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LARA MARKET BANI MARKET - ESTABLISHMENTS Gla LARA'S MARKET-) K� 73 HARBOR STREET i 0 v CRIMINAL COMPLAINT DOCKET NUMBER NO.OF COUNTS Trial Court of Massachusetts 4 POLICE COPY. 0736CROO2465 1 District Court Department lk` DEFENDANT NAME&ADDRESS COURT NAME&ADDRESS Luis Lara Salem District Court 159 Boston St 65 Washington Street Salem, MA 01970 Salem, MA 01970 (978)744-1167 1 DEFENDANT DOB COMPLAINT ISSUED DATE OF OFFENSE ARREST DATE 08/02/2007 01/01/2007 OFFENSE CITY I TOWN OFFENSE ADDRESS - - NEXT EVENT DATE&TIME Salem 09/07/2007 9:00 am SUMMONS POLICE DEPARTMENT POLICE INCIDENT NUMBER - NEXT SCHEDULED EVENT Salem PD Arraignment OBTN ROOM/SESSION , r 1P( Arraignment Session &.i n Ja its .. .` Iitt PR The undersigned complainant, on behalf of the Commonwealth, on oath complains that on the date(s) indicated below the defendant committed the offense(s)listed below and on any attached pages. COUNT CODE DESCRIPTION '.. 1 666666 MISCELLANEOUS MUNIC ORDINANCEIBYLAW VIOL jOn 01/01/2007 did Failed to pay fine for not receiving food permit,in violation of 111/127 A/B of the City or Town of Salem. I i IC ! SIGNATURE OF COMPLAINANT SWORN TO BEFORE CLERK-MAGISTRATE/ASST.CLERK/DEP.ASST.CLERK DATE X X NAME OF COMPLAINANT A TRUE it CLERK-MAGISTRATEI ASST.CLERK DATE CgPY Im i ATTEST aRPliPlf`,�tf'. W.Me eP-10 0602200714-.5628 Varmnn 20-11M COURT DOCKET NO. CITATION NO. QCITY OF SALEM n Q VIOLATION NOTICEPD 608 NAME(LAST,FIRST,INITIAL) CITY WN STATE ZIP STREETADDRESS ZW --'V �O�/I`PI�'�/4A 0 f?)O LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNERS NAME(LAST,FIRST,INITIAL) STREETADDRESS CITY/TOWN STATE ZIP /z✓S� -Co- �"1-4 l I ?b REGISTRATION NO. STATE EXP.DATE MAKE/TYPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL ❑AM INJURYO VES 0P J' YES LOCATION OF VIOLATION Lei f f{ %"lrpc 4 ENFORCING DEPT. OFFENSE CHAP. SECT. FINES A e � C OFFICER I.D.NO. TOTAL $ I FINE f/ J_ 2 DUE O ICER CERTIFIES COPY GIVEN TO VIOLATOR r �❑I_IN HAND X I [! r,SY MAIL DO NOT MAILCASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK, CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL APPLICATION FOR APPLICATION NO.(COURT USE ONLY) PACE Trial Court of Massachusetts CRIMINAL COMPLAINT of District Court Department I,the undersigned complainant,request that a criminal complaint issue against the accused charging the offense(s) listed below. If the accused.HAS NOT BEEN ARRESTED and the charges involve: Salem Dtsffict Court 65 Washington Street ❑ONLY MISDEMEANOR(S),I request a headng p WITHOUT NOTICE because of an imminent threat of Salem. MA.01970 ❑ BODILY INJURY ❑ COMMISSION OF A CRIME ❑ FLIGHT ❑ WITH NOTICE to accused. ❑ONE OR MORE FELONIES, I request a hearing ❑ WITHOUT NOTICE ❑ WITH NOTICE to accused. ARREST STATUS OF ACCUSED ❑WARRANT is requested because prosecutor represents that accused may not appear unless arrested. ❑ HAS ❑ HAS NOT bees+arrested INFORMATION :• NAME(FIRST MI LAST)AND ADDRESS BIRTH DATE SOCIAL SECURITY NUMBER Luis LAra PCF NO. MARITAL STATUS 159 Boston Street Salem, MA 01970 DRIVERS LICENSE NO. STATE GENDER HEIGHT WEIGHT EYES HAIR RACE COMPLEXION SCARS/MARKS/TATTOOS BIRTH STATE OR COUNTRY DAY PHONE EMPLOYERISCHOOL MOTHER'S MAIDEN NAME(FIRST MI LAST) FATHER'S NAME(FIRST MI LAST) INFORMATIONCASE COMPLAINANT NAME(FIRST MI LAST) COMPLAINANT TYPE PD Salem Board of HEalth ❑ POLICE ❑ CITIZEN ❑ OTHER ADDRESS 120 Washington Street, 4th Floor PLACE OF OFFENSE Salem, MA 01970 73 Harbor Street, §a1emo HA INCIDENT REPORT NO. OBTN CITATION NO(S). OFFENSE CODE DESCRIPTION OFFENSE DATE 111/127 A B efendant faile VARIABLES(e.g.victim name,controlled substance,lype and value of property.other variable information,see Complaint Language Manual) Failed to pay fine for not recivin 2007 Food Permit from the OFFENSE CODE DESCRIPTION OFFENSE DATE 2 VARIABLES OFFENSE CODE DESCRIPTION OFFENSE DATE `S VARIABLES REMARKS COMPLA NT IGN E DATE FILED X✓ 1 COURT USE ONLY I A HEARING UPON THIS COMPLAINT APPLICATION ? DATE OF HEARING TIME OF HEARING COURT USE ONLY 30 WILL BE HELD AT THE ABOVE COURT ADDRESS ON }-7 '` U AT E occR-2(M04) COMPLAINANT'S COPY( CASHIER REFRIGERATOR FAU CET 36 FEET 12 FEET 3V EXIT BATH ENTRANCE ROOM FREEZER 0073 Harbor Street Lara's Market City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 978-744-4569 Handwash Facilities FAIL Critical RED Owner: Comment:The restroom is missing soap. Provide soap in the restroom at all times. Luis Lara i Violations Related to Good Retail Practices (Blue Items) PIC: Food and Food Protection FAIL Critical BLUE Maribel Jimenez Inspector: Comment:The following items found outdated: 10-Packages ham David Greenbaum 21 -Corn tortillas Date Inspected:Correct By: 2-Baby formula 5/16/2007 Owner must closely monitor all expiration dates. Equipment and Utensils FAIL Non-Critical BLUE Risk Level: Comment:The ice cream freezer needs a visible,accurate thermometer. Permit Number. The Kenmore freezer needs to be thoroughly defrosted. BHP-2007-0318 Status: I The same unit needs a visible,accurate thermometer. i PARTIAL COMPLY The Beverage air reach in needs a visible,accurate thermometer. #of Critical Violations: j 2 Time IN: Time OUT: i Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 17,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 17,2007 ) Page 2 oft 0073 Harbor Street Lara's Market City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 978-744-4569 1 Food and Food Protection FAIL Critical BLUE Owner: Comment: Food stored directly on the floor of the basement. Store all food at least 6-8 inches off the floor. Luis Lara PIC: The following items removed from shelves at the time of inspection: 7-Quaker oats Inspector: 6-Quaker instant oats 1 -Salad dressing David Greenbaum Closely monitor all expiration dates. Date Inspected:Correct By: Equipment and Utensils FAIL Non-Critical BLUE 6/26/2006 Comment: The True cooling unit needs a thorough cleaning. Risk Level: I The Kenmore freezer needs a thorough cleaning and defrosting. Permit Number: , The same unit needs a visible,accurate thermometer. BHP-2006-0130 Status: The Beverage air cooling unit needs a visible,accurate thermometer. PARTIAL COMPLY The Frigidaire freezer needs a visible,accurate thermometer. #of Critical Violations: GENERAL COMMENTS: 1 Time IN: 676:Owner to notify the Board of Health within one week that all violations have been corrected. Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 27,2006 ) Page I oft ti Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) A)7Q/—� City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 27,2006 ) Page 2 oft a„ �A. v i „ 'I * �Commonwealth of Massachusetts�y fI " rkc *p� _ { City of Salem ... � • u `,� � '�'c..a. .. l..'aF` F-cehk{�%�. P y��. G,�,.x',�`^� R. �$.,'_.,ta�s#y r*�� " Board of Health IGmberley Dnsooil 7 ' 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2007 ESTABLISHMENT NAME: Lara's Market File Number:BHF-2004-000006 159 Boston Street Salem MA 01970 LOCATED AT: 0073 HARBOR STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions I Notes RETAIL FOOD BHP-2007-0318 Jan 5,2007 Dec 31,2007 $50.00 TOBACCO VENDOR BHP-2007-0319 Jan 5,2007 Dec 31,2007 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 Kimberley Driscoll www.sALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT T-O�OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT-�F-YN' � t � {�Q�J, TEL#9 `y'j- Pys69 ADDRESS OF ESTABLISHMENT /_ LQFAX# MAILING ADDRESS(if different) EMAIL--Business': Owner's: OWNER'S NAME ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# JDAYSOfOPERATION — Monday Tuesday Wednesday Thursday EridaY Saturday Sunday HOURS Of OPERATION Please write in time of day. (for example/lam-ttpml TYPE OF ESTABL.I NT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES O less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 _._.............- - .._. -..... - - ......_......_.... ---..----- - ---....__... ---- _._..------------ ----------.---- BED/BREAKFAST YES NO $100 - - - ... -- -- - - ---------.... .... ......... - -------... ADDITIONAL PERMITS �''� MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE $ NN $5 TOBACCO VENDOR YE NO $50 ALL NON-PROFIT(such as church kitchens) S NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. - Signature Date Social Security or Federal Identification Number - --------------------- ---------------------------. . ----- - - Revised 11117/06 FOODAP?.007.adm Check#& Date Commonwealth of Massachusetts City of Salem ` Board of Health 1 . 120 Washington Street,4th Floor 1 SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Lara's Market File Number:BHF-2004-0006 159 Boston Street- Salem MA 01970 i LOCATED AT: 0073 HARBOR STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0130 Jan 3,2006 Dec 31,2006 $50.00 TOBACCO VENDOR BHP-2006-0266 Jan 3,2006 Dec 31,2006 $50.00 Total Fees: $100.00 PERMIT EXPIRES IDecernber 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page t of 11 ,t CITY OF SALEM, MASSACHUSETTS ,�. BOARD OF HEALTH ( a 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAx 978-745-0343 MAYOR W W W.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOODESTABLISHMENT NAME OF ESTABLISHMENT IT—�I�I��t S �Aq g [��.ei EL#q!� ADDRESS OF ESTABLISHMENT I q� ��1 V� galu", , i o' OR6 MAILING ADDRESS (if different) ' l � 'v l Pkrn V l OWNER'S NAME LU IS TEL#' L;1 W-E CJI a 1 ADDRESS16c. &ate CITY_ STATE A ZIPS(_ CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON S HOME TEL HOURS OF OPERATION: Mon. Tue. - Wed. Thu. - Fr " Sat. —Sun.ka TYPE OF ESTABLISH FEE (check only) RETAIL STORE ES NO less than I000sq.ft. J� r� 1000-10,000sq.ft. =$100 more than I0,000sq.ft. =$250 --- .. .............. RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats =$200 ---------------------- ......----------------------------- ---------- BEDIBREAKFAST YES NO $100 ..----------------------------------------------- --------.......------------------------------------ ADDITIONAL PERMITS MAKE_(notjust serve) ICE CREAM, YOGURT, SOFT SERVE NO $5 LTOBACCO VENDOR] S --0(0 ES NO ALL NON-PROFIT(such as church kitchen ) Y S NO x$2255 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. , E 1f1(3s 0al - 710 - )Q3 Signature Date Social Security or Federal Identification Number -------------------------------------------------------------- ----------- -- Revised 11103/05 FOODAP2.adm Check#&Date��g//� '� 0073 Harbor Street Lara's Market City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 978-744-4569 Non-compliance with: Not Done Owner Anti-Choking PASS ❑ S ' Luis Lara a Tobacco PASS ❑ PIC: Maribel Jimenez FOOD PROTECTION MANAGEMENT Not Done Inspector. y, PIC Assigned/Knowledgeable/Duties PASS ❑J RED David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑Q RED 4/25/2005 Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level: FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2004-0167:, Receiving/Condition PASSd❑ RED Status: Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNED OFF a »- Conformance with Approved Procedures/HACCP PASS RED # of Critical Violations: Plans 1 PROTECTION FROM CONTAMINATION Not Done Time IN: Time OUT: Separation/Segregation/Protection PASS RED Notes' m-.. Food Contact Surfaces Cleaning and Sanitizing PASS ❑d RED Proper Adequate Handwashing PASS ❑d RED Urgency Description(s): Good Hygienic Practices PASS ❑d RED BLUE: Prevention of Contamination from Hands PASS Q RED Violations Related to Good:, Retail Practices (Critical Handwash Facilities PASSd❑ RED violations must be corrected'r immediately or within 10 days)(Non-critical violations GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 26,2005 ) Page I of 0073 Harbor Street Lara's Market must be corrected immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) Approved Food or Color Additives PASS ❑d RED REDtiViolations ons Related to Toxic Chemicals PASS ❑d RED Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASS ❑./ RED - immediate corrective action) ` Reheating PASSd❑ RED Cooling PASS ❑d RED Hot and Cold Holding FAIL Critical ❑d RED Kenmore freezer had a temperature of 10°F. Repair unit to maintain a temperature of 0°F or below. This unit also needs to be defrosted. Time As a Public Health Control PASSd❑ RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE Price label on baby food covering expiration date. Do not cover any expiration/sell by dates. 11 items found outdated. Owner must closely monitor all expiration dates. Equipment and Utensils FAIL Non-Critical ❑ BLUE Beverage air cooling unit needs a thorough cleaning. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE Owner must employ the services of a licensed pest control operator and have monthly extetmination. Owner will notify Board of Health with regards to which company will be used. GeoTMSO'2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 26,2005 ) Page 2 of 0073 Harbor Street Lara's Market GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Apr 26,2005 ) Page 3 of IiAiD 120 4THFLO} k A,NLEY J. USOViC2, +..i,. JO.;,tlt, "-.' cion ! , MPH, RS, Ct MAYOR HE:A A H AGENT i • C0110 IONWEAL I'd l OF' Pi€!MSS CHUSETTS PERMIT TO OPER ' ? ': .%', II=t C;; + 4 sTABLISi-i! '•EK1 In accordance with regulations ;:rr;?i!igatE:r undo- author y c? Gt.a�?! r 94, Section 305A and Chaptai ill Secncv i General Laws c:, a Food Establishment in the City of Saler i is her(;h granted tp: Type •' '=stabi!sl anent: RETAIL_ F00111 Name o"i -7stabiishment: Lara's Market Addresf ;1, Establishment: 73 Harb!x Strk-�O� Owner's Name: Luis Lara ;='•astrictions: Application Date: 1/2.7/2005 '111-mit for : +;od Establishrne!:t Dessertsilce Crear Oernq,.N `'c)r the Sale of Tobacco Pro.iuc,*.S T P-d E:v ` .'=s'nit"<; 1..;:pire Th;, -errnii is not transfer, .i - ` ;mm.0 reissued upon, of + •IcLlnip Or location. The jx,,o' :1"s:.-•i U t posted in a proal n,,>_vr: .00ation f:stablish?TieFit, ,1 i,4� :):C'}once VI'liih the Stagy t7t ']'afi:{i: any r n vrs'ltii w-,, + p.,; . vv'ments, oi;w quipmeY3i ale itiaGe., r:„I pl pti for `..n"u& must be :oubrnitted to and approved tea "t ' ai;:r i Dos::i •, HRalth. H,:ALTH Af3ENT ' •,w`fit- �_«y:. �_ CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-74 1-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT I I y� q�t p 7,'L, u NAME OF ESTABLISHMENT I,,Af(KI'-1 S M�0� STEL# ` 1 O" /?'7—' gS 9 ADDRESS OF ESTABLISHMENT '9.3 Afi Y `JG �e ( ,� O�� ✓ MAILING ADDRESS (if different) Q OWNER'SNAME ` _ y _y\ TEL#918-"1yy-�la� ADDRES VY), CITY Q STATE ZIP \ CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PE, AON \R �1�HOME TEL (P Pn1 I I It ( , It , , t HOURS OF OPERATION: Mon:�Tue. Wed. Thu. Fri. Sat. Sun. TYPE OF ESTABLISHM FEE check only RETAIL STORE E NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES N� less than 25 seats =$100 25-99 seats =$150 more than 99 seals =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERV NO $5 TOBACCO VENDOR <� YES ` $50 ALL NON-PROFIT(such as church kitchens) ^�� YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before ariy renovations, improvements, or equipment changes are made, all plans for such must be submittedrto,and approved by the Salem Board of Health. Pursuant lu MGL Chapter 62C, Section 49A, I certify unc'41,thC Pads anQ„[)u1a1t1e..0f perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number ------ -- ----- ------- --- ------------------ rLn3 -di]/01'031-n01)AI'Z.uhn Chicksy uJIQ iso iI�G�S COURT DOCKET NO. CITATION NO. O CITY SALEM C4 VIOLATIOIO FD QN NOTICE r J J.V NAME(LAST,FIRST,INITIAL) STREETADDRESS CITY/TOWN STATE ZIP LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LA//ST,FIRST,INITIAL) Z"'i 3 G ci+it F7 STREETADDRESS CI7Y/TOWN STATE ZIP REGISTRATION NO. STATE EXP.DATE MAKE/TYPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN PERSONAL ❑AM INJURY ❑PM ❑VES /"//-G .[$NO LOCATION OF VIOLATION ENFORCING DEPT.., /Yea�F L + OFFENSE CHAP. SECT. FINES C OFFICERj1 I.D.NO.I TOTAL $ DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR fir" El IN HAND X ✓'�/�.�li,'/+�.. <-ti..• �eBY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR c SALEM, MA 01970 .� TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Lara's Market Address of Establishment: 73 Harbor Street Owner's Name: Luis Lara Restrictions: Application Date: 8/25/2004 Permit for Food Establishment 320-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT e n A CITY OF SALEM, MASSACHUSETTS • 6t" '� BOARD OF HEALTH 3 y 120 WASHINGTON STREET-4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A 9FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Z a r�t S W/ M Y- rQ T ADDRESS OF ESTABLISHMENT '75 ypb D Y S MAILING ADDRESS (/— U/ 'S if different)/— OWNER'SNAME U/ S Ck/r( TEL# 5,-- 7r/y 00 ADDRESS / S-'/ C; O S /c yr S / CITY 1?7 STATE ig ZIP O CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICA E#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON/t//S h G Y"-C^- HOME TEL# k-,7 415- 0/e2 HOURS OF OPERATION: Mon?-/OTue.7-/9 Wed.7-/0Thu. 7-/0 Fri.7 i0 Sat. 7 la Sun.7-5- TYPE OF ESTABLISHM X10�11 FEE check only RETAIL STORE YES NO c3 less than 1000sq.ft. _$ 50 1000-10,000sq.ft. more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO TOBACCO VENDOR YE NO $5 ALL NON-PROFIT(such as church kitchens) S NO Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best k o Q and lief, have filed all$e ate tax returns and paid all st to taxes re uir d under the law. ��-- �a3 O �( � �� Signature Date Social Security or Federal Identification Number -------------------------------------------------------------------------------------- 8-�o--6 - ----- ------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date / ' F- aZ X0 CITY OF SALEM BOARD OF HEALTH /1Establishment Name: S-4 Date: .a y D f< Page: / of / Item Code C Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY A. /P-o .ph P � avr G fk PsA* Wsti . ✓S QP !LL C7 ! c o t p I - 0- 1„A�j Coe Pv /"�o P 1/-7 5 u o a a & V 617 . 39V- Oz!'0cl t'04/ cbsdea ad —n /o%/s All ♦Po2ti ~-4 -cve /65// ws/A&- ✓S Qer, / s W of q/°` Or /acust r✓ �SJ k ° Osect 4V 114,ero S / //rr V 5haze IZ&a Ittin4 !/ d/S f l'Lv ✓Yt-t1 S �ft<� ILrI S XPi a I >� r viw"4 lot9 Fi So 4- s OSer /a�rS D / ` S IA_Jh 1, d f k,,1- /,t_ 4 W1E4044, do ete Discussion With Person in Charge: '>IDo t b Corrective ion Require : :3 No ❑ ` Yes C Fl /”-�-�. / I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code I understand that noncompliance may result in daily fines oft enr< drs or uspension/revocation of LI Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Rreeived at'remperatwes Violations Related to Foodborne Illness Interventions and Risk According to Law Coolcd to) Factors(items 1-22) (Cont) 41'F145°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 (7mling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding '3-501-16(B) Cold PRFs Maintained at or below 3-202.12 Additives 590.004(F) 41'745'F* 3-302.14 Protection from l hiappi oved Additives'` 3-501.16(A) Hot PRFs Maintained at rn-above 15 Poisonous or Toxic Substances 140°F * 7-101.11 likiniAring Information-Original 3-501.16(A) Roasts Held at or above 130`E Containers" 20 Time as a Public Health Control 7-102.11 Common Name-Working Containers*" 3-501.4( Time as a Public Health Control 7-201.11 Se amcion-Sloiave* " 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Rcc uh-ement 7-202.12 Conditions(if Use' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 'roxicContainers-,Prohibitions* POPULATIONS(HSP 7-204.11 Sanitizcrs.Criteria-Chemicals^ 7-204.1_2 Chemicals for Washing Produce,Criteria* 21 3-801.1.1(A) Unpasteurised Pre-paokaged Juices and Beveraes with Warnine labels* 7-2(14.14 Drvin"Adapts,Criteria' 3-801.11(6) Use of Pasteurized E�'"'s" 7-205.11 Incidental Food Contact,'Lubricants* 3-801.1.1(D) Raw(it Partially Cooked Anunal Food and 7-206.11 Restricted Use Pesticides,Criteria" 7-206.12 Rodent Bait Stations' Raw Seed Sprouts Not Served. 3-801-11(C) Unopened FoUd Package Not Re-served 7-206.13 Tracking Powders, Pest Control and R4oniurrin*" CONSUMER ADVISORY 71ME(fEMPERATURE CONTROLS 22 3-603.11 Consurner Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Fiords That are Raw.Undercooked or PRFs Not Otherwise Processed to Eliminate 3-401.rir 1)(2) Ekes- i5S°F 15 Sec. Pathogns 4"r Immediate Service 145`Flssco 3-302.13 Pasteurized Eggs Substitute'fla Raw Shell 3-40L11( )(2) Comminuted Fish. Meats&Game Eggs* Animals- 155"F 15 sec. SPECIAL REQUIREMENTS 3-401.11(6)(1)(?) Pork and Becf Roast ted Meats- 155`P 15- 1.305F 121 minim 3-40L11(A)(2) Ratites,Ltjctaed Me590 009(A)-(D) Violations of Section 590.009(A) (D)in sec. * catering,mobile fail, temporary and 3-401.11(A)('3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,'Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145°F^' 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3-401.1](A)(1)(b) All Other PHFs- 145'F l5 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(,A)&(D) PRFs 165'F 15 see. 't (Items 23-30) 3-303.11(6) Microwave-165'F 2 Minute Standing Critical and non-cribra(violations, which do not relate to the Time" foodborne illness iniervemions and risk factors listed above, call be 3-403.11(C) Commercially Processed RTE Food- found in the following sections eJ the Fond Code and 105 C311? 1400F* 590.000. 3-403,11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices , FC 599000 Roasts " 23. Mana ement and Personnel FC 2 003 lg Proper Cooling of PHFs 24. Food and Food Protection FC 3 004 25. Equipment and Utensils FC-4 005 _ 3-501.14(A) Coling Cooked PHFs from 140°F to 26. Water Plumbing and Waste FC 5 006 i 70°F Within 2 Hours and From 70`F 27. Physical Facility FC-6 .007 to 41'F'/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling MacreFtatn Ambient 29. , Special Requirements _ .009 Temperature Ingredients at 41°F145`F 130 Other __ ----.-..... ---- Within 4 Hours* *Denotes critical item in the federal 1999 Foal Code or 105 CNIR 590.000. CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH m 9 120 WASHINGTON STREET, 4TH FLOOR o SALEM, MA O 1970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. .JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT August 23,2004 Demaris Market - 73 Harbor Street Salem, MA 01970 Dear Owner, On August 11,2004 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old male purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Demaris Market is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes,chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of ONE hundred dollars($100)for the FIRST offense. FOLLOWING THE THIRD(3ao)OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked withY ou and our Y employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4"' Boor,within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health w hin seven (7)days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours,, /Joanne Scott Health Agent JS/bas Cc: North Shore Tobacco Control Program Christina Hannington, Board of Health Chairman and Members N° 2185 "�. City of Salem - Board of Health Violation Notice- Tobacco Sale to Minors This notice is to inform you that during a tobacco sales compliance check,your establishment violated the Salem Board of Health regulation#24 prohibiting the sale of tobacco products to persons under 18 years of age. ^n Name of establishment Address Di Me of sale,, ,—Time of sale Minor's age/gender Minor's ID# Adult supervisors Narrative report of incident and description of seller by adult supervisor who will testify at the Salem Board of Health meeting including a description of the seller: I affirm, under the pains and penalties of perjury, that the above report is true to the best of my knowledge and belief. Adult supervisor(Signature) Qa> ,•yam � Adult supervisor (Print name) e( VENDOR STATE M T: I acknowledge [ received this Violation Notice on I l +g— at � 1 ( t AM nd I am being given a carbon copy of this notice. I also acknowledge that I have been told that a letter regarding Board of Health folio«°-up to this violation will be mailed to me at the above address. Own r/Manag Icrk (Signature) ZG / i Zuro_ Owner/Manager/Clerk (Print name) If vendor refuses this Notice or if Adult Supervisor feels unsafc in delivering it, an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information, contact the North Shore Tobacco Control Program at 978/741-5646. Board of Health-white/NSTCP-vellow/Establishnient-pink CITY OF SALEM BOARD OF HEALTH Establishment Name: L.ArA Ma Date: S a3 O,-! Page: I of / Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY L 0 Gd�•c uwdl /se_ ocu•� a 4- 7i s Oma 6-e,. APs r /e ,, a /?O 74 Ae -0o /P X�O fC1 1.944O 5//C/ Ole ArLm 14if'U1 44, ro o LiiS t°5�a //S S 4. � 6ou e4 's Ca c90c) PALY dlrPr+ /�I C.>5 v 1 o L sem. 'Co /_1/ Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes j 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 ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. '�`� ❑ Voluntary Disposal ❑ Other: 3-501.14(0) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk Accordin;to Law Cooled to Factors(items 1-22) (Cont.) 41'F/45'F Within 4 Hours. " PROTECTION FROM CHEMICALS 3-501A5, Cooling Methods for PHFs 1q --- Food or Color Additives 19 PHF Hot and Cold Holding >-202.]2 _ FooAddid r C 3-i0LI6(B) Cold PHFs Maintained at or below 590.004(F) 41^/45°F* 3-302.14 Protection from Una roved Addinves` 15 Poisonous or Toxic Substances 3-501.16(A) 1I PHFs Maintained at or above l40'}r * 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers* 7-102.11 Cotntnon Name-W o kin-Containerg* 20 Time as a Public Health Control 7-201.11 Separation-Stora e° r 3-501.L9 Time as a Public Health Control 7-202.11 Restriction-Presence turd User 590.004(H) Variance Res uirement 7-202.12 Conditions of Use, 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 204.11 Sattitizers.Critria-Chemials* POPULATIONS HSP 7- 7-204.12 Chemicals for feria �Produce.Cdterra* 21. 3-80L 11(A) Unpasteurized Pre-packaged.Juices and 7-204.14 Drying Agents. Cnrcna* Hever tPes with Warning Labels* 7-205.1.1 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized 6��* 7-206.11 Restricted Use Pesticides,Criteria" 3-801.1.1(D) Raw of Partially s NotCooked Animal Food and Raw Seed S trouts Not Served. * ff 06.12 Rodent Bait Stations* 3-80LI1(C) Uno ened Food Package Not Re-served. 01.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Elhninate 3-401..,11A(1)(2) Eggs- 155'F 15 Sec. Patio c': 11S.4;r ego rni2oo� LE,,s-Immedi rte Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* 3-401.1 I(A)(2) Comminuted Fish.Meats&Game Animals- 155"F 15 sec. H` 3401.11(13)(1)(2) Pork and Bcci Roast- 1.30°F 121 min'" SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Inject:d Pleats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(I))in sec. * catering,mobile food, temporary and 3-401.11(A)('3) Poultry,Wild Gatne.Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15,sec. * above if related to foodborne illness 3-40 1 11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F I 590.009 violations relating to ga>d retail 3-401.12 Raw Animal Folds Coked in a practices should be debited tinder#29- Microwave 1.65'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. 37 Reheating for Hat 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 and non-critical violations, which do not relate to the Tune* ,foodborne illness interventions and riskfactors listed above, can be 3-403.11(C) Commercially Processed R'rh Food- fonnd in the following sections of the Food Corte and 105 C.MR 1 4'f'" 590.000. 3-403.L1(E) Remaining Unsiiced Portions of Beef Item Good Retail Practices _FC 590.000 Roasts` 23. Managemani and Personnel FC-2 .003 and Food Protection FC-3 _004_ 1g Proper Cooling of PHFs 24. Food -- 25. Edupment and Utensils I_FC-4 .Ou5 3-501.14(A) Cooling Cooked PHFs from 140OF to 26. Water,Pluin r and W aste r FC 5 .008 70"F Within 2 Hours and Prom 70°F 27. Physical Facility FC-6 .007 to 41'F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29_. Sgecial Re�c uirements _ .009 7"empetature Ingredients to 4l'Fl45°F 30. rOtherI.--_.---------- ----_...... ...........t Within 4 Hours* sstoia,�rvrN+-,e� 'Denote,criliau item in the tederal 1999 Food Code or 105 CMR 590.000. Entrance Cashier Restroom Exit b