce,Criteria* 3-801.11(13) Use of Pasteurized 1' '
7-204.14 D ink A enls,Criteria' 3-901.11(1)) Raw or Partially Cooked Animal Food and
R° 7-205.1 I Incidental Food Contact, Lubricants' Raw Seed Sprouts Not Served.•
fy. 7-206.11 Restricted Use Pesticides,Criteria' 3-801.11(C) Unopened Food Package Not Re-served
�7 7-206.12 Rodent Bait Stations'
7-206.13 Trucking Powders,Pest Control and CONSUMER ADVISORY
Monitorin • 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw, Undercooked or
TIME/TEMPERATURE CONTROLS Not Otherwise Processed to Eliminate
f+ 16 Proper Cooking Temperatures for Pathogens.*E�°`•'a2°01
CC 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs*
3401.11A(I)(2) Eggs- 1559' 15 Sec.
1
Eggs-Immediate Scrvicc 145°PI Ssec• SPECIAL REQUIREMENTS
3-401.11(A)(2) Comminuted Fish,Meats&Game 590.009(A)-(D) Violations of Section 590.009(A)-(D) in
Animals- 1559F 15 sec.
3-001.11(13 I catering, mobile food, aand
' )( )(2) Pork and Beef Roast- 130°P 121 min' residential kitchen operations
ons sshhould be
3-401.11(A)(2) Ratites,Injected Meats- 155°F 15 sec. debited under the appropriate sections
3-401.11(A)(3) Poultry,Wild Game,Stuffed PIIFs, above if related to foodbome illness
Stuffing Containing Fish,Meat, interventions and risk factors. Otter
Poultry or Ratites-1651' 15 sec. 590.009 violations relating to good retail
3-401.11(C)(3) Whole-muscle,Intact 13cef Steaks practices should be debited under#29-
145"F' Special Requirements.
3-401.12 Raw Animal Foods Cooked in a
` Microwave 165°F• VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-401.1 l(A)(1)(b) All Other PIIFs-1459' 15 sec. • (Iters 23-30)
Ek 17 Reheating for Hol Holding Critical and nor-crifical violations,which do not relate to the
k 3-403.11(A)R(D) Reheating
PI lFs ting f165*F I S of • foodborne illness intervention and risk factors listed above,can be
found in die following sections r f the food Code and 105 CMH
3-403.11(13) Microwave- 165°F 2 Minute Standing 590.000.
Time*
Item Good Retail Practices FC 590.000
3-403.1 1(C) Commercially Processed RTE Food- 23. Manegement and Personnel FC-2 .003
q 1400F• 24. Food and Food Protection FC-3 .004
3-403.11(1-) Remaining Unsliced Portions of Beef 25. Equipment and Utensils FC-4 .005
Roasts' 26. Water,Plumbing and Waste FC-5 .006
I'. F I8 Proper Cooling of PHFs 27. Physical Facility FC-6 .007
28. Poisonous
Materials FC-7 .008
3-501.14(A) Cooling Cooked PIIFs from 1409'to 29. Special Requirements .009
709F Within 2 Hours and From 709'to 30. Other
41017459'Within 4 Flours. ' 5�2.m
3.501.14(13) Cooling PI IFs Made From Ambient
Temperature Ingredients to 41017/4501'
l1 Within 4 Flours'
E 3-501.14(C) PI lFs Received at 7entpemuues
Accordine to law Cooled to
41°1745°'Within 4 1[ours.
Ft 'Denotes critical item in the federal 1999 rood Code or 105 CMR 590.000.
i1
�r
City of Salem, Massachusetts
lu
Board of Health
120 Washington Street, 4th Floor, Salem, MA 01970
° Tel. (978) 741-1800 Fax. (978) 745-0343 P11b11CHP.alth
Iramdln@salem.Com Prevent. Promote. Protect.
Kimberley Driscoll Larry Ramdin, MPH, REHS, CHO
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2015
Permit Number: FM-15-254
Permit Type: Food Establishment< 25 seats
Goods& Services: Food Service: 0-24 seats
Name of License Holder: Cindy Planet/ Cindy Yen
Name of Food Establishment Cindy's Planet Pizza &Grill
Address of Food Establishment 177 Fort Avenue Salem MA 01970
i
Restrictions:
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on
12/31/2015 unless sooner suspended or revoked.
Permit Fee: $140.00
Issued: 3/10/2015
I
I
I
§ . CITY OF SALEM,
MASSACHUSETTS
Public Health
BOARD OF HEALTH
120 WASHINGTON STREET,4TM FLOOR
hLMBERLEY DRISCOLL TEL.(978)741-1800 FAX(978)745-0343 LARRY RAiIVDIN,RS/RENS,CHO,CP-FS
Iramdinoo m salcm co
MAYOR - HEALTH AGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: ,•, Z� d V��.• �
2) Establishment Address: 1 T7 ,1 7D
3) Establishment Mailing Address(if different):
4) Establishment Telephone No:
5) Applicant Name&Title:
6) Applicant Address:
I 7) Applicant Telephone No: j 24 Hour Emergency No: ' Zv9t."FO Email:(2l' ' &—Q6'l'lC[>S ..4
8) Owner Name&Title(if different from applicant): •`
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership, give name,title and home address of
officers or partner.
❑ An association Name Title Home Address
VIA corporation __
❑ 'An individual }rc� (�G-�� ks d 1)'
❑ A partnership
❑ Other legal entity
F-
12) Person Directly Res onsible For Daily Operations Owner Person in Charge, Supervisor, Manager,etc.
Name& Title: Q/✓�
Address: V r//•� p
Telephone No: Zc� Fax: Email: pY11[C�Qr
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
y-� •�/1/�(/j�� G
Check#: Z/ tr'�c i/ I Date: Amount:
_. Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: (if applicable) L
16) Days and Hours of Operation: I Q yY- 17) No.of Food Employees: — .e✓I '
18) Name of Person in Charge Certified in Food Protection Management: � n I
Required as of 10/1/2001 in accordance with 105 CMR 590.003(A) I vx
19) Person Trained in Anti-Choking Procedures (if 25 seats or more): Yes 0 No /,j
20) Location: 22) Establishment Type(check all that apply)
(check one) ❑ 0 Retail ( Sq. Ft) 0 0 Caterer
Permanent Structure ❑ 0� yFF od Service-( Seats) O Frozen Dessert Manufacturer
❑ Mobile ❑ 0?'Food Service-Takeout ❑ Cl Residential Kitchen for Retail
Sale
❑ 0 Food Service-Institution 0 Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
21) Length Of Permit: 0 Food Delivery Cl Residential Kitchen for Bed and
(check one) Breakfast Establishments
❑ Annual
.......................... ......ESTAU..6 ............... .
RETAIL STORE RRANT
0 Seasonal/Dates: 0 Less than I000sq.ft. $70 Bless than 25 seats $140
0 1000-10,OOOsq.ft. $280 0 Residential Kitchens $140
0 More than 10,OOOsq.ft. $420 0 25-99 seats $280
❑ Temporary/Dates/Time: 0 More than 99 seats $420
❑ Bed 8 Breakfast/Childcare Services/Nursing Home $100
.....................................................................................................................................•....
A DAKE ICITIONE CREAAL PER
MITS
MM,M,YOGURTISOFT SERVE $25
0 PASTURIZATION $25
0 ALL NON-PROFIT* $25
*Including, church kitchens state funded childcare 8 private club
23) Food Operations: Definitions: PHF-potentially hazardous food(timeltempereture controls required)
Non-PHFs-non-potentially hazardous food(no time/temperature controls required)
(check all that apply): RTE-ready-to-eat foods Ex.sandwiches salads muffins which need no further processing
❑ Sale of Commercially ❑ PHF Cooked to Order 0 Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PRFs for More Than a Single Meal Service
❑ Sale of Commercially ❑ Preparation of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
❑ Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be ❑ Vacuum Packaging/Cook Chill
Prepared by Consumer
❑ Reheating of Commercially ❑ Customer Self-Service ❑ Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service Within 4 hours contact alternative,time as public health
control.
❑ Customer Self-Service of ❑ Ice Manufactured and Packaged for ❑ Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
0 Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for ❑ Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
:]
❑ Offers RTE PHF in Bulk Quantities
To be completed by the Board o(Heallh
❑ Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of ttPe`ihfornation provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable lawI have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code. 71- W11
24) Signature of Applicant: I/r
Pursuant to MGL Ch. 62C,sec.49A, I certify u er th penalties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state xes required under law.
25) Social Security Number or Federal ID: A/), J -3,z3
26) Signature of Individual or Corporate Name:
L/
WeiRecycir
SERVICE AGREEMENT
NON HAZARDOUS WASTES N9 4.432
265 Newbury Street CUSTOMER ACCOUNT NO.
Peabody,MA 01960-1315
(976) 536-2500 EFFECTIVE DATE s�>�/ -5-
BILLING r / / ACCOUNT / Q J
NAME �lL e�. 7 NAME ( �Lfcc, S
BILLING SERVICEI L
ADDRESS ADDRESSAte-
CITY, ZIP .59/1e'I77 / (_ r CITY,ZIP S2 J, � ce70
TEL.# Z-�Z3-�/l FAX# TEL.# 23'-S/yC�� FAX#
CONTACT CONTACT L[ I
EQUIPMENT/SERVICE SPECIFICATIO S
SITE# TMP a
SERV. On. SIZE LOCKS FREQUENCY SCHEDULE B ROUTE NO. CHARGE(S)
Mon._Tues. Wed.' Thure`Fd.Sal. Su
n. 0MonthMon._Tuss._Wed._Thwe._Fd. Sol._S13
Moth DMon. Tues._Wed._Thm._FrL_SoL_SYonN O UR DMon. Tues. Wad. Thum. Fd. SaI. m 13
SLIXMan. Tuea._Wedti_Thure._Fd._SaL_S . UR ❑
S UR ❑
Mon._Tuee.Wed._Thurs._Fd,_Sal._Sun. Mcn h D
i UR ❑
Ymah B-
f LIR O
SPECIAL INSTRUCTIONS lf/i.S. l S IrIL -0�SO?1.4eQ vac SI Hess -
��`�
WASTE MATERIAL '
RENEWABLE:
Msw ?—I/-- ADDITIONAL CHARGES
MIXED DEMO TERM: 3L.
Fuel................................................_ — %
CONCRETE ONLY
CARDBOARD Locks...............................................$ ._
YARD WASTE Extra PICku 2^
RECYCLING P................................_$
P.O.NUMBER BILL TO ACCT# Extra Yards......................................$
RECEIPT REOUIRED7 DISPOSAL SITE Bulk Items.......................................$ �L
THE UNDERSIGNED INDIVIDUAL SIGNING THIS AGREEMENT ON BEHALF CRT Items........_..............................$ a OF CUSTOMER ACKNOWLEDGES THAT HE/SHE HAS READ AND White Good Items.........,
UNDERSTANDS THE TERMS AND CONDITIONS OF THIS AGREEMENT, ON """"""""'$ 2's
REVERSE SIDE ND THAT HE/SHE HAS THE AUTHORITY TO SIGN ON
BEHALF OF S OMER.
CUSTO
IAvT sw RLQ CONT c CTO
T (DAT¢)
NAME(PRINT OR TYPE) l 'l N,�,/ Y�� e /N u /f' L
t City of Salem, Massachusetts
'�:� Board of Health lu
120 Washington Street, 4th Floor, Salem, MA 01970 PublicHeeth
Prevent.Promote.Protect.
Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin, MPH, RENS, CHO
Mayor Iramdin@salem.com Health Agent
FROZEN DESSERT PERMIT
Permit# License For : Frozen Dessert
FD-15-10
Date of Print Granted To: Cindy's Planet/ Cindy Yen
3/10/2015
Permit Issued Address: 7 Oak Street Apt. A Boston MA 02111
3/10/2015
Location of Establishment: 171 FORT AVENUE
Permit Expires
12/31/2015
Permit Fee Restrictions: Cindy's Planet Pizza & Grill
$25.00
Late Fee Notes:
$0.00
This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2015 , unless
sooner revoked or suspended.
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
Name C� A Date. -t T pe of Operation(s) Type of Inspection
r�' 0 4�Z.`1'� ��U- 0% (z 49Food Service ❑Routine
Address Risk ❑ Retail ❑ Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone ❑ Mobile its.
Owner1`r�a� HACCP YIN ❑ Temporary Pre-operation
❑ Caterer ❑Suspect Illness
Person-in Charge(PIC) Time ❑ Bed&Breakfast El General 0 HACCP Complaint
In:
Inspector t - ��� Out: I Permit No. ❑.Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors-(Red
Items) Anti-Choking 590.009(E) ❑
ViTobacco 590.009(F) ❑.
Violations marked may pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑
corrective 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'CHEMICACS'
❑ 2. Reporting of Diseases by Food Employee and PIC
El 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
F.00D'F.ROM'APPROVED SOURCE -
TIMErrEMPERATURE.CONTROLS.Patentfelly Hazaidous'F.00ds)'
El 4. Food and Water from Approved Source (
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hol and Cold Holding
❑ 8.Separation/Segregation/Protection ❑20. Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY-sUS.CEPbdLEEPOPULATIONS.(H8P):
El 10. Proper Adequate Handwashing C321. Food and Food Preparation for HSP
i
❑ 11. Good Hygienic Practices CONSUMER ADVISORY '
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical (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-3X590.004)
order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-4X5 0.004) 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 (r-C-5X599.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (F-C-6X590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FcaX590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signatur
PICS Signature: UAPrint: {� Page of-Pages
,�• ' � =r 1i• •z •-i r.��' �.N�.�w �'l J+ '�t'r i �f"-5"1
Violations Related to Foodborne Illness
interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(1) Raw Animal Foots Separated from
1 590.003(A) Assi g anent of Res>onsihilit * Cooked and RTE Fools*
590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11. Person in charge.-duties 3-302.11(A)(2) Raw Animal Fools Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsihility of the person in charge to 3-302.1 I(A) Food Protection"
require reporting by RKKI employees and 3-302.15 Washing Fruits and Vegetables
a licutts" 3-304.11. Food Contact with Equipment and
590.003(F) Responsibility Of A Fool Employee Or An Utensils"
Applicant To Report To'llre Person In Contamination from the Consumer
Charge.* 3-306.14(A).B) Returned Food and Reservice of Fad*
590.003(G) Reporting by Person in Charge,**
3 590.003(D) Exclusions and Restrictions* FoodDispoon ofAdulterafedorContaminated
Food
590.003(E) Removal of Exclusions and Restrictions 3-701..11 Discarding or Reconditioning Unsafe
_FOOD FROM APPROVED SOURCE Food"
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food law'" 4-501.111 Manual Warewashing- Hot Water
3-201.12 Food in a Henneticall •Sealed Container* Sanitization Temperatures*
3 201.13 Fluid Milk and Milk Products" 4-501.112 Mechanical Warewashing-Not Witter
3-202.13 Shell E s'"
Sanitization Temperatures* '
3-202.14 Eggs and Milk Products. Pasteurized" 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 lee Made From Potable-Drinking Water* concentration and hardness. *
5-101.11 Drinking Water from an Approved System* 4-601..11(A) P-quipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean"
590.006(6) Water Meets Standards in 310 CMR 22.0* 4-602'1 t Cleaning Frequency of Equipment Contact Surfaces and Utensils* Food-
SheNTsh and Fish From an Approved Source 4-70n 11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703..1 I Methods of Sanitization-Hot Water and .
3-201.15 Molluscan Shellfish front NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms*
3-202.18 She'llstock Identification Present* 2-301.12 Cleaning Procedure*
590.004(C) Wild lvlushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals*' 11 Good Hygienic Practices
5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures*- 240[.12 Discharges From the Eyes,Nose and
3.202.15 Package Integrity* Mouth*
3-101.11. Foal Safe and Unadulterated° 3-30[.12 Preventing Contamination When'rastin "
6 TagslRecords:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.60a(E) Preventing Contamination from
3-203.12 Shellstoekfdcntiftcation Maintained* Enr,lo ees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement* _
7 Conformance with Approved Procedures 5-20.5.11. Accessibility.Operation and Maintenance
IHACCP Plans Supplied with Soap and Hand Drying
3-502.11 Specialized Processing Methods* Dovkas
3-502.12 Reduced ox en acka'ng,criteria* 6-301.11 Handwashin Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hared Drying Provision
*Denotes critical item in die federal 1999120 M Code or 105 CN1R 590.W0.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name:t✓1.'.�'941-1 Q> =s�C S'>'Z �a a Cy'L-, Date: "2- Nc— A Pager Z of �
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item VerHted
PLEASE PRINT CLEARLY
r
l
i
l
i
I
i
S Discussion With Person in Charge: Corrective Action Required: ❑ .No ❑: Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Foge5tode.. I understand that
noncompliance may result in daily fines of twenta�or
S:usension/revocation of o Embargo ❑ Emergency Closure
kS your food permit.
i ❑ Voluntary Disposal 0 Other:
t
3.501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to
Factors(Hents'1-22) (Cont.) 41°F/45°F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-50L.15 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Not and Cold Holding
3-50L16(B) Cold PHFs Maintained at or below
3202.12 Additives*' 590.004(F) 410/450 F*
3-302.14 Protection from Unapproved Additives* 3-50i.16(A) Hot PHFs Maintained at or above
IS Poisonous or Toxic Substances 140°F. *
7-101.11 Identifying lafonnation-Original 3-501.16(A) Roasts Held at or above 130°F.
Containers* ' 20 Time as a Public Health Control
7-102.11. Common Name-WorkingContainers* 3-501.19 Time as a Public Health Control*
7-201.11 Separation-Storage*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Require
7-202.12 Conditions of Use* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals' 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.t2 Chemicals for Washine Produce,Criteria* Beverages with Warning labels*
7-204.14 Drying Agents.Criteria* 3-801.11(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contac,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and .
7-206.11 Restricted Use Pesticides:Criteria* Raw Seed Sinvats Not Served
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw,Undercooked or
16 Proper Cooidng Temperatures for Not Otherwise Processed to Eliminate
PHF9 ens.'�..,1n 1
340LI1A(1)(2) Eggs- i55°F 15 Sec. Paste
'
Eggs-Immediate Service 145°F15sec* 3-302.13. tired Eggs Substitute for Raw Shell
3401.11(A)(2) Comminuted Fish.Meats&Game Eggs*
Animals-155°F 15 sec. * SPECIAL REQUIREMENTS
3.401.11(13)(1)(2) Pork and Beef Roast- 130'F 121 min* 590 009(A){D) Violations of Section 590.009(A)-(D)in
3-401.11(A)(2) Ratites,Injected Meats- 155°F 15
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 1.5 sec.* above if related to foodborne illness
3-401..11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. 'Other
1450F* 590.009 violations relating to good retail
3401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3.401:11(A)(1)(b) A0 Other PRFs- 145°F 15 sec. °
17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) `PHFs 165°F 15 sec.* (Items 13.30)
3403.11(B) Microwave- 165°F2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3403.11(C) Commercially Processed RTE Food- found in the fellaxdng sections of the Food Code mid 105 CMR
140*Fv 590.000.
3403.11(E) Retraining Unsliced Portions of Beef Hem Good Retail PracticesFC 590.000
Rte* 23 t and Personnel FC-2 .003
18 Proper Cooling of PHFa 24.. Food and Food Protection FC-3 .004
25. Equipment and Utensils I FC-4 .005
3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water.Plumbing and waste FC-5 .008
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 I FC-7 .008
3-501.14(B) Cooling PRFs Made From Ambient 29, 'Special Requirements .009
Temperature Ingredients to 41°P/45°F 30' Other
Within 4 Hours* saarcaoana.xe:
Nnot s critical item in the federal 1999 Food Code or 105 Cr,4R 590.000.
4
City of Salem, Massachusetts
1 Board of Health
j 120 Washington Street, 4th Floor, Salem, MA 01970
Tel. (978) 741-1800 Fax. (978) 745-0343 PUCH@Slth
Iramdin@salem.com Prevent. Promote. Protect.
Kimberley Driscoll Larry Ramdin RS/RENS, CHO,CP-FS
Mayor Health Agent
FOOD ESTABLISHMENT PERMIT
(must be posted on the Premises of the Food Establishment)
2014
Permit Number: FM-14-372 I
i
Permit Type: FOOD SERVICE ESTABLISHMENT
i
Goods &Services: IFood Service: 0-24 seats
Name of License Holder: Cindy Yen
Name of Food Establishment Cindy's Planet Pizza&Grill
Address of Food Establishment 177 Font Avenue SALEM MA 01970
This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and
expires on 12/31/2014 unless sooner suspended or revoked.
Permit Fee: $140.00
Issued: 3/14/2014
i
i
1
' CITY OF SALEM, '
MASSACHUSETTS `
Public Health
BOARD OF HEALTH ��•'....m...."•,••.
120 WASHINGTON STREET,4-FLOOR
KIMBERLEY DRISCOLL TEL.(978)741-1800 F,\C(978)745-0343 LARRY RAiMDIN,RS/REHS,CHO,CP-FS
MAYOR Ir din calem.com '1-JEALTHAGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: ( 'FL2,1,OLy
2) Establishment Address: 177 4 ,(
/wc �e 01 170
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: 7 —
5) Applicant Name&Title: CA CLe4 l (2—A — OW _ PS
6) Applicant Address: �- �
7 D1/ ?� 02U I
7) Applicant Telephone No&a'ga 24 Hour Emergency No:617-U3 mail r elle
8) Owner Name&Title (if different from applicant):
! 9) Owner Address (if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
❑ An association Name Title Home Address
V A corporation
❑ An individual Y0'6'\ ° &A'trw/44
❑ A partnership
❑ Other legal entity ?tL
12 Person Directly Res onsible For Daily Operations Owner Person in Charge,Supervisor, Manager,etc.
Name&Title: a A —
Address: w1. S� 14 yy.
Telephone No: `0/ 1GL Email:Q aYL
Emergency Telephone No: �D ( — $'23- 1 l SZ 5 V-v
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: Date: Amount:
Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: (if applicable)
16) Days and Hours of Operation: $ Lit /Vi 17) No. of Food Employees: 21 - 3
18)
-
18) Name of Person in Charge Certified in Food Protectioh Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A) �1�� Ye
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): Yes V`ko
20) Location: 22) Establishment Type(check all that apply)
/ (check one) ❑ 0 Retail ( Sq. Ft) ❑ 0 Caterer
tp/ Permanent Structure ❑ 0 Food Service-( Seats) O Frozen Dessert Manufacturer
❑ Mobile 0 M'Food Service-Takeout ❑ ❑ Residential Kitchen for Retail
Sale
❑ O Food Service-Institution El Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
21) Length Of Permit: O Food Delivery 0 Residential Kitchen for Bed and
(check one) ............•-•........ ,Breakfast Establishments,,,,,,,,,,,,,,,,,,,,,,
...................................................... ......................................
Annual RETAIL STORERESTAURANT
❑ SeasonallDates: 0 Less than 1000sq.ft. $70 esLZ s than 25 seats $140
O 1000-10,OOOsq.ft. $280 0 Residential Kitchens $140
0 More than 10,OOOsq.ft. $420 0 25-99 seats $280
0 Temporary/Dates/Time: 0 More than 99 seats $420
-------------------- -----------'-1---a"r'e' '---- -----..........-n----,-..m.''----------------------*------------------------' '""*....
O Bed&BreakfasUChildcare Services/Nursing Hoe $100
..........................................................................................................................................
rITIONAL PERMITS
KE ICE CREAM,YOGURTISOFT SERVE $25
0 PASTURIZATION $25
0 ALL NON-PROFIT' $25
*Including, church kitchens state funded childcare 8 private club
23) Food Operations: Definitions: PHF-potentially hazardous food(timekemperature controls required)
Non►PHFs-non-potentially hazardous food(no t/me/temperature controls required)
(check all that apply): RTE-ready-to-eat foods .sandwiches salads muffins which need no further processing
0 Sale of Commercially RIF PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
❑ Sale of Commercially e Preparation of PHFs For Hot And ❑ PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
0 Delivery of Packaged PHFs ❑ Sale of Raw Animal Foods Intended to be ❑ Vacuum Packaging/Cook Chill
Prepared by Consumer
❑ Reheating of Commercially ❑ Customer Self-Service ❑ Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan (including bare hand
Service Within 4 hours contact alternative,time as public health
control.
❑ Customer Self-Service of ❑ Ice Manufactured and Packaged for ❑ Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
❑ Preparation of Non-PHFs ❑ Juice Manufactured and Packaged for ❑ Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
❑ Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
❑ Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of a information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all oth plicable law I have be instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
i
24) Signature of Applicant:
Pursuant to MGL Ch. 62C,sec. 49A, I certify and r t penalties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID: Z 301 Ll
26) Signature of Individual or Corporate Name: A J
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: G C¢ Z Date: Page:_ of
Rem Code C-Critical nem DESCRIPTION OF VIOLATION/PLA OF CORRECTION Date..
No. Reference R-Red Item - Verified
PLEASE PRINT CLEARLY
` ` /
t hG
I
0
i it
•
Discussion With Person in Charge:
Corrective Action Required: ❑ No' ❑ Yes
I have read this report, have had the opportunity to ask qtjestions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
violations before the next inspection, to observe all cc d ions as described, and to
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food od . I understand that
noncompliance may result in daily fines of twenty-fiv Ilars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
0 Voluntary Disposal ❑ Other:
i
3-501.14(0) PHFs Received at Temperatures
V/olatlons Related to Foodborne Illness lntervendons and Risk According to law Cooled to
Factors(items 1-22) (Cont.) 41'F/45'F Within 4 Hours.°
l PROTECTION FROM CHEMICALS 3-501.15 CoolingMethods for PHFs
14 Food or Color Additives _ 19 PHF Not and Cold Holding
3-501.16(B) Cold PHFs Maintained at or below
3,202.12 Additives*'
590.004(F) 41°145°F*
3-302.14 Protection from Unapproved Additives" 3-SO1.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances 140'F. °
7-101.11 Identifying Information-Original 3.501.16(A) Roasts Held at or above 130'F. °
Containers* 20 Time as a Public Health Control
i 7-102.11. Common Name-Working Containers* 3-50IA9 Time as a Public Health Control*
1( 7-201.11 Separation-St
+� 7-202.11 Restriction-Presence and Use* 590•(104 HI VerianceR Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY.SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals* 21 3-801.11 A) Un Pre-packaged lances and
7-204.12 Chemicals for Washi Produce,Criteria*_ (. pasteurized Pa Bed
Beverages with Warning Labels'
' 7-204.14 Drying Agents.Criteria' 5-801.11(B) Use of Pasteurized Eggs*
-� 7-245.11 Incidental Food Contac,Lubricants* 3-801.11(D) Raw or Partially Cocked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served.*
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re=served °
i 7-206.73 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
•',s 22 3-60'3.11 Consumer Advisory Pasted for Consumption of
TIMEITEMPERATURE CONTROLS
tat Animal Foods That are Raw,Undercooked or
}• 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate
f PHFs Pathogens.*arOOvp 1n`AO1
'3-401.11A(i)(2) Eggs- 155 F 15 Sec.
i� E Immediate Service 145°FLSsec• 3-302.13. Pasteurized Eggs Substitute for Raw Shell
5 3401.11(A)(2) Comminuted Fish.Meats&Game E
Amtrwls-155°F 15 sec. ° SPECIAL REQUIREMENTS
3401.11(B)(1k2) Pori:and Beef Roast- 130'F 121 mita*
l(A)(2) Ratites,Injected Meats-155°F 15 590-009(A)-(D)D) Violations of Section 590.009(A)-(D)in
sec.* catering,,mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate Sections
Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness
3-401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
Y 145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
`' Microwave 165*F° Special Requirements.
S 3401:11(A)(lxb) All Other PHFs- 145°F 15 sec. °
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
K 3403.11(A)&(D) PHFs 165°F 15 sec.* (Items 23-30)
'? 3403.11(8) 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
l 3-403.l 1(C) Commercially Processed RTE Food- found in the fallowing sections.of the Food Gale and 105 CMR
'y 140°F* 590.000.
' - Rem Good Retail Practices .FC 590.000
3--103.1 I(E) Remaining Unsliced Portions of Beef
} '��* 23. I Management and Personnel FC-2 .003
{ 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004
25. E ui stent and Utensils I FC-4 .005
+ 3-501.14(A) Cooling Cooked PHFs from 140"F to 26. Water.PlEimbinq and Waste FC-5 .006
,A 70°F Within 2 Hours and From 70°F 27. -Physical Facility
to 41'F/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008
t 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41*F/4561F 30• Other
Within 4 Hours* SD90f"'mi263G•`
p "Denotes critical item in the federal 1999 Food Cale or 105 GMR 590.000.
1
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4"'Floor
Division of Food and Drugs . Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
1
CltyrToWn of .�( ,� Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
Nameplcpbo� 01 D TypeofOperation(s) Type of Inspection
�/ t' ( [m] Food Service ❑Routine
Ri
Address �i r sk Retail El Re-inspectio n
Telephone(
lLevel El Residential Kitchen Previous Inspection
'lLit-' I ❑ Mobile Date:
Owner . HACCP YIN ❑ TemporaryQQ��Preoperation
❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint
Inspector r In.S Out: Permit No. ❑Other
Each violation checked requires doxplanation on the narrative_ page(s)and a citation of specific provision(s)violated.
Noncompliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors-(Red Anti-Choking590.009(E) ❑
Items)
Vi
Violations marked may pose an imminent health hazard and require immediate To590.008(F) ❑,
Allergen
Awareness 590.008(G) ❑
corrective action as determined by the Board of Health.
F ' -PROTECTION MANAGEMENT' ❑ 1 . Prevention of Contamination from Hands
1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE HEALTH�r°" - 13. Handwash Facilities
r1PROTECTIOXFit M CHEMICALS` ! _ -
❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives
r ❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
F,OOD'FROM-APPROVED SOURCE � '� �---_- �.T_.-r-.___-__,-�•.T�_�._:-�
Q 4. Food and Water from Approved Source � �TEi'�?ER??.uRE:CONTROLS.(P.oteittlaltyHazerdou__s_F._ood_s)=
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved ProcedureslHACCP Plans ❑ 18.Cooling
' .PRO ❑ 19. Hol and Cold Holding
❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR_HIGHLYSUSCEP7IBL'E_POPOLATICIW(HSP)�
0 21. Food and Food Preparation far HSP
❑10. Proper Adequate Handvrashing
❑ 11.Good Hygienic Practices CONSUMER`AD SORY .
El 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical(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. 590.000tfederal Food Code. This report,when signed below
C N by a Board of Health member or its agent constitutes an
24. Food and Food Protection (Fc-3x
23. Management and Personnel C-3)(59sso.00o4) order of the Board of Health. Failure to correct violations
) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4x590.005) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (FCSx590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6x590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address
a�q.�
Special Requirements (590.009) within 10 days of receipt of this order.
Other DATE OF RE-INSPECTION:
.ea
Inspector's Signature: Print:
P[CsSignature: Print: Page of, Pages
Violations Related to Foodbome Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590.003(A) Assig mens of Responsibility* 3-302.1 I(A)(1) Raw Animal Foals Separated from
Cooked and RTE Foods*
590.003(6) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11. Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3.302.11(A) Food Protection*
require reporting by food employees and 3-302.15 WashingFruits.rad Ve etables
applicants* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Feud Employee Or An
Applicant To Report.To The Person In Utensils*Contamination from the Consumer
Charge*
590.003(0) Reporting by Person in Charge* 3-306.14(A)(.B) Retuned Food and Reservice of Food*
Disposition of Adulterated or Contaminated
-
3 .590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE F0 d*
q 1 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermeticall •Scaled Container* Sanitization Temperatures"
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* Sanitization Tem ratures*�
3-202.14 Eggs and Milk Products.Pasteurized* 4-501.1 14. Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. *
5-101.11 Drinking Water,from an Approved S tem" 4-601..11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water' Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food-
Shellfish and Fish From, an Approved Source Contact Surfaces and Utensils*
4-702.1 I. Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Ha Water and
3-201.15 Molluscan Shellfish from NSSF Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Autf Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms*
Requ/ato Aufhodt
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" LLL Good Hygienic Practices
5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and
3-202.15 Package hue it r Mouth*
3-101.11 _ Foal Safe and Unadulterated * 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock IdentificationS90.004(E) Preventing Contamination from
3-203.1.2 Shellstock identification Maintained* Employees*
Tags/Records:'Fish Products 13 Handwash Facilities
302.11 Parasite Dcstmction*
Conveniently Located end Accessible
3.402.12 Records,Creation and Retention* 5-203.11 1, Numbers and Capacities*
590.004(l) Labeling of Ingredients* 5-204.11 Laxation and Placement*
7 Conformance vrlth Approved Procedures 5-205.11 Accessibility.Operation and Maintenance
/HACCP Plans Suppled with Soap and Hand Drying '
3-502.11 Specialized Processin Methods* Devices
3-502:12 .Reduced oxygen packaging,criteria* - 6-301.11 Handwashing Cleanser,.Avai[abilit
8-103.!2 1 Conformance with Approved Procedures" 6.301.12 Hand Drying Provision
I
Denotes critical item in the federal 1999 Fax!Code or 105 CMR 590.000.
CITY OF SALEM
�s f BOARD OF HEALTH
Establishment NameL cr fel' S_�CZl?P Pi'1: 'I- Cj L Date: ( Page: of —Q
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date•
No. Reference R-Red Item Verified
PLEASE PRINTLEAR
5 5qo LY O a
4
9�o m3
NO -lo
5 .005 ( U ZT( c, et coM
I'S A`t ko
?c�11a rs Al
r. i
� e
Discussion With Person in Charge: Corrective Action Required: ❑ . No o. Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal Cl Other:
t
3-501.14(C) PHFs Received at Temperatures
Violations Aelafed to Foodborne Illness interventions and Risk According to Law Cooled to
Fadors(Hems-1-22) (Cont.) 4I°F/45*F Within 4 Hours.
i PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs
1 19 P
14 Food or Color Additives HF Hot and Coal Holding
i 3-50L16(B) Cold PIFs Maintained at or below
3-202.12 Additives* 590.0040 4101450 F*
3-302.14 Protection from Un proved Additives* 3-501.16(A) Hot PHFs Maintained at or above
, 15 Poisonous or Toxic Substances 140,E
7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130*F.
Containers* 20 Time as a Public Health Centrad
7-102.11. Common Name-Working Containers
7-201.11 'on-Sta * 3-501.19 Time as a Public Health Control'
7-202.11 .Restriction-Presenceand Use° 590.004 H) Variance Requirement
7-202.12 Conditions of Use*
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions*
7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP
7-204.12 Chemicals fox Washi Produce,Criteria• 21 3-SOI.II(A) Unpasteurized Pre-packaged Juices and
7- . Criteria* *UseofBeverages with alantin Labels*
20414
y Agents. 3$01.11(6 'Use of Pasteurized Eggs*
t 7-205.11 lncidentel Food Contac.Lubricants* 3-801.1 I(D) Raw or Partially Coed Animal Food and
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served
7-206.12 Rodent Bait Stations* 3-801.1] C Unopened Food Package Not Re-served
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures tar Animal Foods That are Raw.Undercooked or
Not Otherwise Processed to Eliminate
i PHF9 Pathogens.*°hC1e 1n��
3-401.11A(Ix2) Eggs- 155°F 15 Sec.
Eggs7 immediate Service 145°Fl5sec' 3-302.13. Pasteurized Eggs Substitute for Raw Shell
3401.11(A)(2) Comminuted Fish.Meats&Game
E _
Animal's-155*F 15 sec. * SPECIAL REQUIREMENTS
3401.11(6)(1)(2) Pori:and Beef Roast- 130*F 121 min* 590.009(A)-(D') Violations of Section 590.009(A)-(D)in
3 401.11(A)(2) Ratites,Injected Meats-155*F 15
sec.* catering,,mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
'1 Stuffing Containing Fish,Meat, debited under the appropriate Sections
Poultry or Ratites-]65*F t5 sec. * above if related to foodborne illness
3.401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
t 145°F• 590.009 violations relating to good retail
r 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165*F* Special Requirements.
3-401.I I(A)(1)(b) All Other PHFs- 155*17 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.11(A)&(D) PHFs 165T 15 sec. * (Items 23-30)
3-403.11(6) Microwave--165*F 2 Minute Standing Critical,mid non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, care be
3.403.1I(C) Commercially Processed RTE Food- found in the follondng sectionsof the Food Code and 105 CMR
1400Fs 590.000.
3403.11(E) Remaining Unslic ed Portions of Beef Item I Good Retail Practices FC 590.000
i Roasts* 23, 1 Management and Personnel FC-2 .003
24.. Food and Food Protection FC-3 .004
i is Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .1x15
3-501.14(A) Cooking Cooked PRFs from 140*F to 26, Water.Plumbina and Waste FC-5 .006
70*F Within 2 Hours and From 70*F 27. Physical Facility FC-6 007
to 4l`F/450F Within 4 Hours.* 28. Poisonous or Toric Materials FC-- 7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to41*17145617 30. Other
Within 4 Hours* 5_�
? "Denotes critical hem in ate federal 1999 Foal Code or 105 CMR 390.000.
I
i
nvr. N. 2014 1 :h0r'M No. 203 F. 1/2
Search: Score Analysis Report Page 1 of 1
Disclaimer This Exsm Scare Repor,may not be ueneldered appropriate ammemeaon to meet regulatory requirement,.
CERTUTMATE DINoPb t1TION BY EXAM
Ifyeu passed Ne SmSaf,Food Protection Manager GordRlcotioo Faiaminotion,the SmSate Alcohol Primary(Print only)or SmSafe Alcohol Proctorod
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If you Passdd the SarvSafa Alcohol Primary(Onllne Exam),}ca will receive a Confi ela et the addmes you indicated CO your Exam Reg!atradon Form.
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' 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: 02/20/2013
ESTABLISHMENT NAME: Cindy's Planet Pizza & Grill
File Number:BHF-2008-000009 177 Fort Avenue
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2019-0372 Feb 20,2013 Dec 31,2013 $140.00
ESTABLISHMENT
FROZEN DESSERTS BHP-2013-0373 Feb 20,2013 Dec 31,2013 $25.00
Total Fees: $165.00
PERMIT EXPIRES 0ecember 31, 2013
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. Paye 1
' CITY OF SALEM,
MASSACHUSETTS
Public Health
BoARDOFFIEALTH ��� • ' A•..
120 WASHINGTON STREET,4TM FLOOR
KMBERLEY DRISCOLL TEL.(978)741-1800 FAX(978)745-0343 LARRY RAAtDiN,RS/REFIS,CHO,CP-F
Iramdin salem.com
MAYOR HEALTH AGENT
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: r 6
2) Establishment Address: 1 ✓ lg vvl D 1(r ,2 U 19
lL/
3) Establishment Mailing Address(if different): l O
lo AA
4) Establishment Telephone No: 7 16 O CS
S) Applicant Name&Title:
6) Applicant Address: (961L 30–Aul" 0-21
7) Applicant Telephone No: 8 24 Hour Emergency No: Z Email:CI
8 Owner Name&Title if different from applicant): Af
0) Owner Address(if different from applicant): A)
10) Establishment Owned by: 11) If a corporation or partnership, give name,title and home address of
officers or partner.
0An association Name Title Home Address
VA corporation (� �
0 An individual nQ^ lJ q LO�(Bre
0 A partnership
❑ Other legal entity
12 Person Directly Res onaible For Daily Operations Owner Person in Charge,Supervisor, Manager,etc.
Name&Title: y P,V\
Address: OeA= -t &' 01( u
Telephone No: la Q,92,1 -W20 Fax: — Email: CpW[GIfT.
Emergency Telephone No: Q (
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check 5:, 19. Date: �� / Amount: Y Q-J
l
Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: (if applicable)
16) Days and Hours of Operation: - vi = 11)'M-0 17) No.of Food Employees: -
18) Name of Person in Charge Certified in Food Protection Ma agement: i J
Required as of 101112001 In accordance with 105 CMR 590.003(A) y� (Q
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): Yes ❑ No
20) Location: 22) Establishment Type(check all that apply)
/ (check one) 0 0 Retail( Sq.Ft) ❑ 0 Caterer
t3 Permanent Structure 0 0 Food Service-( Seats) 0 Frozen Dessert Manufacturer
❑ Mobile 0 fH end Service-Takeout 0 O Residential Kitchen for Retail
Sale
❑ O Food Service-Institution 0 Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
21) Length Of Permit: 0 Food Delivery 0 Residential Kitchen for Bed and
(check one) ..............................................................................8regk(ast EstBblishmefts-.......-.............
0 Annual RETAIL STORES�IAT
IAU_6
fa Seasonal/Dates: 0 Less than 1000sq.ft. $70 LesL�7 s than 25 seats $140
0 1000-10,OOOsq.ft. $280 0 Residential Kitchens $140
31s- 0 More than 10,OOOsq.ft.$420 0 25-99 seats $280
❑ Temporary/Dates/Time: 0 More than 99 seats $420
.............- r"e'a"-......-..----- ---.-.------.-.......-..- -----------------............--....-.......------------....----------------
0 Bed 8 Breakfast/Childcare Services(Nursing Home E100
..........................................................................................................................................
PAD ITIONAL PER ITS
MAKE ICE CREAM,YOGURTISOFT SERVE $25
0 PASTURIZATION $25
0 ALL NON-PROFIT" $25
*Including, church kitchens state funded childcare&private club
23) Food Operations: Def7nldons: PHF-potentially hazardous food(timeRemperature controls required)
Non,-PHFs-non potendally hazardous food(no Bme/temperature controls required)
(check all that apply): RTE—read tout foods .sandwiches salads muffins which need no further essin
❑ Sale of Commercially PHF Cooked to Order ❑ Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
❑ Sale of Commercially ❑ Preparation of PHFs For Hot And 0 PHF and RTE Foods Prepared For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
0 Delivery of Packaged PRFs 0 Sale of Raw Animal Foods Intended to be ❑ Vacuum Packaging/Cook Chill
Prepared by Consumer
❑ Reheating of Commercially ❑ Customer Self-Service ❑ Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(Including bare hand
Service Within 4 hours contact alternative,time as public health
control.
❑ Customer Self-Service of ❑ Ice Manufactured and Packaged for ❑ Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
❑ Preparation of Non-PHFs 0 Juice Manufactured and Packaged for ❑ Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
0 Offers RTE PHF in Bulk Quantities
To be completed by the Board oflfeallh
0 Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
1,the undersigned,attest to the accuracy of ih formation provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 890.000 and all other p cable law. I have bee Instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code. 1
24) Signature of Applicant:
Pursuant to MGL Ch. 62C,sec.49A,I certify under the p4naltles of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID: 0 / 33 3
26) Signature of Individual or Corporate Name:
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978)741-1800 Fax (978) 745-0343
r .
City/Town of Address:
FOOD EMBILISHMENT INSPECTION REPORT Tel.
Name Dat �TTyp"�eIFOperation(s) Type nspection
LVIFood Service outine
.Addres Risk ❑ Retail r ' ❑Re-inspection
Telephone Level ❑ Residential Kitchen Previous Inspection
❑ Mobile Date:
OwnerHACCP YIN 11Temporary ❑ Preoperation
❑ Caterer ❑Suspect Illness
Person-in-Cha a(PIC) Tim Li Bed&B akfast El General Complaint
In: ❑ HACCP
Inspector Out: I1 I' Permit No ❑Other
Each violati cked require an Kplanation on the narrative j )and a citatio sp cific provision(s)violated.
Noo-compiiance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti-Choking590.009(E) ❑
Items) Tobacco 590.009(F)
Violations marked may ❑.
y pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
.FOOD PROTECTION MANAGEMENT' ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
El13. Handwash Facilities
'EMPLOYEE HEALTH
" PROTECTION�FROM'CHEMICACS''
E1'2. Reporting of Diseases by Food Employee and PIC -
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15. Toxic Chemicals
F..00DIF.ROM�APPRN SOURCE
❑ 4. Food and Water from Approved Source TIM E/TEMP.ERATURE'.CONTROLS.(P.ateiiia y Hazardous F.00ds)'
❑ 5. Receiving/Condition [116. Cooking Temperatures
❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION ❑19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑ 20.Time as a PublidHealth Control s
04"Food Contact Surfaces Cleaning and Sanitizing REQUIREM_ENMFFOR HIGHLYSUSE�PO
CEPTIBLPULATIOMA(HSP)'
❑ 10. Proper Adequate Handwashing [121.Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMERAnVISORY -
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22)-
of Health. Noncritical(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 Nby a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2X590.003) order of the Board of Health. Failure to correct violations
2 ood and Food Protection (Fc•OXsso.00a) cited in this report may result in suspension or revocation of
5. Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food,
26.Water, Plumbing and Waste (FCs)(590.006) establishment operations. If aggrieved by this order,you
. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing
28 isonous or Tom aterials (FC-7X590.008) and submitted to the Board of Health at the above address
Special Require en (590.009) within 10 days of receipt of this order/
30. Other DATE OFRE-INSPECTION: (nC (l I
i
Inspector's Signa a Print:
PICS Signature: Print: Pagel off.Aes
1^��..ti�r...-^---'-�.,,--`.. �-.,��,;.`.-� � �--..---.^'.ti•:...•^"^moi""".---`^-�..V.�v+..� `+w .��� V.- r..^^-.r.. --�
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
3-302.11(A)(1) Raw Animal Foods Separated from
1 590.003(.0) Assig men[of Responsibility*wldCooked and RTE Foods*
590.003(6) Demonstration of Knowledge Contamination horn Raw Ingredients
2-1.03.11. Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTHOther*Contamination from the Environment
2 590.003(C) Responsibility of the person inch charge to 3-302.1 I(A) Food Protection*
require reporting by food employees and 3-302.15 Washin Fruits and Vegetables
applicants* 3-304.11 Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An
Utensils
Applicant To Report To The Person to Contaminatbn from the Consumer
Charge* 3-306.14(A)(B Returned Food and Reservice of Food*
590.003G Reporting b Person in Charlie* Disposition of Adulterated or Contaminated
3 590.003(1)) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact surfaces
590.004(A-B) Compliance with Food law* 4501.1.1 I Manual Warewashing-Hot Water
3-201.12 _Food in a Hermetically Sealed Container* Sanitization Ten eratureO
3-201.13 Fluid Milk and Milk Products' 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Eggs* Sanitization Temperatures*.
3-202.14 Eggs and Milk Produced" 4-
.Pasteurized" Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.*
5-101.11 Drinking Water.from an Approved Systej0
4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 31.0 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food
Shellfish and Fish From, an Approved Source Contact Surfaces and Utensils°
4-702.11 Frequency of Sanitization of Utensils and .
3-201.13 Fish and Recreationally Caught Molluscan
Shellfish* Food Contact Surfaces of Equipment*
4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSF Listed Chemical*
Sources*
Game and Aulhod Mushrooms Approved by 10 Proper,Adequate Handwashing
RegMato Auf2-301.11 ' Clean Condition-Hands and Arms-
3-202.18 Shellstock identification Present" 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
5 RecelvingfConditlon 2-401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges.From the Eyes,Nose and
3-202.15 Package Integrity' Mouth*'
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventin¢Con[anunation When Tasting*
6 Tags/Records;Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification" 590.004(E) Preventing Contamination,from
3-203.12 Shellstock Identification Maintained* Employees*
Tags/Records:'Fish Products 13 Handwash Facilities
3402.11 Parasite Deatmction*
Conveniently Located and Accessible
3-40^_.12 . Records,Creation and Retention* 5-203.11 Numbers and Capacities*
590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11. Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying --
3-502.11 S cialized Processing Methods* Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cfeanser,.Availabilit
8-103.12 1 Conformance with Approved Procedures* 6-301.12 HandDrying Provision
*Denotes cii ical item in the federal 1999 fail Code or 105 CMR 590.000.
. . IMPTZ
R-Red Item
Al"IMATERIT11"IMMARIPW1.13111IMM if WO
r . WRl. ; ;'moi. lilqMMAMPA.r��..
100111M ME lf�WWW MIT"MAMMAM 10MANIMAM &M 10
I►C�. Eqd I AM i�J� � J,M.,9 111! // � /L Il ■�
Pi71 '�'OPJ�/AGI ':�71:►a, �lYAM O 'J.�1YUQU, .N ��i►'i .i�7i.1 -MAXJMIME
I
4
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne/linese Interventions and Risk According to Law Cooled to
I Factors(items 1-22) (Cont) 4l°F/45�F Within 4 Hours.
3-501.15 Cooling Methods for PHFs
PROTECTION FROM CHEMICALS 19 P►IF Not and Cow Holding
F1_4 Food or Color Additives 3-501.16(B) Cold PHFs Maintained at or below
3-202.12
Additives* 590.004(F) 41°145°F*
3-302:14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances 1400F °
7-101.11 identifying Information-Original 3.501.16(A) Roasts Held at or above 130°F. °
Containers* 20 Time as a Public Health Control
7-102.11. Common Name-Working Containers'
r
7-201.11 Separation-Storage* 3-501:19 Time as a Public Health Control*
7-202.11 .Restriction-Presence and Use*
590.004 H) Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBI E
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
7-204.12 Chemicals for Washing Produce,Criteria; 21 3-801.11(A) Unpasteurized Pre-packaged luices and
.Bevcragjes with Warning Labels*
7-204.14 Drying Agents.Criteria* 3-801.11(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Comtam Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
{ 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served *
s 7-206.12 Rodent Bait Stadons° 3401.11 C Unopened Food Package Not Re served
'p 7-206.13 Tracking Powders,Pest Control and
II Monitoring* CONSUMER ADVISORY
TIMEMEMPERATURE CONTROLS 22 3603.11 Consumer Advisory Pasted for Consumption of
16 Proper Cooking TemperaRures for Animal Foods That are Raw.Undercooked or
Not Otherwise"Processed to Eliminate
PHFs
3-401.11A(1)(2) Eggs- 155°F 15 Sec.
Patbo !p1eOBinxer
E Immediate Service 145°Fl5sec* 3-302.13, Pasteurized Eggs Substitute far Raw Shell
3-401.11(A)(2) Comminuted Fish.Meats&Game E °
Animals-155*F 15 sec. °
3401.11(6)(1)(2) Porto and Beef Roast- 130OF 121 rein* SPECIAL REQUIREMENTS
I 3-401.11(A)(2) Ratites,Injected Meats-155T 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
I sec.* catering,,mobile food,temporary and
3-401.1 UA)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
I Stuffing Containing Fish,Nleat, debited under the appropriate Sections
{
Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness
3.401.11(0(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145*F* 590.009 violations relating to good retail
3401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-401:11(A)(1)(b) All Other PHFs- 145715 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PHFs 165°F 15 sec. * (Items 13-30)
3-403.11(B) Microwave 165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
.1 3-403.11(C) Commercially Processed RTE Food- found in the follondng sections.of the Food Code and 105 CMR
}I 1400P 590.000. .
3-403.118) Remaining Unsliced Portions of Beef Item Good Retail Practices .FC 590.0w
`lp Roasts° 23. - Man emend and Personnel FC-2 .003
i 18 Proper Cooling of PHFs 24.. Food and Food Protection FC-3 .0D4
25. Equipment and Utensils FC-4 .005
l; 3-501.14(A) Cooling Cooked PHFs from 140°F to 26, Water.Plumbing and Waste FC-1; .006
��. 70*17 Within 2 Hours and From 70°F 27. Physical Fad' FC-6' .007
to 41°F/45°F Within 4 Hours. • 28. Poisonous or Toxic Materials FC=7 .008
' 3-501.148) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41 OF/456F 130• Omer
I,• Within 4 Hours* s�vor5a e .
:7
Dinotes critical item in the fedeeil 1999 Food Cade or 105 CMR 590.000.
r
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4m Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax (978) 745-0343
City/Town of SQL Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel. `
Name f� Date T pe of Operation(s) " Type of Inspection
✓>�� A n.�tJ 1�l �� - -) f Food Service ❑Routine
.Address 1 1� Risk Retail ❑Re-inspection
Telephone Level El Residential Kitchen Previous Inspection
❑ Mobile Date:
Owner HACCP YIN [I Temporary Preoperation
❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) S� Time ❑ Bed&Breakfast El General Complaint
In: [IHACCP
pedoF D h
InsJ � Out: Permit No. ❑.Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Norwcompliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors-(Red A,itiCfwkin 590.009(E) ❑
IVT ations marked may pose an imminent health hazard and require immediate Tobacco s 590.009(F) El.
Allergen Awareness 590.009(G) ❑.
corrective action as determined by the Board of Health.
�OODPROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
EMPLOYEE HEALTH ❑ 13. Handwash Facilities
--" �� _-- -- PROTECTI.O_N'FROWCHEMICALS':
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 3. Personnel with Infections Restricted/Excluded ❑ 14.Approved Food or Color Additives
❑ 15.Toxic Chemicals
FOOD'FROMAP_PROVEDSOURCE .-__ _.
4 Food and Water from Approved Source LWER�?E��R_E:C.ONTROLS.(P,oteirtlalty Hazardous foads)�
❑ 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
REQUIREMENTS_fOR:N)GHLYSUSCEPTIBLE'-POPULATIONS. _SP
❑ 9. Food Contact Surfaces Cleaning and Sanitizing _ _. _ _. (N.--
• ❑21.Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
❑ 11.Good Hygienic Practices CONSUMERADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical(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-zx590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)[590.0044)) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-axsso.00s) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5X590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6x590.007) 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
Special Requirements (590.009) within 10 days of receipt of this order.
3Other DATE OFRE-INSPECTION:
M21,
reds
Inspector's Signatu Print. V�
P[CsSignature: Print: Page' ofPages
Violations Related to Foodbome Illness
Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamnatbn
3-302.11(01) Raw Animal Foods Separated from
1 590.003(A) Assignment of Responsibility* Cooked and RTE Foods*
590.003(B) Demonstration of Knowledge* Contamination frau Raw Ingredents
2-103.11. Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3=302.1 I(A) Food Protection*
require reporting by food employees and 3-302.15 Washing Fruits and Vegetables
applicants* 3-304.1 I Food Contact with Equipment and
590.003(F') Responsibility Of A Food Employee Or An
Utensils*
Applicant To Report To The Person In Contamination from the Consumer
Chat •
590.003 C Reporting by Person in Charge* 3.306.14(A)(B) Returned Food and Reservice of Food*
Disposition of AdNterated or Contaminated
131 590.003(D) I Exclusions and Restrictions* Food
590.003(E) I Removal of Exclusions and Restrict ons 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
q 1 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Ford law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures"
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot 1Vater
3-202.13 Shell Eggs* .Sanitization Tem ratures*�
3-202.14 Eggs and Milk Products. Pasteurized* 4-501-114 Chemical Sanitization-temp.,pH,
3-202.16 fee Made From Potable Drinking Wawr* concentration and hardness.*
5-101.11 Drinking Water from an Approved System*
4-60 LI I(A) Equipment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.0* 4 602.I i Cleaning Frequency of Equipment Food
SheLYcsh and Fish From an Approved Source Contact Surfaces and Utensils*
4-702.1 I Frequency of Sanitization of Utensils and
3-201.74 Fish and Recrea!iorediy Caught Mollusc to Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Ha Water and
Sources*
3-201.15 ouresc�n Shellfish from NSSF listed Chemical*
S10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority 2-301.11 Clean Condition-Hands and Atms*
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 Came Animals* 11 Good Hygienic Practices
5 Recelving/Condition 2-401.11 Eating,Drinking or Using Tobacco*
3-202.1 I' PHFs Received at Proper Temperatures* 2-401.12 Dischuges,From the Eyes,Nose and
3-202.15 Package lntegrity.. Mouthy'
3-!01.11 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* Employees*
TagslRecords: Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction*
Conveniently Located end Accessible
3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacifies*
590.004(D Labeling of Ingredients* 5-204.11 Location and Placement*
7 Conformance vAth Approved Procedures 5-205.11 Accessibility.Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.11 S rializxd Processin Methods* Devkas
3-502.12 Reduced oxygen packafting,criteria* 6-301.11 Handwashing Cleanser,.Availabilit
8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision
Denotes critical item inure federal 1999 rood Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: CN.�_�1A � L:Ltd 41r �. �\L\_ Date: Page: Z of
Rem code c-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date.:.
No. Reference R—Red Item Verified
P EASE PRINT CLEARLY
Discussion With Person in Charge: Corrective Action Required: ❑ . No O yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to obsery all conditions as described, and to Exclusion
P ❑ Re-inspection Scheduled a Emergency Suspension
comply with all mandates of the Mass/Feder F od Code. I and s nd that .
noncompliance may result in daily fines of a y-five tars o s pension/revocation of a Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
r I
i
3-501.14(0) PHFs Received at Temperatures
Violations Related to Foodborne Illness Intervent/ons and Risk According to law Cooled to
Factors()tens'/-22) (Cont.) 41°F/45"F Within 4 Horns.°
PROTECTION FROM CHEMICALS3-501.15 Coolie Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-501.16(B) Cold PHFs Maintained at or below
3-202.12 Additives*' 590.004(F) 41014 5°F*
3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hat PHFs Maintained at or above
15 Poisonous or Toxic Substances 140eF ,
7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F.
Containers* ' 20 Time as a Public Health Control
7-102.11. Common Brame-Working Containers*
7-201.11 Separation-St * 3-501.19 Time as a Public Health Control*
7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers.Criteria-Chemicals*
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(0) Bevvrage i it Pre-packaged Juices and
S Bevan s with Warning Labels* '
'! 7-204.14 ents.Criteria° 3-801.1 l(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact,Lubricants* 3-801.1 I(D) Raw or Partially Codted Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed S Not Served.
7-206.12 Rodent Bait Stations* 3$01.11 C Unopened Food Not Reserved
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
t
I 22 3.603.11 Consumer Advisory Pasted for Consumption of
TIMER EMPERATURE CONTROLS Animal Foods That are Raw.Undercooked or
1.i 16 Proper Cooking Temperatures for Na Otherwiseirow9sed to Eliminate
1 PHFs
Pailto .mo.°,nrant
(I ' 3-401.11A(1)(2) Eggs- 155F 15 Sec.
j Eggs-Immediate Service 145'Fl5sec" 3-302.13. Pasteurized Eggs Substitute for Raw Shell
1E °
� 3Comminuted01.11(0)(2) � Coninuted Fish.Meats&Game .
Animals-155°F 15 sec. °
`( 3-001.11(8x1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(0}(DI Violations of Section temporary and in
sec , catering, mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness
3-401.11(0)(3) Whole-muscle,Intal Beef Steaks mtetventions and risk factors. Other
t 145°F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirement's.
3-401:14A)GO) 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)
3-403.11(B) Microwave-1650 F 2 Minute Standing Critical,mtd non-critical violations, which do not relate to the
Time* foodborne illness interventions and riskfactors listed above, cam be
3.403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR
1400F* 590.0000.
3-403.11(E) - Remaining Unsiiced Portions of Beef ItemGood Retail Practices .FC 590.0(10
tl Roasts, 23. 1 Management and Personnel FC-2 .003
t lg Proper Coding of PHFe 24. Food and Food Protection FC-3 .004
25. Equipment and Utensils I FC-4 .005
3-50f.14(A) Cooling Cooked PRFs from 140°F to Water,Plumbing and Waste
70°F Within 2 Hours and From 70°F 27. Physical Facility FC-6 .OW
to 41`F/45°F Within 4 Hours. * 28. Pasonous or Tosdc Matedais t FC--7 .008
3-501.14B) Cooling PRFs Made From Ambient 29. Special Requirements .009
4 Temperature Ingredients to 410FAST 30• Other
It Within 4 Hours*
"Denotes critical item in the federal 1999 Food Cate or 105 CMR 390.000.
F
7
lm!! MT MESSA69 ;
FOR
DATES i TIME 0 'P.M. '
M PGS . _
OF '
PHON—IL— F2 srl,
AA E NUMBER EMENSION
O FAX I
O MOBILE '
AREA CODE NUMBER ' TIME TO CALL
E�j . . _
PLEASE
TELEPHON
CAMEJO SEE,YOU, , WILL CALL AGAIN r
WANTS TO SEE YOU RUSH
- .,. ^, ,
RETURNED YOUR CAL WILL FAX TO YOU
b
MESSAG
SIGNED
ftjI ERSAL. 48005 MADE IN U.S.A.
NOTES T' .t
Commonwealth of Massachusetts
s ; City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 03/07/2012
ESTABLISHMENT NAME: Cindy's Planet Pizza& Grill
File Number:BHF-2008-000009 177 Fort Avenue
SALEM. MA 01970
LOCATED AT:
SALEM, MA .01970
Permit Type Permit.No. Permit Issued Permit Expires Fee Restrictions/Notes
SEASONAL FOOD. ;BHP-2012-0376 Mar 9,2012 ',Dec 31,.2012 .$140.00
ESTABLISHMENT.
Total Fees: . $140.00
PERMIT EXPIRES ecember 31, 2012
Board of Health
'Phis Permit is not transferable and must be reissued upon change U ownership or.location:The permit must be posted
ina'prominent location in th'e Establishment.
Iaaccordance witti 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
I . .
L. ,
V CITY OF SALEM, MASSACHUSETTS
• � BOARD OF HEALTH
120 WASHINGTON STREET,4n'FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR LRAM131 @SALEM.COM
LARRY RAPIDIN,RS/RF1-IS,CHO,CP-FS .
HEALTYI AGENT
2011 APPLICATION FOR PERMIT TSO, OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT ( /1 4Vl� �1-*1\J/ Ft? k 4 L L# q 7g'' 7/-/- 1 ' l
i
ADDRESS OF ESTABLISHMENT 17 rI LVi rl FAX#
MAILING ADDRESS('If different) 1� I,
EMAIL-Business': C'I . Vt Website:
OWNER'S NAME 1041\ y� TEL#
ADDRESS oull
STREET 0 (� CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) �V\ - eJA, CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food its prepared) r�
EMERGENCY RESPONSE PERSON 'l HOME TEL# (D( !-7-7 3 CI�
DAYS OF OPERATION Monda Tuesda Wednesday Thursday Friday Saturday Sunda
HOURS OF OPERATION
Please
orexa kelotlineofaay.
For exam `.17am17
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES 1O: less than t000sq.fL =$70
1000-10,000sq.fL =$280
more than 10,000sq.ft. 444200
---•-•...:..:..................................... . ... ...........................................................................
-'---....G ,413
RESTAURANT YES NO less than 25 sea..t•s
(Outdoor Stationary Food Cart$2 25-99 seats =$280
more than 99 seats =$420
......................
BED/BREAKFAST/ YES $100
FHILDGAR ..$. RY.I� S/NUR IIJG,HOMI ...............................................................................................................................
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES <OD $25
TOBACCO VENDOR YES $135
ALL NON-PROFIT(such as church kitchens) YES (: $25
'Please pay total with one check payable to the City of Salem.
This Permh to 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'IG,GL Chapter
62_sC,Section 49A,1 certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns a pr
all stet -tax req under the law.
Signature Date Social Security or Federal Identification Number
Updated 5/23/11 FOODAP201 I.adm Check#&Datcm�G $
CITY OF SALEM
f {� BOARD OF HEALTH
�i
Establishment Name: P A°/S P'G ItiA Date: g �� Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date..
No. Reference R-Red Item - Verified
PLEASE PRINT LEARLV
A- noo-, iu 7pec6 v�-�' i 5ecp h11 � 1, .,f
faufa, - c,Jftrbc:7) �ryd (R 1. fCl .��fl lid �Ct tICY e 7r e
I -
po to r ,crow .
d SOI/ rovi ca v As-)( onorl
did Q Ql'C c
-(,',n .moi i i 2 bc;c+tzytc� prwD a-tC (Ulun
(vk( 1 dD)Cen.
rn 51- rt�r,71 c J� o ( C f fPct
avid Ck-Er-)z'iP
ens Iyl I f Y " s�
V - I _ �
I \ecac (/ ( i I•t _ -F� .�72 ce Hc, l wo �c� (l �i� I �)Pem
o I I t4 °4 -zr�rwi 6 '
Discussion With Person in Charge: Corrective Action Required: O .No ❑: ,Yes
I have read this report, have had the opportunity k questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to obsery all onditions as described, and to Exclusion
I I ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Cod Code. I understand that
noncompliance may result in daily fines of tweAty! eI'dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. ff\\ 1
❑ Voluntary Disposal ❑ Other:
1\
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Item-1-22) (Cont.) 410F/45°F Within 4 Hous. *
PROTECTION FROM CHEMICALS3-50L15 Coolie Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-501.16(B) Cold PHFs Maintained at or below
31202.12 Additives*" 590.004(F) 410/450 F*
3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above
15 Poisonous or Toxic Substances
140°F. *
7-101.11 Identifying Information-Original 3-501.I6(A) Roasts Held at of above 130°F.
Containers* "
7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control
7-201.11 Separation-Storage" 3-501.19 Time as a Public Health Control*
7-202.11 .Restriction-Presence and:Use* 590.004H) Variance Require meat
7-202.12 Conditions of list* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Cattainers-Prohibititns* pppULATIONS HSP
7-204.11 SartChemicalszers.for Was i Chemicals, 21 3-801.1](A) Unpasteurized Pre-packaged Juices and
7-204.12 Chemicals for Washing Produce,Criteria*
7-204.14 Drying Agents.Criteria* Beverages with Wartrino Labels*
3-801.11(8 Use of Pasteurized E *
R
7-205.11 IncidentalFood Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served*
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIMET TEMPERATURE CONTROLS 22 3-603.1 t Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for
Animal Foods That are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
'3-0Ol.L1A(i)(2) Eggs- i55°F 15 Sec.
Pathogens.' vuxoi
Eggs-Immediate Service 145*F15sec- 3-302.13 1 Pa7rized Eggs Substitute for Raw Shell
3401.11(A)(2) Comminuted Fish.Meats&Game
E
Animals- 155°F 15 sec. * SPECIAL REQUIREMENTS
3401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A}(D)in
3401.11(A)(2) Ratites,Injected Meats-155°F 15
sec. * catering, mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Mea[, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness
3-401.11(0(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
1450F* 590.009 violations relating to good retail
3401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3401:11(A)(1)(b) All Other PHFs-145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3.403AI(A)&(D) PHFs 165°F 15 sec.* (Items 23-30)
3403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* - foodborne illness inlementions and risk factors listed above, caabe
3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140°F* 590.000.
3-403.11(E) Remaining Unsliced Portions of Beef Rem Good Retail Practices FC 590.000
oastsFCRManagement and Personnel 1'FC-2 .003
18 Proper Cooling of PHFs ' 24. Food and Food Protection I FC-3 .004
25. Equipment and Utensils I FC-4 .005
3-501.14(A) Cooling Cooked PRFs from 140°F to 26. Water.Pitimbintl 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 I FC=7 .008
3-501.14(B) Cooling PKFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41°F/45-F 30• Other
Within 4 Hours* s:wn:a,m,w:ex
Dnotes critical item in the federal 1999 Foul Code or 105 CMR 590.000.
Commonwealth of Massachusetts
` City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
FooWRetail Establishment Permit
DATE PRINTED: 03/18/2011
ESTABLISHMENT NAME: Cindy's Planet Pizza & Grill
File Number.BHF-2008-000009 177 Fort Avenue
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2011-0370 Mar 18,2011 Dec 31,2011 $140.00
ESTABLISHMENT
Total Fees: $140.00
PERMIT EXPIRES IDecember3l, 2011
Board of Health
' 4-/1
_ v
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
i .
J
�- �� t� P�
�—�� 12er 5r�(I 5 i�l e-
S7�? �s�
I �
CITY OF SALEM, MASSACHUSETTS
• a BOARD OF HEALTH
120 WASHINGTON STREET,4' FLOOR
TEL. (978)741-1800
KIMBERLEY DRISCOLL FAx(978) 745-0343
MAYOR DGRF F'NBAUM(@SALE'M.COM
DAVID GREENBAUAI,RS
ACTING HEALTH AGENT
2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENTJki TEL#
I
ADDRESS OF ESTABLISHMENT ) �� FAX#
MAILING ADDRESS(if different)
EMAIL-Business': Website: G
OWNER'S NAME y/ TEL#
ADDRESS I � O3 ?)bLoll �Z.
STREET J CITY STATEZIP
CERTIFIED FOOD MANAGER'S NAME(S) � i ONS CERTIFICATE#(S)
(Required in an establishment where potentially hazardous food is prepared) // --
EMERGENCY RESPONSE PERSON HOME TEL# to (7n,3ri�
DAYS OF OPERATION I Monday Tuesday Wednesday I Thursday Fliday Saturday Sunda
HOURS OF OPERATION (l n M r l� , ( I ^ „� I /L , _ I �„rr _ j ' 11
Please write in time of day. I /T/Y I /"I �r1 �T "I
Forexam lellam-11 m
TYPE OF ESTABLISHMENT EE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
RESTAURANTY S NO less than 25 seats =$140
(Outdoor Stationary Food Cart$21 25-99 seats = 280
more than 99 seats =$420
............... `...... .... [ - - $100
BED/BREAKFAST/ YES O
CHILDCARE-SERVICESMURSI NG-HOME-----------------------------------------------------------------------------------------------------------------------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE N
TOBACCO VENDOR $13
ALL NON-PROFIT(such as church kitchens) YES NO $25
I
'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 s mitted to and approved by the Salem Board of Health.
Pursuant to M apter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
returns and p ' al slate taxes uire nd r the law.
3- 7-11 ocl - 332- 301
SignatureDate Social Security or Federal Identification Number 71
Revised 10!771 I FOODAP201 La Checkil B:Date $
CITY OF SALEM
(�l BOARD OF HEALTH
Establishment Name: 1 /V 1'I ( — G� I I I .51 Date: I Page: of
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dete_
No. Reference R-Red Rem Vertned
...�p PLEASE PRINT CLEARLY .
t7tce m -7t wce
7YI �n ( /P
1 U
vc c
o
Pkr nAcva , ani ,
Vi(-I r n1AA/o �Ik n,w al o )c- 5
v
v
lv u1 cv
+ t� A I 1
Discussion With Person in Charge: Corrective Action Required: ❑ ..No ;❑: .Xes;
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 toExclusion
comply with all mandates of the Mass/Federal Food Code. I understand that ❑ Re-inspection Scheduled ❑ Emergency Suspension
` noncompliance may result in daily fines of twenty five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
t your food permit. / ' (//J/
❑ Voluntary Disposal ❑ Other:
f
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.) 4l*F/45°F Within 4 Hours. *
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Not and Cold Holding
3.202.12 Additives* 3-50IA6(1J) Cold PHFs Maintained at or below
3-302.14 ' Protection from Unapproved Additives* 590.004(F) 410/450 F*
15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above
140*F. *
7-101.11 Identifying Information-Original 3501.16(A) Roasts Held at or above'1300F.
Containers* '
7-102.11. Common Name-Working Containers* 20 Time as a Public Heatth Control
7-20111 Separation-Storage* 3-501.19 Tinte as a Public Health Control*
7-202.11 .Restriction-Presenceand Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP
7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurised Pre-packaged Iuices and
7-704.14 'n*Agents.Criteria* Beverages with Warning Labels*
3-801.11(B) Use of Pasteurized E=*
7-205.11 Incidental Food Contact,Lubricants* 3-801..11(Dy) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served. *
7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-706.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or
PHFs Not Otherwise Processed to Elintinate
3401.11A(1)(2) Eggs- i55*F 15 Sec. Palk° * *rn roc
Eggs-Immediate Service 145*1715sec* 3-307.1.3 Pasteurized Eggs Substitute for Raw Shell
3401.11(0)(2) Comminuted Fish.Meats&Game
Eggs*
Animals-155*F 15 sec. *
3401.11(B)(I)(2) Pork and Beef Roast- 130*17 121.min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites,Injected Meats-155*F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec * catering, mobile food, temporary and
3-401.1I(A)(3) Poultry,Wild Came,Stuffed PHFs, residential kitchen operadons should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165*F 15 sec. * above if related to foodborne illness
3-401.11('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 under#29-
Microwave 165°F* Special Requirements.
3-4010 I(A)(1)(b) All Otber PHPs- 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)
3.403.11(B) Microwave- 165*F 2 Minute Standing Critical,mid non-critical violations, which do not relate to the
Titre* foodborne illness interventions and risk factors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140*F* 590.000.
3403.11(E) Remaining Uasticed Portions of Beef ' Rem I Good Retail Pracflees .FC 590.000
Roasts"' 23. Man smart and Personnel FC::::2 .003
18 Proper Cooling of PHFs 24.. Food and Food Protection FC-3 .004
25. Equipment and Utensils FC-4 205
3-501.14(A) Cooling Cooked PHFs from 1407 to 26. Water Plumbing, and Waste FC-5 206
70*F Within 2 Hours and From 70*F _ 27. • Physical Facili FC-6 .007
to 4I`F/45°F Within 4 Hours.* 26. Poisonous or Toxic Materials FC=7 .008
3-501.14(B) Cooling PRFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41*F/45*17 30m Other
Within 4 Hours*
*Wnotes critical item in the federal 1999 Foal Code or 105.CMR 590.1100:
r
Commonwealth of Massachusetts
City of Salem
Board of Health IGmbertey Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED:. 03/08/2010
ESTABLISHMENT NAME: Cindy's Planet Pizza & Grill
File Number.BHF-2008-000009 177 Fort Avenue
SALEM MA 01970
-LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2010.0375 Mar 8,2010 Dec 31,2010 $140.00
ESTABLISHMENT -
Total Fees: $140.00
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. Paye 1
CITY OF SALEM, MASSACHUSETTS
` f ` BOARD OF HEALTH
120 WASHINGTON STREET,4'FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAx(978) 745-0343
MAYOR oGRrEl, AM Ca)sm .COM
DAVID GREENBAUM,
ACTING HEALTH AGENT
2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
EST(A�BLIIS7'HrMENT �y.a
NAME OF ESTABLISHMENT 1.1 I PC✓ #L# -I�11 - / `T 1 - I d I) k
ADDRESS OF ESTABLISHMENT 1�et AV2 FAX#
MAILING ADDRESS(if different)
EMAIL-Business': ll v Website: p ^'
OWNER'S NAME ( P.✓1I ^ TEL#
ADDRESS RRS� ( 1)0 4(,22 u Y ` (Qr4 Jai &t'm M ,+ 02Zt I t
STREET �^ CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAMES) V N yak CERTIFICATE#(S) r✓iz I 1 7P
(Required in an establishment where potentially hazardous food is prepared)
EMERGENCY RESPONSE PERSON c HOME TEL# (0L-1- K Z Z3-&J /!I
DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Su
j HOURS OF OPERATION
please lof day.
(Foexamplelim-11IMI m }1QN - II m tlA 'Il� I16 - ( � I(Ar�- II t1t(Awt- l1 lIA- - (
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES Q less than 1000sq.fL =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft =$420
- _ -146...._...........................................•----------------.............................
RESTAURANT YES less than 25 seats =$140
(Outdoor Stationary Food Cart$21 25-99 seats =$280
more than 99 seats =$420
- ............. ..-------------------------------..............................................$100
BED/BREAKFAST/ YES
CHILDCARE SERVICES/NURSING HOME.....................-----------------------------------------
...--------------------------------
...........
.•--•---•---.......
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM,YOGURT/SOFT SERVE YES (0) $25
TOBACCO VENDOR YES <fD $135
ALL NON•PROFIr(such as church kitchens) YES (:IT9 $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
suc ust be submitted to and approved by the Salem Board of Hea@h.
P M to MGL Chapter 6 C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
7=
and p all stat t s required under the law.
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B .
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: S CY IZ + I Date: a('2I/
IT o Page: t of
Item Code C—Critical Item
DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION
No. Reference R—Red ItemPLEASE PRINT CLEARLY4rBied,r
Ah i IVl ion , ea r is
_r-} , Vit i v► i 1C- . c,i? g ali•io
Dt t I <<
Discussion With Person in Charge: Corrective Action Required: ❑ No. ❑'.'Yei ;.. -
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
L
mply with all mandates of the Mass/Federal Food Code. I understand that
compliance may result in daily fines of twe,fy,^-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
r food permit. / / �� �jJ
0 Voluntary Disposal 0 Other:
3-5t11.14(C) PRFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Items 1.72) (Cont) 41`F/45`F Within 4 Haw's.
PROTECTION F130M CHEMICALS3-501.15 Cooling Methods for PHFs
19 PHF Hot and fold Holding
14 Food or Color Additives 3-501.16(8) Cold PHFs Maintained at or below
3-202.12 Adcfitives't 590.004(F) 41`/-45°F'
3-302.14 Protection from Una roved Additives° i-j01.16(:i) Hot PH13 Maintained at or above
15 Poisonous or Toxic Substances
7-101.11 Identifying Inkmation-Oiigimd 140'1. `
Containers" 3-501.16(A) Roasts Held at or above I3U F.
7,102.11 Common Name-Working Coiwiiner:." 20 ._- Time as a Public Health Control
7-201.11 Sc aration-Stora e" 3-501.19 'fimr.as a Public health Control'
7-202.11 Restriction-Pre.:ncc and Use Sgijj)04(H) Variance Re uircment
7-202.12 Condiricros of Usc"
7-203.11 Toxic Containers-Prohibilionsc' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Saniiizers,Criteria-Chemicals POPULATIONS(HSP)
7-204.12 Chemicals for Washing PrrxJua,Criteria" 21 +-801.11(A) Unpasteurized Pre-packaged Juices wid
Ileveraees With Warning UWILS"
7-204.14 Orin Aeents.Crirzriu" - - 3-801.11(13) Use of Pasteurized Eggs*
7-205.11 Ltcidental Fc 1)d Contact.l.trbricattrs_ 3.501.!1(11) Raw or P.utially C,nkcd Aaimal Food and
7?06.!1 Resiricled Use Pesticides.Criten.0
j 7-266.1Rodent Bait Stions - Ra:e Surd-/ 4\ut Served.
Rodent Unopened PackageNor R
f;.,,.-rvei1.
7-206 I_ 17a:king rnwir•. Pest Cuntnl and __
-
Nlonitorim' .I
L- coNsuMEf1 aDvls(?Rv
TIME/TEMPERATURE CONTROLS22 i 3jW_1.1 I�CQP..�muer Art%isory Posrrd Ior Crnrsuuiption of
I I
Animal FxyJz ILut.ac Raw. is ndrnz".tked w
16 Proper Cooking Temperatures for-- I ?'nt!T,hrnvi:;r Pray ssvd to iaim;n:;!e
!_ _. .-_- PHFs
3 --
_ __ •.. __
-lOL1L�(i+(J; fyg:. 15>`F L Sa:. i'athaerr.
---..-_. .._. ...._-----
_ _ F.:ggs-bnro::di:ue.Scrvia 145°P15sec_
I it?.1.1 l }?,a�:•sri::.cit (i g:'rul•sorute for Raw Shell
3-401.3.IiA)(2) Crmi::inuted fish. Mcarc gGain
Animals- I iTT 15 sec. ' __ _
SPECIAL REOUIREMEid'f5
3-401.11(8)(!.(2_I Pork sou' Ocel Roast- I (1`I 121 nri_n" -----�- ------------,
-'~'-_--' -- - -iD1 590.fX)9lA'
3-491.!It' s' ) Violations n[Sectic•n 590.009W-W)in
Inieefe,
ts)l:1 R,�Irtea, M11i�ati-- i5 FIS
catcru:c, mobile food. temp;miry and'
'
3411.1!(Air ) � Pmdtrv. N'i!d carne,Stuffed PI1Fs, i a:;ideat;iai !.itehen opa'ations at:xrld br:
(,:ontaining Fish, Meat. - I ! d!:h!ted under the approp[iafe tiCi'tiOnS I
'rc:a!!n_rRadces-16_57, !-;s,.cy4. _ ! :,Ik•ref,c!; ';•rlrnf'.�tJix+::n '!lm:•s�.
,GL.L'rC, =r - '.iholr•mn> Je hutci Oct tievsk. ) 1 I fmcl t'nlMi :nd far (,t! cr
' _ LFS'F'- 5,41" tu- tion tc.l wog to -th>•1 tclail 1
';.401.1'. 71:aw mins,) F oO. (","l,"d .r ,t ! ••r.; !c(. . .' I,: r.�. . r,.p.•,t ,_:.dc. 6"4 l
-- _ ..-- ----- --------- --- __ _. __... gip.•:' ::i :o. m,111'.
Plli's - 141 1- i' 'cc
X17 Reheating tot Hot Holding_ _ WOLAT1ONS RELATED TO GOOD RETAIL PRACTICES
:-103.11(A)KtL)) PHF:. 165'115 sec. - (Items 23-30)
3.403.11(6) Microwave- 1650 F 2 Minute Standing Ciincal and run-u'itical wolcnimo. which do unr relarr!n thr
Time'' Jiwelhrrne ilhws'.c imer%entimw roil ris*ji!c'(ors livied above. (an Lf•
3-403.1 1(C) Commercially Prcxe<scd RTE Ft.xf- furard in the f'llnum!g scc!inns('(the Four/Code and 10-5 Cb1)?
3403.11(1:) Remaining Cnsliced Portions of llcvf ! Item Good Retail Practices9_meni and Pei�onn _ FCJ` 590.000 i
I 23. Mana aal FC-2 I A03
Rnasrc` __-_--"--- '
l8 Proper Cooling of PHFs 24. Food and Foocl Protection_-- FC-3 (A4_�
25. E j ipmenI and Utensils FC-4 065 _ r
3-5(11.14(A) C_'a:rlige Catkcd PHFs from 140`P to 26. Water.Plumbin tnd waste FC-5 i .046 -_1
9 ---
70"1 Within 2 flours and From 70`'i` 27�Etly �J FacilitL__ 607
to 41'F145"F Wi11Jn 4 Hours. ° 28. Poisonous or Tox;c V2!er.,,Is _�FO_-7 I 008 -j
3-501.14(8;^- Cooling PHFs Made Front Ambient . -�ecrat RWcirema{tis 009 _
TemVeruture Ingredients u,d)`F/45` - L30 -f Other_..._
LWithin 41iuurS` "i0i'`"r' •6'
r _•:+->:r+.dca!ir;n:in rR.L,Ier.l f,YI', f,i C:'A"in9('\q!<5M:',lf. .
IMPORTANT MESSAGE
FOR
IOA TIME P.M.
M�/
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F
PHONE
AREA UMB NSION
O FAX ..
O MOBILE
AREA CODE, NUMBER ..,TME TO CALL
TELEPHONED :; .PLEASE.CALL.
CAME M SEE YOU WILL CALL AGAIN
i
WANTS MOSES YOU RUSH
RETURNED YOUR CALL WILL FAX M YOU : '-t
ESSAGE
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SIGNED
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Commonwealth of Massachusetts
City of Salem
Board of Health l tnberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED:, 03/13/2009
ESTABLISHMENT NAME: Cindy's Planet Pizza & Grill
File Number:BHF-2008-000009 177 Fort Avenue
SALEM MA 01970
LOCATED AT:
SALEM, MA, 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2009-0397 . Mar 13,2009 . Dec 31,2009 $140.00
ESTABLISHMENT
Total Fees: $140.00
PERMIT EXPIRES Ilbecember 31, 2009
Board of Health
4 A2
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
�amg 120 WASHINGTON STREET,4"'FLOOR
TEL. (978)741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR ]DIONNI£a&H.EM.COM
JANETDIONNE,
SENIOR SANITARIAN
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2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT ZZc- 4GA I TEL#
ADDRESS OF ESTABLISHMENT �Y� 2 FAX# —
MAILING ADDRESS(if different)
EMAIL-Business': &A &iComa..ly. Kz+ Website:
OWNER'S NAME I_ TEL#
ADDRESS �'F� ����,SYI� 2 SO3 SoSEM f�A- evil
STREET CITY STATE ZIP
CERTIFIED FOOD MANAGER'S NAME(S) N�w h �PiY� CERTIFICATE#(S)
(Required in an establishment where potential azardous food is prepared)
EMERGENCY RESPONSE PERSON HOME TEL#
DAYS OF OPERATION ! Monday Tuesday' Wednesday i Thursday I Friday I Saturday Sunda
HOURS OF OPERATION
Please write in time of day. II �1'1 '\A ,w l�a"t� (D m l( — J0 rk llAm—t(r (I'.M —
For example 1lam-11 m W 0
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than I000sq.ft. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
-------------------------------------------------------------------------------------------------
RESTAURANT YES NO less than 25 seats - 140
.(Outdoor Stationary Food Cart$ 25-99 seats =$280
more than 99 seats =$420
----------------------------------------------- --•--..........---------------------------------------------------------...----•-••--•-•.
BED/BREAKFAST/ YES' NO $100
CHILDCARE SERVICES
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25
TOBACCO VENDOR YESc1YArtS) $135
ALL NON-PROFIT(such as church kitchens) YES O $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 locatio
in the Establishment
In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for
such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax
returns and paid all state taxes required under the law.
Dq33Z3o ) q
Signature Date Social Security or Federal Identification Number
Revised 424/07 FOODAP2008.adm Check#&DateA11/447 s
k
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: G'1 �;�s "Q nig Q6iij -+GC*,U Date: 3 Ln (Oc Page: of
Item Code C-Critical Item - DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No, Reference R—Red Item Verified
PLEASE PRINT CLEARLY r
�c I -O Ing 1 n5 V1?L�1 �n ( in. ) C_nncu.G�P. Q'
� G (niTr•P. � —t�- �
1dC F)V 4d t II c�f -� f'v Ode( �J t�c�.r 51(11
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t " o P1 tnantC{�S On I( h n 1il1� PC .bI1. YKo vlrt V> U� h
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Discussion With Person in Charge: Corrective Action Required: ❑ No. ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/FederalFood Code. I understand that
noncompliance may result in daily fines of twe ty-five dollars,orluspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
G/,� �, ❑ Voluntary Disposal 0 Other:
3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to
Factors(Items 1.12) (Cont) 41'F/45°F Within 4 Hours.
PROTECTION FROM CHEMICALS Cold PHFs Maintained at
3-501.15 Cooling Methods for PHFs
14 Food or Calor Additives. 19 Hot end Cold dl
3-202.12 Additives* 3-501.16(6) Colat or below
590.00
3-302.14 Protection from Una 3-5016(.16( 41°145°F*
Unapproved Additives* 1
15 Poisonous or Toxic Substances A) Hnt PHFs Maintained at a alcove
140'F.'
7401.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 110°F.
Containers" 20 Time as a Public Health Control
7-102.11 Common Name-Working Containers*
7-201.11 Separation-Storage*
3-501.19 Time as a Public Health ConuroP
7-202.11 Restriction-Presence and Use" 590.004(H) Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Saniiizers,Criteria-Chemicals*
7204.12 Chenticals for W'ashin Pr duce,Coiter a" 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Dryingencs.Criteria" Beveraees with Warninglabels*
7-205.11 Incidental Pond Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs*
3-801.11(D) Raw or Partially Conked Animal Fad and
7-206.11 Restricted Use Pesticides.Criteria* Raw Seed S routs Not Served. *
7-206.12 Rodent Bait Stations" 3-801.1 1(C Unopened Fond Packs a Not Re-served.
7?06.13 Tracking Powders.Pest Control and
Monitoring-4 CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3603.11 Consumer.Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods Thut are Raw. Undercooked m
PHFs Not Otherwise Processed to Eliatinate
31101.L I A(I)(2) Patho gens.*
Eggs- 155'F 1.5 See.
`'re`°"'''•''�0°'
E es-Immediate Service 1450F]5sec-
3-302.13 Pasteurized Eggs Substitute fo Raw Shell
3401.11(A)(2) Ccmuninuted Fish, Meats&Game
L' 's*
Animals- 155"17.15 sec, * SPECIAL REQUIREMENTS
3-401.11(6)(1)(2) Pork and Beef Roast- 130°F 121 min*
3-401.11(A)(2) Ratites. lniected Meats- 155"F 1.5 590.1)U9(A)-(D) Violations of Section 590.009(A)-(D)in
sec.* catering. mobile fool,temporary and
3-401.11(A)(3) Poultry, Wild Game,Stuffed PHPs, residential kitchen operations should be
Sruffine 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
31101.12 Raw Annual Fo xis Corked in a practices should be debited under X29-
Microwave 165°F* Special Requirements.
3.401.11(A)(10) All Other Pt{Fs- 145°F 15 sec.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.11(A)R(D) PHFs 165F 15 sec. * (items 23-30)
3-403.11(6) Microwave- 165"F 2.Minute Standing Critical cord non-crilical violidions, which do not relate to the
Time" ,foodborne illness interventions and risk factors listed above, con be
3-403.11(C) Commercially Processed RTE Fool- found in the following sections of the Food Code and 105 CMR
1400F* 590.000.
340'3.11(E) Remaining Unsficed Portions of Beef Item I Good Retail Practices FC 590.000
Roasts* 23. Management and Personnel _ FC-2 .003
18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004
3-501.14(A) Cooling Cooked PHFs from 140`F to 25. Equipment aril Utensils FC-4 .005
.26. Water.Plumbing and Waste FC-5 .006
70°F Within 2 Hours and From 701-' 27. Physical Facility FC-6 .007
to 41 QF/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(6) Cooling PFIFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 410F/45°F 30. Other
Within 4 Hours* s.rhav,rnx.:.,r.
I..)enotes critical item in the[Mer:l 1999 Fottl Cade or 105 CMR 591)ODO.
i
177 Fort Avenue Cindy's Planet Pizza & Grill
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephoner ."'; k PROTECTION FROM CONTAMINATION
(617) 823-8198
" ' Handwash Facilities FAIL Non-Cribcal ❑� RED
Owner: '�'^ "% u •4. ;, Comment:Install a wall hung a wall hung soap dispenser in the restroom. Soap available at the time of inspection.
�1 .0
Cindy'.Yen d1 .k
PIC ,..,. a ,
Inspector:
David Greenbatimr
Date Inspected Correct 13y:,
15/14/2008' 14 ^N a 'e'
Risk Level• 4 IF,
;Permit Number ;
BHP-2068-045TL f
Status ^. r•F Y '
SIGNED OFF?r der -i
#of Critical Violations +"
Time IN 2 Ne v Time OUT
jUrgency Description(s),.,,,,
BLUE:; ;R 11u f * , In accordance with the Federal Code and the State Sanitary Code all other requirements to open have been
;violations Rela(ed to Goode satisfied.
Retail P.ractices (Critical 1K Z".�'.•
Violations must be corrected Expected opening is 5/16 or 5/17 2008.
immediately,or within,l0$•
days)( Non-critical violations??' Owner has stated they would like to serve ice cream in the fall at this location. Please notify the Health Agent
must be corrected immediately,, prior to selling ice cream at this location.
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 14,2008 ) Page ! of
Q • '
Item Status Violation Critical Urgency
RED r t .x
IVlolatlons Related to ,�)✓� <.,:
Foodborne Illness Interventions
and Risk Factors (Require e.
,immediate eorrective action) '-f
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 14,2008 ) Page 2 of
Commonwealth o(1Vtassachusetts
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
Temporary Food Permit
DATE PRINTED: 05/13/2008
ESTABLISHMENT NAME: Cindy's Planet Pizza & Grill
File Number.BHF-2008-000009 177 Fort Avenue
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No.. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2008-0457 May 13,2008 Dec 30,2008 $140.00
ESTABLISHMENT
Total Fees: $140.00
PERMIT EXPIRES IDecember3O, 2008
Board of Health
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CITY OF SALEM, MASSACHUSETTS
• • BOARD OF HEALTH
120 WASHINGTON STREET,4n'FLOOR
TEL. (978)741-1800
KIMBERLEY DRISCOLL FAx(978)745-0343
MAYOR ISCo•rr(a,SALENf.CONI
JOANNE SCOTT,
HEALTH AGENT
2008 APPLICATION FOR//PERMIT TO OPERATE FQQD E/STABLIS�IHMENT
NAME OF ESTABLISHMENT ( ytLwl S T(4IL2
IL-24 -1 TEL# [�/ 7 —cT Z3—e5('?8
ADDRESS OF ESTABLISHMENTI FAX#
MAILING ADDRESS(if different)
EMAIL-Business': Iti Website: 2
9f5
OWNER'S NAME n�i 2l/\ TT�E,L# 717,LSZ3'CT1 / &
ADDRESS 2f 6 -S 7 O3 G� /u" K� Dz///
STREET y CITY STATE �_ ZIP j�
CERTIFIED FOOD MANAGER'S NAME(S) Lz Vl `e V\ CERTIFICATE#(S)/JZ 13: ? 7(f
(Required in an establishment where potentially hazardous food is prepared) l-oN 6 ZU!Z
EMERGENCY RESPONSE PERSON " 2 HOME TEL# &(7—ff2 31—Fri 5&
DAYS OF OPERATION Monday Tuesday Wednesday Thulsd 'Friday Saturday Sunda
HOURS OF OPERATION 1 (AM-10
�I n� T !p /'p'rA
Please write in time of day. 1 (f[{ —10 MM— Lg/,(�1''�� �1 /I (N-/O
Forexamplellam-11pm tt^t�t YY( I
TYPE OF ESTABLISHMENT �� FEE (check only)
RETAIL STORE YES l less than 1000sq.11. =$70
1000-10,000sq.ft. =$280
more than 10,000sq.ft. =$420
-------------------------------------------------------------------- ----------------- -
RESTAURANT Y 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
---------------------------------------------------------------------------------
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES N $25
TOBACCO VENDOR YES $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 mus
Pursuant t b bmitted to and approved by the Salem Board of Health.
Puant G Chapter 62C,S ion 4 ,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax
retums d p ' all stat es r r oder the law.
- 3 v2,30/
Signature Date Social Security or Federal Identification Number .
:i
CITY OF SALEM
BOARD OF HEALTH
Name of Establishment: Cindy's Planet Pizza & Grill
Address: 177 Fort Avenue
Owner(s): Cindy Yen
Phone: (.0- 81S - 919F
Date: March 13, 2008
The owner of this establishment presented a Floor Plan and Menu for review in
accordance with the State Food Code.
FLOOR PLAN
The Floor Plan is approved as presented.
Hand sinks must have wall hung soap and paper towel dispensers. These
must be stocked at all times. Hand sinks must be used for hand washing
only. The hand sink must be labeled "For hand washing only."
A splash guard must be installed between the hand sink and the second
bay of the sink.
A food prep sink or the 3rd bay of the 3-bay sink may be used for washing
vegetables, etc.
All floors, walls, and ceilings where food, utensils, paper products, etc, are
stored, prepared or served must be intact, impervious, and easily cleanable.
MENU/FOOD PREP
All food must be purchased from a wholesaler licensed by the State.
All food must be held at 41°F or lower, or 140°F or higher, at all times.
Salad display items, such as vegetables, must be cold prior to being held cold in
the salad unit.
Food may not be added to containers in salad unit. Instead, a sanitized
container with new product may replace the existing container and the old
product may be placed on top of the new product.
There may be no bare hand contact of ready-to-eat foods. Gloves, tongs,
or tissues must be used when handling such food.
Reviewed preparation of chicken caesar salad and pasta with chicken
parmesan.
CERTIFICATION
There must be a Certified Food Manager working at this establishment full
time.
When a CFM is not onsite there must be a Person-in-Charge (PIC) who is
fully trained in sanitation techniques and has a thorough understanding of the
operation.
The owner will become a Certified Food Manager. The Food Manager at
this establishment will be the the CFM from Cindy's Planet Ice Cream.
When a CFM is not at the establishment, there must be a Person-
inCharge, PIC. This person must be familiar with all sanitation requirements.
UNDERCOOKED FOODS
There must be an asterisk and advisory on the menu regarding
undercooked foods, if such foods are served. If the owner decides not to serve
undercooked foods, the menu must state this also. The required wording was
given to the owner
EXTERMINATION
Monthly services of a Licensed Pest Control Operator are required.
Please keep receipts for inspections.
SANITIZING SOLUTION
Sanitizing Solution must be accessible at each prep station aad-forttr2
Test strips corresponding to the kind of sanitizer, must be on hand to
check concentration of solution. Solution must be made daily, tested, and the
results recorded on a log sheet for examination by Board of Health inspectors.
Solution may be prepared in the 3rd bay of the 3-bay sink and spray
bottles and/or wiping pails may be filled there. Spray bottles with clean paper
towels may be used, as well as wiping pails with wiping clothes always held in
the solution in the pail. Spray bottles and wiping pails must be clearly marked
"sanitizer".
TRASH.
Outside area of premises, including the dumpster area, must be kept
clean and sanitary.
Any changes in Floor Plan or Menu must be approved by the Board of Health.
Please call one week prior to opening to schedule an opening inspection.
3- I3-OP'
ann ott ' Date
He gent
/ // ?-/3 08
Yen Date
ClzeA—
FiR ?4U1 11;A%R7B- 75 5-7777
EQUIPMENT . FF400
Four Tube Gas Floor Fryer-""TCO
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Features W
• All stainless steel fry tank,50 Ib.capacity '.
• Stainless steel front,lop ledge and header • '� ` t _ • Fad• a
11/4 ball type-full port drain ^;{ It
• • why �;4, k rc'r tf�-0`` „. x
• Coobzone in fry tank ' a „ . , ;+'"• .
• Four(30,000)BTU heat exchange tubes � ., s "�"` 5 _ '� •_ ' ^+. `�'�5;
with high heat baffles,total 120,000 BTU
'
• Double rod basket hanger f`., e w• �x
• Stainless steel door with integral liner ' - y a � v H s�°* '� � ..• -
• Smooth finish,high.grade G90galvanized
sides and back k , ..i ' a 4F.E,`rx`>•.xl :' ■
• Two nickel chrome wire mesh fry baskets red • �'• ►., ` F •
-plastic coated handles
Tube rack to rest fry baskets is nickel plated
• Invensys thermostat-200°F to 400°F
• • Auto high limit reset - 1 ;..• ; ; - ^
• 6 inch adjustable legs,casters available - -
• Warranty: 1year parts and labor - -
Description _ Technical Data::
_..._ -....._
Capacity. _ `50165.
The Avantc0 FF400 Floor Fryer is a four tube, .._ -.- -�.t --Z--
50
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50 lb.capacity freestanding gas fryer.The fry Dimensions(W x D z H) 1'15-.5'x 30.25"x 47.125'^
tank is all stainless steel and includes 4 heat . n-
tubes
with a•high heat baffle system,cool zone - ^'-- •_.t,�.:_.�-s__:.-.
and 11/4 full port ball type drain valve.The .Tank Size ' s 14"x 14'
'x front and,door is all stainless steel.The door • BTU/HR 120000`
includes a fully integrated door lines
Shipping weight ;'200Ibs.- -
Two fry baskets have red plastic coated -- ---�--
handles.An Invensys thermostat allows Hose Connection .75'+ ).
— _ .. .i
—temperature range from 200017to 400°F.
High Limit control shuts fryer down if
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shortening exceeds maximum temperature.
"ANTMvrm•.A:•ainco�gwpm_nLwin r °.0•i y SANITATION SANITATo
Pian View
1s 1h"
14"
301/4'
14"
301/4"
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101/4"
41 '/8' 471/1" 461/4"
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17 Y 2 sle"
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cleaner powder offers thorough boil out of
DEEP FAT FWm CIEANER encrusted grease and grime.
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FOOD PREMISES SICKNESS POLICY
WHEN AND HOW DOES THE POLICY APPLY?
Vomiting and Diarrhoea
No one.(including an employee, contractor, maintenance worker, visitor etc) is permitted to be'in a food-
handling area if they are suffering from vomiting or diarrhoea. Anyone who has had an episode of
vomiting or diarrhoea within 24 hours prior to entering food premises must report if to
.................................................................
Any members of staff who handle food and who has had diarrhoea or any vomiting on two or more
occasions within a 24 hour period must see their Doctor. If the Doctor requires it they must also submit a'
faecal specimen so that the cause of illness may be identified.
Anyone suffering from vomiting or diarrhoea may not return to work until they have been cleared.
••••................................. will also carry out a risk assessment to decide whether or not alternative
work may be offered that does not involve direct contact with open food, or with food surfaces and
equipment.
Any member of staff who handles food and who has a vomiting episode whilst at work must immediately
report this to ........................................... The staff member will immediately be excluded from all
food handling areas.
Any affected area that have been contaminated such as work surfaces, equipment and utensils, must be,
immediately cleaned and sanitised. This will also include any toilet seats, handles, taps, etc in staff
facilities where appropriate).
Any food that may have become contaminated must be safely disposed of so that it cannot be re-used.
No one with jaundice (yellowing of the.skin) who is suspected of having hepatitis A, or who has hepatitis
A, is permitted into a food-handling area.
A record of all employee illnesses must be entered into the record sheet.
Where there is doubt as to whether or not a food handler may pose a risk, advice will be sought from
Public Health South in Dunedin.
Skin conditions
Non-infected skin wounds must be totally covered with a distinctively-coloured waterproof dressing.
These must be changed as often as is necessary to keep them clean and old ones must be safely
disposed of so that they do not end up within food.
Staff will not be allowed to handle food if they have infected fingernail-beds or boils on the face or other
areas of exposed skin where they are likely to contact food, even if they are covered with a suitable
waterproof dressing.
Infections of the eves ears mouth and throat
Any food handler whose eyes, ears, mouth or gums are weeping or discharging must be excluded from
food handling until they are better. Those with a persistent sore throat and no other respiratory symptoms
such as a runny nose or cough may have a streptococcal throat infection and should be referred to a
'doctor for assessment.
Other Factors which are not associated with contamination of food
Some bowel disorders [such as Irritable Bowel Syndrome, Crohn's disease or ulcerative colitis] are not
considered relevant to food safety, even though they may result in diarrhoea. Staff who suffer from such
conditions should be advised to see their Doctor if they have not already done so. They must make sure
that ........................................... Is aware of their condition and if any change from their normal bowel
habit occurs. This must then be assumed to be infectious until shown to be otherwise.
Chest and long-term respiratory diseases such as Tuberculosis are not spread through food handling.
However, these types of disease may affect an individual's general health so as to make them unfit for
work, or they may pose a risk of infection to others in the workplace. Public Health South must be
contacted for more information on this.
Blood bome infections such as HIV, Hepatitis B or C, do not themselves present a risk of contaminating
food. As long as they are well, there is no reason why people withh these infections should not be
employed as food handlers. If staff suffering from these conditions cut themselves, any blood must be
treated as if infected. Any area with blood spilled upon it must be thoroughly cleaned and sanitised, e.g.
with a diluted bleach solution Any food that has had blood spilled upon it must be safely disposed of.
Staff who have been required to say away from work will only be allowed to return to food handling duties
in accordance with the clearance advice from the Medical Officer of Health. Advice on this will be sought
from Public Health South as and when appropriate.
The question of whether or not there is alternate work that staff can undertake when they are feeling well
but have not received clearance will be decided in,consultation with a Health Protection Officer from
Public Health South.
Where it is decided that such a return is possible, the staff member must not undertake any food handling '
work or work with equipment that is likely to come into contact with food until clearance has been given
and a full return to work is allowed.
i
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offers the ultimate in durability in combination with the excellent characteristics of the prevention of fungus growth on the p
primer itself. Specular Gloss:50@ 60°t 0
Recommended Volume Solids: 32.8% 32
Stopz Mold&Mildew Eliminator is designed to stop residual mold and mildew that may grow on the primer after Solids by Weight: 42.1%32
predeaning contaminated surfaces,as well as to inhibit the future growth and spread of mold and mildew on the cured Vehicle: 85,5%32
film surface in residential&institutional buildings.Stopz Mold&Mildew Eliminator is recommended for use on interior Pigment: 14.5%32
wall surfaces such as plaster,wallboard,Sheetrock®,concrete,masonry block,wood,primed metal and galvanized Dry Film Thickness: 1.7 mils
metal.Stopz Mold&Mildew Eliminator is also recommended for use on interior or exterior wood framing,primed metal, 77°F: 98 KU 3 5
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WARNINGI If you scrape,sand or remove old paint from any surface,you may release lead dust. LEAD IS TOXIC. Flash Pt°F: Non-combustible
EXPOSURE TO LEAD DUST CAN CAUSE SERIOUS ILLNESS,SUCH AS BRAIN DAMAGE,ESPECIALLY IN Thinner: Water
CHILDREN. PREGNANT WOMEN SHOULD ALSO AVOID EXPOSURE. Wear a NIOSH-approved respirator to control Clean-Up: Soap&Water
lead exposure. Carefully clean up with a wet mop or HEPA vacuum. Before you start,find out how to protect yourself
and your family by contacting the U.S.EPA/Lead Information Hotline at 1-800424-LEAD(5323)or log on to Available Colors and Bases:
www.epa.govllead.
White
Stopz Mold&Mildew Eliminator is supplied ready to use.Stir thoroughly.Do not mix with any other coatings,solvents or
colors in oil.Remove damaged materials and dean surfaces.Patch surface irregularities with an appropriate patching
compound.Do not apply when air or surface temperature is below 50°F or when drying conditions are poor.Keep from
freezing.Use adequate ventilation during application.
Remove gross filth or heavy soil.For heavily soiled areas,a pre-cleaning step is required. Surfaces should be
thoroughly scrubbed with a solution of detergent and household bleach(sodium hypocholorite).Apply Stopz Mold& Available Package Sizes:
Mildew Eliminator generously and uniformly by brush or airless spray and ensure that the surface is completely coated.
Allow to air dry.Clean and inspect regularly for damage to coating film-reapply if cured coating film becomes damaged. Quart Gallon 5 Gallon
Stopz Mold&Mildew Eliminator will kill all existing visible mold and mildew on the wall surface,and then will prevent the
growth of mold and mildew on the surface of the cured film.
Clean tools and drippings with warm soapy water before Stopz Mold&Mildew Eliminator dries. (weight Per Gallon: 9.7 lbs.t.e lb)
Architectural Drying Times:
•Interior walls or wood trim subject to moist conditions,steam,or high humidity conditions(such as kitchens,baths,ora
below grade basement) To Touch: 2 hrs.
OPTION 1:2 coats Stopz Mold&Mildew Eliminator No.58300(Product can also be used as a finish
coat) To Handle: 4 hrs.
OPTION 2:1 or 2 coats Stopz Mold&Mildew Eliminator No.58300(use 2 coats for severe conditions),1 or 2 coats To Recoat: 4 hrs.
Califomia®Kitchen and Bath 100%Acrylic Latex with Microban Interior Finish:512XX(Eggshell)or 513XX
(Semigloss) (@ 70-77°F,50%R.H.)
OPTION 3:1 or 2 coats Stopz Mold&Mildew Eliminator No.58300(use 2 coats for severe conditions),1 or 2 coats
California 2010,'100%Acrylic Super Scrub®Ceramic with Microban Interior Finish:551 XX(Eggshell),552XX(Semi- Surface Spread Rate:
gloss)or 653XX(Matte).
Smooth: 300-350 s.f./gal.
Do not add solvents,oils or colors in oil,or mix with other paint types.Do not apply when air or surface temperature is Porous: 175-300 s.f./gal.
below 50°For when drying conditions are poor.Keep from freezing.Use adequate ventilation. (Spray Application is s0%or above)
Safety Information:
FIRST AID:Have the product label or MSDS with you when calling a poison control center or doctor,or going for Tools and Equipment:
treatment.See product specification for details.FOR MEDICAL ASSISTANCE,CALL YOUR LOCAL POISON -
CONTROL CENTER.PRECAUTIONARY STATEMENTS:HAZARDS TO HUMANS.CAUTION.KEEP OUT OF REACH
OF CHILDREN.Do not lake internally.Close container after each use.Harmful if swallowed or inhaled.Avoid breathing
spray mist.Avoid contact with skin,eyes,or clothing.Wash thorughly with soap and water after handling.Remove
contaminated clothing and wash clothing before reuse.When applying with a sprayer,applicator should wear a filtering
respirator(MSHA/NIOSH approved).PHYSICAL AND CHEMICAL HAZARDS:Do not apply this product in or on
electrical equipment due to the possibility of shock hazard.
I
'Only claim is that this primer contains bioddes which will eliminate the growth of mold&mildew on the paint film itself
California Paints•150 Dascomb Rd.•Andover,MA•01810•www.californiapaints.com•800.225.1141
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