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LESLIE RETREAT GRUB & PUB - ESTABLISHMENTSVL ts fefrmf 6fvb c euB Q 6 NQf1b JIB ftNIVERSAL® UNV-12110 Ow////QQ��\\ MADE IN USA \`(J ORTE EE MN.MCMM IMtNtM CONTENT10® COMOnner Soueft PDSELOKISW m .fipmgm.OM 4i a1LW 3 Commonwealth of Massachusetts City of Salem V ' Board of Health Kimberley Driscoll t> 120 Washington Street, 4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Leslies Retreat Grub & Pub File Number:BHF-2004-000008 96 North Street Salem MA 01970 LOCATED AT: 0096 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0251 Jan 1, 2011 Dec 31,2011 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health i 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 v' a BOARD OF HEALTH 120 WASHINGTON STREET,4"-'FLOOR TEL. (978) 741-1800 KIMI3ERLEY DRISCOLL FAX(978) 745-0343 N4AYOR DGBr:ENBAUNI&ALEM.CONI DAVID GREENBAUAI,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT �/ ke ^S 12tq �fi SG'� .r `i' cG NAME OF ESTABLISHMENT irl'J,Vg Ct�eJ51�3 ,p�s �T-oc-,/ �/ i T-,4m,4 ��/fEL# Of 7 V 7 t-/ ADDRESS OF ESTABLISHME"IT_ql!e [ ol?`l L SIS .7. I ( { 4 FAX# TL 7 P '7 (t6 .-t P5- MAILING 5'MAILING ADDRESS(if different) EMAIL-Business`. Website: OWNER'S NAME_Cj.,,)6-10 �_�',� tl )L ✓L TEL# ADDRESS STREET -� CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S)-��_ 6.M_CAC_ bL1L9l S CERTIFICATE#(S) 4 7 2-'? .3 / (Required in an establishment where potentially hazardous food is repared) CC,Q-(j tt 8 2(U G 42-Z- EMERGENCY RESPONSE PERSON I hLLZ�= lXnc��llw�' HOME TEL# x(19 -Z�FS'S7`FS iDRYS'OF,OPERATION Monday ;l'`° .'Tuesdays .Wednesday IC.. Thursday , j HOURS OF OPERATION `n' Please write in time of day. ( � / t°t'/'f �'�� ! �— ( / _l ''Z la For example I lam-11 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 --------------------------------- - ---------------- ---- RESTAURANT ES NO less than 25 seats 40 (Outdoor Stationary Food ,i$2 i v/ 25 $9 s ats $2° more than 99 seats 0 BED/BREAKFAST! YES ,---------------------------------------------------------------------------------$100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS ---- - ---------------------------------------------------------------------------------------------------------------------------------- MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $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 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 lax retum��paid all state t/ aXes�requir un e�he law. Stgtature Date Social Security or Federal Identification Number ------------- ------------- -- -------------- ------- ------------------ Revised ion/i l FOODAP201 Latina Check#&Date Q $ ..a, f,w. .. -. 'ei�:. �'-�''Y!',:,si 4y", ,..fir .,,i,,.. •,^-sS. r Gg� r.. pit • t�a ....a r:iaa'+„ t. . r.i +<. �"•.: •i j Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'" Floor g Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name n Date Type of Ooeration(s) Roe f Inspection 11P D ( t tt�t Ys �(JbLAJ\Food Service / Routine Address / �. T Risk ❑ Retail 0 Re-inspection l lY�� Level ❑ Residential Kitchen Previous Inspection Telephone (� (�Ci_ t� 4L-It- ^ c-) ElMobile Date: I,�� HACCP YM ❑ Temporary ElPre-operationOwner _1 OO �� 1f �1f Cp ���ty� El Caterer [I Suspect Illness Person in Charge(PIC)/y J �J Time ❑ Bed&Breakfast ❑ General Complaint / \L..l1/.-,d "-A 1 —t7- In3 ;(/�q�'y'ry:� ❑ HACCP Inspector �Jb b e Out:y ,f( Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking ,- Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) © 590.009(F),Ej t action as determined by the Board of Health. (FOOD PROTECTION MANAGEMENT "M,' ..m.. '; ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned%Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ,e>e; ., xeK 'r•a� as-u,ue l&a. ' ,�,d s da' F:PROTE&h0f4 FROM CH---------- - r ❑ 2. Reporting of Diseases by Food Employee and PIC WTIuR ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded [115.Toxic Chemicals &FOOD FROM APPROVEQSOttROE h .,e'. i W.'a: �w°�w" w w ' p.t iu 4: Food and Water from Approved Source „TIME/TEMPERATURE CONTRDLS(Potemfaliy Hazardous Dodds) in�l d �' wi ti-a�ml�:el,»,m«i,-a'p!.• �a Yi, rsd.uM.u, ,n'�z�i eeeEwo Yy� -a..-e nd 4❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures I] 6., Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling ❑ 19 Hot and Cold Holding 4 PROTECTION FROM CONTAMINATION'" '.;�� 9 L z, w€.a.w.-, i W`� . Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ��. i rV (.fid 9. Food Contact Surfaces Cleaning and Sanitizing -REQUIREMENTS FOH HIGHLY SUSCEp#iBLE POPULATIONS (,A— . Proper Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing 3CGNSUMER-ADVISORY;i� � 3=a ,i �!`, i1�! .`��=co El 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C Nby a Board of Health member or its agent constitutes an I 23. Management and Personnel (FC-z) order of the Board of Health. Failure to correct violations !� 24. Food and Food Protection (Fc-3)(5590.090.0 044)) 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>(sso.00s> establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007)' have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 5: Inspector'sSignature:Si ature:hj V/� �� Print: -Y'�.�7I-�l-i',1,�.2-��.vr, YJ �✓ r// PIC's Signature: / p Print: Page. of TPages Violations Related to Foodborne Illness interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 I 590.003(A) Assignment ofResponsibility* 3-302.1.1(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of ,]edge* Cooked and RTE Foods* 2-103.11. Person in char 'e_lubes Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Pools Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1.l(A) Food Protection* a tlicants* 3-302.15 Washin Fruits andVe�*stables 590.003(F) Responsibility Of A Fool Employee Or An 3304.11 Food Contact with Equipment and - Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge" 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discardingor 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 Foci in a Hermetically Sealed Container* Sanitization Temperatures* - 3.201.13 Fluid Milk and Milk Products* 4-501.11.2 tnMechanical Warewashing-Hot Water 3-202.13 Shell Eg s* Sanitization Temperatures* 3-2(}2.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp., pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and- 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1D Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority2-301.11 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 g Receiving/Condition 2-401.11 Eatin ,Drinkin or Usinp Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and 3-202.15 Packa e Ante it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting" 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained'" Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* ConvenfertV Located and Accessible 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.1.1 Location and Placement* 590.004(1) Labelingg of Ingredients' 7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance fHACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing(vlethods* Devices 3-502.1.2 Reduced oxygen packaging.criteria* 6-301.11. flaridwishing Cleanser, Availabilit, 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision "Denotes critical item in the federal 1999 Food Code of 105 CMR 590.000. - Y r k �- i CITY.OE SALEM w BOARD OF HEALTH 4; Establishment Name:j n i Y ill a. I.RS ��cXr' Date: n " 01-r) Page: c2 of of Item Code C-Critical Item `DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item --1--.._ _ .Verified i PLEASE PRINT CLEARLY t 'C�/"VI.S-Y> D v 'e 33 F ars I I CA 11P1_ Y �� P� .�� d �_q r , -tfnrt6) UkA <� rq� a 0A pt ( Cn� GU 7 u, r� z ,, ll D n n 42 rN nn Q Gn,(T( )_-,' -All J_)WA : C`( (>11 7 'D, AX G R, ;e rVVnAl l -'")1 0,rt 1.— r l n.. AA s n D I - t�P Gr nvn n.; IA olJ`-tl'n _ >✓� �=i t" kx- ti 1911/1 Ir i_n . A r '\1' l ,I w e„ ,Y _ j) I (M Jo _i _ 4j",\ .. 3 » Cs 1-t' lV, i L?A,1A (216AA0 1��I.,i rlI I 0 (JW.o-u_., 12>fr - f' 17)o {.a C(2� r+ Gz k 4�. N— 1( Vn M(N t A ILll;� is cXQ o. . 4 0 Discussion With'Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all. ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal-Food Code. I understand that noncompliance may result in daily fines of twee y-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. < / / �J�' l/I 9 ❑ Voluntary Disposal ❑ Other: -' L/ 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Law Cooled to Factors(Itetma 1-12) (Cont) 41'F/45'F Within 4 Homs. s PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food ----� 19 PHF HM and Cold Holding 3-2(72.12 Additivv es*Color Additives 3-501.16(B) Cold PHFs Maintained at or below 590.(H}1(F) 41`/45°F- 3-3021 14 Protection from S roved Additives*� 3-507 16(A) I lot PHFs Maintained at or above 1.5 Poisonous or Toxicxic Sutsstances ` —`1 -1(11.11 ldentd}mg info(manon--On<r na 14(1F. * i 5(}l 16(A) �Ru't,ts licit at orabove 13J'F. *' _ i Contamer�* _ — ---' 7-102.17 ' Common\un,;. 11�rhing C t,nt un s ` , 1_20 _ ' Time as a Public Health Control --- ---- I iti I 7 cmt as +Public I leatth Control' 720111 iRenaac.t;on Pr.unce and1st.° i)C )07(H) �1 ntrcr Ria�utrement I 7-202.32 Conditi x:-of[iso" _ 7-'_03.11 Toxic Container;-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE — POPULATIONS(HS� _ 7204.1i Savnvecs Ctiteua Chc miC h — 7-204..2 Ch.nu ais for a" �1 ?-501.11[A) Unpa,icu'iicdl re packaged 7uttes u1;d Acceta-exwill) alnm Labels,` 7 204.14 Drt�_n. At ert� (ntc i 1 _ t -- ," - —i -205.11 Lnan malt x>u_c cm3 x= Luhucans'; _ A01 IIIA lie of Patuuv cdtL * 2 801 t I(D) ilaw x Partial) 0,ok. d Aminal FkTT d and 7. (06.1 I R "n t a 1 ec Pr nine Ci leu t — 06.12k1o=Ic Rt; :,l �� �Rn tic di�cn uus'�c Se rve1 l S _rnice I arc .unflr{ane# A9on;ttiin — -- - _CONSUMER ADVISORY TIMEI6EMPERATURE CONTROLS 22 1-003.11�rC onsmuc i Aci,,isoc5 Posted cur C on<utn,tian.,i 16� Proper rooa;ry Tentpe=etu Ea ler Not un tl 1 rs a c rlrc.c�+c r t i : marc rLc,i r Ohl i r d y � � itOLll tri l{t � r s w5! I S S nnt1.,,ill1w 1 �Mea s h C;an c _ itc...=e..' kas AIrmI� J l0(.I ,(B)i'= 11 i t rdG c k}rsi 141 t , Tran,-� SPEC=ALREQUIREMHNt T 40L(1 Sl 5)dOyt. 171 I VielaVnus of Secllc,1 �ti).fNlrfa7 `r?'in K;+roe .he[cti _a 1ClitS I 5 ;. i' catering.rnow z t xr?, temp"lary and 5 3-40L1.1(A)r3) l POLOT",,,N ildriu c titu'rc< R,Nidfmilal kitchen ul7tr.,fiun4,) eelobC 1 S=t f',nr v Cor illm;Fish. M f,t. � � dehit a under'the tpllrominv s,c tions 2 s e la, fJ"3`rt-5 , II'SLBI -[.t r LL.e:int . k ,h`-f7Y' =3Pi x n i 311' tildi i iZ�tlr•i ,. 17 I 1 R; n rrg tar pot Holdmg ViOLA1IONS RELATED TO GOOD RE Ali PRA0710ES }03.11c1)X 171_1 till 1651 t c Utenis21-1Rt 403.JlCtsi ltr suu c� I= iF ' MiOW S+indiaw C,r; t . no nrr filwal rt t � r .i� "+rich i,ITT); ,W !I, i,r �� +ncdbr me 114, cc nu_=nrritnnc iv q t jert to c7i<<e t= t cnn b" j�403.11(C)� { 1n la:ia tv i' tx s.�e? z2(} F.xki - l Jt ra; tic 9;e7 ,rn=1 y.re ". .=,;!ITct ;odcn:it a,ctl , C,i/t{ d• } _ _ei � ui CIUf __ _ -403.1 1(I ) -- Rc n i dr u 1 ne= c ed K,uo s 11 A ( Item Good Retail Practices , !- , r 596,06e) ( ie,as, 1 , t-0 mag(rn&ni n d P r on r.... FG r 1 00-- �(g Proper Cooling of PHFs � ?t Fc xi "nd E axi ProteYtlo'1 FL + -- r 2 qu;Ymc m Intl Utensils f a .. . . - _ ) " 50114(A) x l c C-xk d,PHs ham l ) F to - ._ ?25 Water Plumbing N to F{ 5 1 a , t ° Within 11our '"F i a,Sd From i.) 1 ?r � Fhi,SmrJ Facility c'PC r 007 l t " r,t5 '-I Within 4 Hour _ _ 1d a pots 1 Lis or Tfixic tv it a,, 1 FC_ T 603 -501,W('b) Crt i c Ft-IF 71,dc From Ambient `' S�eci it R uaerrrn, Temllcrdiure 6i rcdieuts is 41 E=u5°P +G Cather Ss-nz:n.,fkuT-N i i CITY OF SALEM ((�� BOARD OF HEALTH Establishment Name:-PD,D,_.. I�G em r' . r- P ,Or- -1 P11 A— Date: 1 o - _J -n,) Pager of Item Code C-Critical Item v DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 0 M A..O in n _ -l\ U40— QA—H-4 '� /� , An `r R� . .cin 1, A --\Aono �"lA-H— DA � a n nor n l� rt04 L �r') C �n /n , �i1� a i) ("t r Y ✓ (, ,+ n. .nV I(�_nn , >h_ ! L/ 1 _ . A, n: ) *71 \t'l� f-1.11.7_0_. .1 1 /A ,l it0 X79 ..Qv P '1' n 1`n . _ Ov,,, v n /,) - /, n 0-11 J' = 0 �p � �n — PA nAQ rnt� � . AAs OAr/!/ ✓_A l f') -t11 10 � )� X� ✓— �s / ,_onn PM (-� � n_Y t,f�lj1 ,_,.( /n, � (�A, N O-Al A 6n.� . - I XDi l_ rim Cir As (2 / 1 I) n 11`ADD n �l_,) t � ,nrl�X� PA �nnG��.,n 0n ] ��✓U� a Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of,twenty-five dollars�cr s spension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 7501.i4(C) PHFs Received at'reniperatures Violations Ralafed to Foodborne Illness Interventions and Risk According to Law Cowled to Factors(Ilelns 1-22) (Cont) 4I".FJ45"F Within 4 Howe z _ PROTECTION FROM CHEMICALS 3-501.15Cooling Methods for PHFs — 19 PHF Hot and Cold Holding 14 Food or Color Additives 3-501.16(B) Cold PHF,Maintained at or below 3-202.12 Add live, 590.0(,4(1P) 41°!450 1 3-302.14 Protection from Unappro;,ed Adddtcea° (li.ffi{A) Hot PHl e Maintained at or above I 15 Poisonous or Toxic Substances 3_j _ 140,E v 1 7-[01.11 Identifying inf2nmalion-Ou,;inalJ-50116(A) PoasicHeld atoribovet30°F. m * Contaer�" 7 102,1111 ' Common tim 'ae 442a tun*C cut unaro." Time as a Public Health Control 'O(.I I Sr m too n Sona n WO 1 _ IAn<-as a Public)iealth Conu:ol* V r mceRc'tuwroent 7 202.1 I _ tteatr,u os - Pr,a<n„ew . d `-L- — --� 7-202.12 Condition,of Usc" - 77 '_03.11 Toxic Co rtairto Prohibitioo?* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7i 204.11 Sannvetr Critcrt+ Chemiri � POPULATIONS(HSP) +-Slli It > UnF+.iri ,Prcpay} g12 sohd73021cd _ Juices and 7 204.14 DrNirw Aocm.Cntutt" &vera es+enm h Ratn-IaWN �--� - — — - 11(B) 1ke of Pastewrnd - t 5.11__- Ltcrd nisi t xxl Contact,tact Lublicams,` 1,11(11) R w or)'small,C'rntl.ed Animal fool a;;d (' -006.!I (be, ti:tea L,;,e Cntcima _ I — ----------12 Ro i 7-206.12 (ti,: Se..d.nproats Na:SzrYcd. . � ds n 8 to S :umm } — —.--- _. t t (C) Urt,lr, ted t,gkfl Pu.' tie ,ti+t rt r�-sat i —.---- �� _ 'fonnonn— _. ) CONSUMER ADVISORY T1IA1E7l1T(E11M{�__PE�R..,iA_IT+U. RE CO_NTROLS r 22 3.00. ' ' Co su ur 1 sot, Post it 1 t n tn ion o, >ma Ftdc tltrt i c Y Cuderulcd+ 16 Proper Cooking Temperatures for PHF m tR,c d o u.d "WF, 15,5 !j 1111ucd te Se "Iui e Tt9,aiu2J,S I , Sihs-tuic fo: Rt4, Shill . j 401.1((A}(2) � �.tn.ninurc<'t _h,�liz _ int tt� Sr6CIAlREQUIREMENTS _ - -40 1. (A) ice td 1 ll i . r i7 I`,1r to ! '+ 15 3F 15 Vick tL ti .-c7 5e.ttoot i1)0.(X)9( N fi)) ;o j t 1}t-, Ri t s u rt t trt+)hlk I x u lopolaf V a td z 4fiLli+Pt 4j�� Pus r. WA"a (r,t t `;tuft, ti'H §. utimin al F;tuhu citta rot , hc,<iid S t ffiis C„n of in I nh NfeL4, debt v undel the appro nt+lte lton� j - i im Willi __ f? # Rehcntmg to Nott 11olciing VIOLkWNS RELATE? TO GOOD RETAIL PRACT.'CE'S -- 1 ;-403.1 liA)&iI))_ I'll] 'e ;F 1 u (Items 2i 30) 1{)T11(H) Mut(P a irti F Niru Standrnd1 G+ au1 .nrlrrn tt:oi11,Irk:its +wth dopur cni '- I nc oe'h<rne lhw,si imeek Ron, and r kfirrw ,11vcis aiov,, (,m b” -443.1 I(C) C un inewia Is Puxssed ;2 E i.Fria- R i u to;in-J,Urn+mg u t n t rii she ruutl f i>dc asci 1"; C"111? __ _ _1 -1(e F _ 00U1 Item 1 Good Retail Practices FC 530,000 7, 4 3 i!(I'. > R ut a ritr,t, t,i tn«,u Pn; acns of 13oe ,_ id Pi - _ l�na�t 7 , Man aermr nt and Personnel Ig Proper Cooling of PRFs — 24 Fonts Ind o0o ProlecUon i- i 604 's-50I,14(A �2 cgui7>mo n+anU their ils t._ r j C to nnC Cork d Plif.e ft m 1401 P n) 2 d✓aferPIL,robinq and Waste F , CrG6 i fr Within 2 1lour':Ind From 'T', I dl t iys fa ink FC C 6 00 Yti .. r 4 F TisF Within 4 Hou 2b 5P }a,n=so.i n;IwRm t1rr Toxic oxec tuM tci !s-.... _ F —_ 7 _ OM ,-5501,i-4(B) Rroimf1F N ,r< FonAmbieni _ a anre diomi41idvr mh. reOther I 'Within-11 1,41 . a _,t­! eu 1,i7.r tod t. i i-,011< . .95 i tC0 l e iI t CITY OF SALEM, 3 BOARD OF HEALTH Establishment Name:_ p o anJ P1ztA t t L 9 ,l 0� d G.ta Date: I o n 0) Page: of Rem Code c—CrRlcal Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Data No. Reference R—Red Item .Verifled /1 PLEASE PRINT CLEARLY ( _VL1 I n n i a n n n/ rl fi lb1 o- LI I an ,/L"") -0 ,! U coo (' �` �J���,n �.x� �t �-Y2e�L•�t� C��� —tea--� ¢� 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 p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal,Fobd Code. I understand that noncompliance may result in daily fines of twenty-five dollars or/s:yions '° /revocation of ❑ Embargo ❑ Emergency Closure yGur food permit. UnJ, (/ C ��� � )( � e� ❑ Voluntary Disposal 0 Other: 3-501.)4(C) 'PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk Accordi ug to Law Cooled to Factors(Items 1.22) (Cont) 41'F/45`F Within 4 Hours * _ PROTECTION FROM CHEMICALS 3-501,15 PHF H ' andMethodl for PRFs --- L9 HF Hot and Fold Holding 14 Food or Color Additives 3-501.16(B) Cold PRFsMiaintained at or below 3-202.12 Additives* 590-W l(F) 41`/45°F* 3-302.14 Protection from Unapproved Additnes' 1-501,16(A) I Int PHFs Maintained at or above 15 P� oisonous or Toxic Substances 7-(01.11 Identifying Information-Ou inal _ 1 Cnntatnen` �� soI 16(>) Roasts Hcld at or above OWE *` , r7 10-111 i Common Name W akin e C ou nn.rs' � L20 Time as a Public Health Control � _ _ I r -t` _-- ---j (11 7 m�.as Public Htrol' _1 ealth Cor ----d _ d 7-201.11 � a attott�51'ntap �---- -_ I ' t -Yr unu and t«- t nU.')(A3r}i) V s arrr,tt "02.11 Resrcuon cyuirem-int. �, _ 7-202.12 �C_'ondroon.of Use 7-203.11 Tomc f ontainen Frob bitiun3" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2(W.i'I Sannrreta Critr to CheiuicNis POPULATIONS(HSP), _ X21 '+-Rr)I li(Aj�lnpisteu,iicdPm-tmcl:n�ed Juices and 7-204J2 Chsnttc tis for is achnl oGu6c Crnt",ip" r .- L I __ H ver i ca with R untag hat ls' -1 7 ?04.I4 6rsw 4tente.Cntcrt RGI11(fit Lis (it ;u1>cdtces-`_ _ 705-11 _ load nttt 1 xxl t vrtut l.,tibrrcant-s' 1 g-W1.1 I(D) K;m or}'aruaI] (,',4cd Animal F(xd and 7306-(( Rasur eo st Pe puri ..Crit iia 4-- ---t Ra Sc d 7{s�rut, Vcf S<rvc _! . i 7-206.12 R(Xic r F t-:won -- - i. _ _-_.� r b(_;i 1/( r t.t ictici Rxxi tat iy Not t2 a ,eiU - __ - - v.._ .,-106_'1 + 1 ra k tv r�u�'k Y -. mmol tail ; c.__.._ _._ L _ 1lonitcvtn 1 — -- - - - -- ------- CONSUMER ADVISORY _ TIMEITEMPERATURE CONTROLS 11 j <ocsu u r Ad cors Po c l for C rnt uwpt pn a -_. Anuu l I axis lira c Rex C,rder x,kvd o 16 Proper Cooking Tem,nei aturas for r i Sr t Other a rsc r'ru c s d n}.',t an ue Wire -Tj - - - -_ �f cis a xnr de tR St is .5 F 15ec_ r nrro ' } I tel r 1 1 q,5 insri ute t.ri Kaw Sfi.l7 } 3401.=1t1h,_? S nii�at;tu'F a 4ca F a.u,ii. s_. i S r 5n i . pec SPECIAL REQUIREMENTS -401 l r(B t,1 .51 r T"IJ F r.d Ui el Ra st - 1 r i I 12train' .._..,- { )WQiT) ')t �idmm Se tlon 9O.WWA !0),n _. AJI.I r(A) _r � Rnrtc - Lij.c .c Lfrrts ( `^ F #S - � c � _aierut t mp jai t a:nd 4frLl1r4P tl t'nahr .l:'rld(i rr c StUtic. l itPs, s rt�stu n al}atc.bc7 rapt ,trans Iutaid be 1 i � S i�E�t rpT(foil ihoi l'1S" '<ri. 1 � ' t7}pp,C_.f i1dBK Tiic 4llhtt�SE3�tG c't'i itBt9 ! �s 401.1 t_ -- i "Villi_ ,-au to,.--. f3c,:, 1 i'_ i ic3um;, j-.__- k littealgEaj Hol troEtl�'tnr,. S indin {G to ) y ._ _. . + TiONS RELATED TO GOOD RETAIL PRAC`T'CE u)t n3-3ti �i-SU_.IalHr Micnmave It , 1 t -rut,tux rr i.:at < rli-r-is uluhdono; : ue ours 00d17V111c 111 u S + -ri.Ot"W10 Md r r {int tors lis ,d ahwr. co,7 u+' .03.i1C) � funinncr.iails l'r c>, c_*ciR[f,hxa j<un< aJt,JtHn r,xe n Ito food Code ar.rt l 'n CIIR rU(trt0 1 R u t nrag L nsnri Po i r is s<!licel i Item T Goold Retail Practices SPC 570._000 _ is tact " i 1 3 aanagemr I rald--Pero-rrafofing of PHFs � _21 �Fd tad aad rt Proieror _ +FC_- m 1 i (t)+_ 3 501.14(A) 1 (cxAtne Ctwk d PRFs trout 1;ti`-F to ! 1-25 �r,)u,r n i n1 and Utersita _ _ _ Fr a i�_ I 26 +Ja+er Plr tb1n tro N rq _ FFG _x)-, _ i r 'F ,4ithm 217our,wid From 01 1 a4 11::15-F Within"n d Hour, = I ! 26 1 n0130ior or nxr Uitf FC_ 7 1 006 . F- i neoiai F y rrtn�evv � _ � 4C? 501.f1(13i �Crrlm�f,t{F ti1.dcFront nn rent '9 S Within riiLruf cuts to 1 FrdS`f + 6 rJtlttr ----- T�fnp _. _..... _. _.._.. ...-.._ ' a ac aiacsir 'A '.erre„ ( 0096 North Street Leslies Retreat Grub & Pub City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency 'Telephone: PROTECTION FROM CONTAMINATION 744-9495 Separation/Segregation/Pro tion / FAIL Critical ❑N RED Owner: �Zomment:Amana freezer,frigedaire freezer and Kenmore freezer had meats stored above fries and other ready to eat items. Yukers Bright Spot Inc. Organize these freezers to properly separate potentially hazardous items from ready to eat items. -PIC: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED Claire Chalifour 0/omment:Sanitizer was weak at approximately 150ppm. Provide sanitizer of proper concentration(200ppm)at all times. Inspector: dicer had accumulate n of food debr's.Th p roughl cle n and sanettize slicer. Elizabeth Salandrea 51 II ssx, tvb115 0,1 cM-sitle. 0Zf 1u-- D.� Date Inspected:Correct By: Butter scoop was being stored in container of hot water between uses.Container must be of sanitizer,not hot water. 1/28/2009 ✓Knife found stored between equipment.All utensils must be cleaned,sanitized and stored in a proper rack or container between - Risk Level: uses. V Large white cutting board is stained and scored.Resurface or replace cutting board. Permit Number: Handwash Facilities FAIL Critical RED BHP-2009-0308 1,16mment: Handwash sink in kitchen had container of knives in it.Handwash sinks must be clear and accessible at all times,and Status: m y be used for handwashing only. VIOLATION Handwash sink downstairs missing paper towels. Provide paper towels for all handsinks at all times. #of Critical Violations: TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 5 - Hot and Cpld Holding FAIL Critical ❑d RED Time IN: Time OUT: ✓/ Comment:Amana freezer at temperature of 15°F.Turn down to reach temperature of 0°F or below. Urgency Description(s): Average air fridge at temperature of 45°F.Turn down to reach temperature of 41°F or below. 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 GeoTMSe 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 02,2009 ) Page 1 oft Item Status Violation Critical Urgency RED; Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions IiC/omment: Hotpoint freezer had unwrapped food in it.All food in storage must be covered/wrapped to prevent contamination. and Risk Factors (Require immediate corrective action) V'�arge walk-in had uncovered bucket of potatoes.All food in storage must be covered to prevent contamination. Equipment and Utensils FAIL Non-Critical BLUE L/Comment: Hotpoint freezer had accumulation of food debris;thoroughly clean this freezer. //Bread storage cabinet downstairs needs general cleaning. —//SJJta-kold fridge has gaskets on the doors in disrepair.Repair gaskets on this fridge. Utieverage air fridge needs general cleaning. VC cream freezer needs general cleaning. 'II/Same unit missing thermometer. Provide visible,accurate internal thermometer for this freezer. Fryolators and grill next to them need general cleaning. Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 02,2009 ) Page 2 oft l z 0096 North Street Leslies Retreat Grub & Pub City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-9495 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:Sta-kold fridge has gaskets on the doors in disrepair.Repair or replace gaskets on this fridge. Yukers Bright Spot Inc. PIC: Claire Chalifour Inspector: Elizabeth Salandrea Date Inspected:Correct By: 2/4/2009 Risk Level: Permit Number: BHP-2009-0308 Status: SIGNED OFF #of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: All other violations noted in the 1/28/09 inspection report have been corrected. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately it or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 04,2009 ) Page I oft Item Status Violation Critical Urgency i 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®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Feb 04,2009 ) Page 2 oft .� Commonwealth of Massachusetts « K M City of Salem Board of Health lImber(ey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED:. . Ot/04/2010 ESTABLISHMENT NAME: Leslies Retreat Grub & Pub File Number:BHF-2004-000008 96 North Street Salem MA 01970 LOCATED AT: 0096 NORTH STREET SALEM, MA 01970 Permit Tye Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0066 Jan 4,2010 Dec 31,2010 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December 31, 2010 - --- Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS + BOARD OF HEALTH 120 WASHINGTON STREET,4r"FLOOR TEL. (978) 741-1800 KUvfBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GREENBAuNi, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT uiLria�' BwGR�i� v0?` ,�G NAME OF ESTABLISHMENT ��cc r. ei tend dhT ry /�rih TEL# 9? 7114��tCO 5 ADDRESS OF ESTABLISHMENT C NOCZ M FAX#q7 1 7q o 5/P_S MAILING ADDRESS(if different) EMAIL-Business': /� L Website: OWNER'SNAME(�i/,_A)i7e- PlAyP01A I TEL# I ADDRESS `l L otZ N �( _ kl2/`I M/, 0 JC( 7 U STREET ,,// �j CITY STATE q ZIP CERTIFIED FOOD MANAGER'S NAME(S) LAt,„�#e k�niS CERTIFIC&# S) (I ��o 7 ✓� ) (Required in an establishment where potentially hazardous foo As preparee( 7 S_ 2_10 & ZZ,Z_ EMERGENCY RESPONSE PERSOt k i ae (_ k”[ nd. ('we HOME TEL# 97F 745'5 7w5- ©AYSOF OPERATIONS Mpntlay . Tuesda w 1Nednes�ay T,,hu sday Fn3a sSstJrday * ")�Sundzy- HOURS OF OPERATION Please write in time of day. Qr�' ,•' �'( I —� ! '-� ` Z For example 11 am-11 m i. TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than I0,000sq.ft. =$420 - -- --- ----- - - - ---- RESTAURANT ES NO less than 25 seats (Outdoor Stationary Food Cart$210) 25-99 seats $280 more than 99 seats = 420 BED/BREAKFAST/ -------------------Y-------ES-----0>---------------------------------------------------------------------------------$-10- ------ -0 CHILDCARE SERVICES/NURSING HOME ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $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 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 nd paid all at s required under the law. ( �,-.,/ / L�Lt.(t � t� ( lU � 0 4tY Q�l 7 477 S`�ature fid/ .. ate Social Security or Federal Identification Number ------------------------------------- -- �/-------- - --------------- Revised 424/07 FOODAP2008.adm Check#&Date i Commonwealth of Massachusetts s e City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/30/2008 ESTABLISHMENT NAME: Leslies Retreat Grub & Pub File Number:BHF-2004.000008 96 North Street Salem MA 01970 LOCATED AT: 0096 NORTH STREET SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1 Notes FOOD SERVICE BHP-2009.0308 Dec 30,2008 . Dec 31,2009 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December M, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. page 1 x- CITY OF SALEM, MASSACHUSETTS • • BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOJ R TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 XIAYOR ]DIONNEQU SLEM.COM V ®EC , JANET DIONNE, ��0� ACTING HEALTH AGENT BC�1 Rp O4(✓/ 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT !V 1 C1" 1314ef c, NAME OF ESTABLISHMENT? 1`. ,�e/5L144 l��efl��� TEL# A G 1 I ADDRESS OF ESTABLISHMENT yl2 I V1 X17 FAX# T7 k Z LfU 57�3 MAILING ADDRESS(if different) EMAIL- Business': Website: p OWNER'S NAME hil �(t I t/2 TEL# 7d ` 7V-5--5-7 ADDRESS 1 0121 61'-' STREET CITY STATE ZIP �2�y3 CERTIFIED FOOD MANAGER'S NAME(S) �.A7ddti G �ti !s l CERTIFICATE#(S) q'7(Required in an establishment where potentially hazardous food is prepared e '17P 7 iK 7 ,`/'� eT71 EMERGENCY RESPONSE PERSON IQ= ( L n i(p,o HOME TEL# 1 Va 4 27-2— DAYS OFOPERATION. ' ,''Monday , 1 –v Tuesda1 ':Wednesda Thursday Frida 1 : Saturda Sul da HOURS OF OPERATION Please wits in time of day. Ii (For example 11 am-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES 10 less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ------------- ---------- RESTAURANT YE NO less than 25 seats 0 (Outdoor Stabonary Food Cart$210 25-99 seats =$280 more than 99 seats $420 – – -------------YEE.S.....BED!BREAKFAST! S -- CHILDCARE SERVICES -- - - --- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES 06 $25 TOBACCO VENDOR YES $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 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 return�d paid all stat requ ed under the law. Signature Date Social Security or Federal Identification Number --------------------------------------------------- ----------^--'-.,—,1------------------------ Revised 424/07 FOODAP2008.adm Check#&Dale Commonwealth of Massachusetts City of Salem Board of Health Kimberley Drisooll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/08/2008 ESTABLISHMENT NAME: Leslies Retreat Grub & Pub File Number:BHF-2004-000008 96 North Street Salem MA 01970 LOCATED AT: 0096 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0303 Jan 7,2008 Dec 31,2008 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December 31,2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 8 of 12 CITY OF SALEM, MASSACHUSETTS A3 /'C BOARD OF HEALTH 120 WASHINGTON STREET,4"u FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR isoo &SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT X o e P X6 31Ztq lv r S(apT x+ NAME OF ESTABLISHMENT TI PDA- ICe?17P� r /4�„,,, TEL# 1:3 '7,V-7�14CtLI-i57'_ ADDRESS OF ESTABLISHMENT 16 HOIZA � qA kt,1 FAX# 9'1 P 7 464)- -1 ?� MAILING ADDRESS(if different) I l( a_4 5 r— EMAIL-Business': Website: OWNER'S NAME_Qk„A 11ZE � /( ( �t11 TEL# � Z' a' 711 V�� ADDRESSq6 I Td R_Ftl /0/1' 0 1 ci - STREET CITY STATE .ZIP CERTIFIED FOOD MANAGER'S NAME(S)CU[q ea ,6l L,�, e 2U D 1 S CERTIFICATE#(S) 3 (Required in an establishment where potentialll)ly_hazardous food is prepared) 0--o—all c(-7 Z,10 (0 EMERGENCY RESPONSE PERSON L/1'11`1112E CbtrbII tfT((�L.��L-4 HOMETEL# 7,P 7V&'-57yj DAYS OF OPERATION Monday Tuesday 1 Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION 16 Please write in time of day. L16 7 --Z p (For example 11 am-11pin) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - - -- - ------------------------------------------------------------ RESTAURANT YE NO less than 25 seats =$140 (Outdoor Stationary Food Cart$2 25-99 seats more than 99 seats = 0 - - - - .-. .....----------------------------------------------------------------------- BED/BREAKFAST/ YE - -NO $100 CHILDCARE SERVICES._._--.- _ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES gO $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 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 return nd paid all state taxes required under the law. / ( -7 5 � Signature Date Social Security or Federal Identification Number ------------------------------------- '------------------- —G---- - --- -ty-�--------------p--- ---- Revised 4/24/07 FOODAP2008.adm Check#&Date g 0096 North Street Leslies Retreat Grub & Pub City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: I PROTECTION FROM CONTAMINATION 744-9495 Food Contact Su s Cleaning and Sanitizing FAIL Critical d❑ RED Owner: scored. Resurface or replace the cutting boards. C me utting boards are stained and sco ed esu p g Yukers Bright Spot Inc. 9 p I the wait station to be placed facing one direction handle side out. PIC: 7 silver ware a Michael Clukey Handwash Facilities FAIL Critical 0 RED Inspector: C nt:There were pots stored in the hand wash sink. Hand wash sinks must be kept clear and accessible at all times and used David Greenbaum or hand washing only. Date Inspected:Correct By: 6/14/2007 Risk Level: Permit Number: BHP-2007-0182 Status: PARTIAL COMPLY #of Critical Violations: 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 14,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Fo rotection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require omment:The Hudson reach inhas uncovered food.All food in storage must be covered. immediate corrective action) Equipment and Ut s FAIL Non-critical BLUE C me he Beverage air salad/desert reach in needs a general cleaning. Th aier ice cream freezer needs a thorough cleaning and defrosting. canopener has an accumulation of grime. Thoroughly clean the canopener. 7 white microwave has an accumulation of food spills. Thoroughly clean the microwave. Th to-Kold reach has an accumulation of food debris. Thoroughly clean this unit. 7 lat to rill has an accumulation of grease amd grime. Thoroughly clean around the flat top grill. - T, he.Hudson reach in needs a thorough cleaning inside and out. l �/ 3T same nit needs a visible,accurate thermometer. 7h of int refrigerator/freezer has an accumulation of food debris. Thoroughly clean this unit. T ar Is in a kitchen are in disrepair. Repalce the barrels. Th itchen flooring needs a thorough cleaning, including under and around all equipment. The Kenmore freezer in the basement needs a general cleaning. PhysicalFacilityFAIL Non-Critical BLUE CommorrrThere are water stained ceiling tiles in the basement. Investigate the source of the leak and repair. Replace all stained g tiles. GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. _�LLL 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. Jun 14,2007 ) Page 2 oft 0096 North Street Les/ies Retreat Grub & Pub City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-9495 Food Contact Surfaces Cleaning and Sanitizing PASS Critical RED Owner: Comments:Cutting boards are stained and scored. Resurface or replace the cutting boards. Yukers Bright Spot Inc. PIC: The silver ware at the wait station to be placed facing one direction handle side out. Michael Clukey Handwash Facilities PASS Critical RED Inspector: Comments:There were pots stored in the hand wash sink. Hand wash sinks must be kept clear and accessible at all times and David Greenbaum used for hand washing only. Date Inspected:Correct By: 6121/200 Risk Level: Permit Number: BHP-2007-0182 Status: SIGNED OFF # of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS&2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 21,2007 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection PASS Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comments:The Hudson reach inhas uncovered food.All food in storage must be covered. immediate corrective action) Equipment and Utensils PASS Non-Critical BLUE Comments:The Beverage air salad/desert reach in needs a general cleaning. The Haler ice cream freezer needs a thorough cleaning and defrosting. The canopener has an accumulation of grime. Thoroughly clean the canopener. The white microwave has an accumulation of food spills. Thoroughly clean the microwave. The Sta-Kold reach has an accumulation of food debris. Thoroughly clean this unit. The flat top grill has an accumulation of grease amd grime. Thoroughly clean around the flat top grill. The Hudson reach in needs a thorough cleaning inside and out. The same unit needs a visible,accurate thermometer. The Hotpoint refrigerator/freezer has an accumulation of food debris. Thoroughly clean this unit. The barrels in the kitchen are in disrepair. Repalce the barrels. The kitchen flooring needs a thorough cleaning, including under and around all equipment. The Kenmore freezer in the basement needs a general cleaning. Physical Facility PASS Non-Critical BLUE Comments:There are water stained ceiling tiles in the basement. Investigate the source of the leak and repair. Replace all stained ceiling tiles. GENERAL COMMENTS: All violations cited in the 6/14/07 inspection report have been corrected. 4L City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS0 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 21,2007 ) Page 2 oft COURT DOCKET NO. CITATION NO. CITY OF SALEM nD E+ VIOLATION NOTICE r 6 NAME(LAST,FIRST,INITIAL) STREETADDRESS CITVITOWN STATE ZIP 16 ifio✓ fi �f S/k �� mF� aG 70 LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) ('11441f1�`- w-7 } 0 4112E ZIP 14STREEIVea 11 15,14 C N STATE qo C19;ro REGISTRATION NO. STATE I EXP.DA1E1 MILK PE YEAR COLOR DATE OF VIOLATION TIM ' DATECITATIO WRITTEN PErvsorvnL J/1z.I�a ::T�rIYES P'M JJ1�. c ❑NO LOCATION OF VIOLATION - ENFORCING DEPT 13414?o Sw��y 'IC9 Sl lz2 ry€�,*� .y'T)}- 11,41k, OFFENSE ,61 'F]dY/ GI JiKP f+Y1✓C/ CHAP. SECT. FINES A_ 1 . . -3 o. B C I.D.NO. TOTAL $ () FINE DUE V.�U OFFICER CERTIFIES COPY GIVEN TO VIOLATOR X 90 y/ / � ❑rB HAND // Oy/�J l/moi" uy BV MAIL i 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)74S-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 H SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL COURT DOCKET NO. - CITATION NO. SCITY SALEM PD L+ /� 1 O VIOLATION NOTICE U`# NAME(LAST,FIRST,INITIAL) A ,O CIQIJZ:oU2/ /c./}/4d; STREETADDRESS � CI�OWN STATE ZIP n ii(i/ll OY47o LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) STREETADDRESS CNA�i�`ovR, ccg�p� `1Z Na e,71 S� S/1CrtGWNn STATE 019 01970 REGISTRATION NO. STATE EXP.DAV'YPE YEAR COLOR DATE OF VIOLATION TIM AT�EJCII/ATIO WRITTEN IwuOLES �I P #;/WRITTEN F1 NO 4449 ENFORCI�+�DEPT E»quh11 ry�4/ OY) f &V) / CHAP. SECT FINE$ rVInce - CkAN �NG� c OFF CER I.D.NO. TOTAL O Ov �, (7ts4�11 FINE DUE ,�OPF,ICER CERTIFIES COPY GIVEN TO VIOLATOR X �\TJ/V�1/� Q!,r�/J ?��S(//./_ ❑ IN HAND BY MAIL bO 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 Dec 07 06 liti3e Joanne Scott Salem 80H 378 745 0343 i CITY of SALEM, MAsuct usEm SoAFto of HEALTH 120 WA4armTdN SrREET,4TH FLoon SAtsm,MA 01070 TEL,978-741-1800 Fax 978-745-0343 Kimberley Driscoll "'WW.SALEWOO t JOANNE SCOTT, MPH, HIS, CHO Mayor HBAITHAOeNT lit h 7tf5`57/S 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABL1SHMENTe_Uk shT t�C2T TEL 4 7ov-7yq c of 5 ADDRESS OF ESTABLISHMENT A u j FAx 7 e 714 U 5"1 S'S MAILING ADDRCSS(if dlf(crent) EMAIL—Business': Ownees: OWNER'S NAME C?LAI-IIZ _j� ja(ta T6Lk r(`� t( 5�J{ttj� ADDRESS<14 Ht>rg-4l 7 Kde'q 11U Qt47� STREET CITY STATE ZIP CERTIFIED FOOD MANAGERS NAME($) iit m int:., 'trkr- CERTIFICATEN(S` 714- (5 (0 !. "VOOLA 0Q C'21( 4, t( Oe a/0 222 ttzequired is an establishment where li lot3ay hazardous food�is A4 L en I 4—A4-T 13 i' EMERGENCY RESPONSE PERSON �.•+(t2t 4�{t t � HOME TEL Is Qt?if -7µ5'-57tf5- mtYS9EePMM standar. - ' ruestlatl li NSI�� to soap 7 r_Ft I�l7— Samrayr7-P, Z ISS IF O@E80.rI0II atcare+ mt�eataw. I TYPE OF ESTASLISHMENT FEE (cheek only) RE YES$TOf2 YES NO Ics,than 1000sq.ft. -$50 1000.10.000sgA. =$100 more than 10,000sq.ft. =$250 _ ... .......... ........... ................. ... ......................................1,111....._. RESTACIfiANT CjE NO less Uiari 25 watt 25•99 scats $15U mors thsrr 94 seats ....._............ ......_..6111. 1111..1111- ........ ................ ._.............. ............... ...........•..............,.-........ . . BEDI9REAKFAST YES NO $100 ............. ........... ................ .. ... ....... ............ .... ....... .._............. .......... f ADDITIONAL PERMITS MAKE(not just se ve)ICE CREAM.YOGURT, SOFT SERVE YES Ivo $5 I OBAGCO VENDOR YFS NO $50 ALL NON-PROFfr(such as church kitchens) YES NO $25 `Please pay total with one check p,yahte to the City of Salem. This Permit is not transferable and must be reissued upon change of ovsnership. The Permit must be posted In a prominent location to 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 Chapin?d20,Simltca 40A,I ceflit f.=Je:lnn pains alta!p;±nalGeS 01retqurl,that1,to my bdst kooWledge;31X1 belie;I. flay rt, all stale LIA ielor r pale all s;aia iLxes I&, - - r ja- 7-C�1 DN 1-�Z97- � s7 r nunrro � Date SpCial S@Gorily c: Fedora{IdgnfificeGon Numher- -- ----- ------------ ........-- --------- .... 111-1 ---------- --•---•-...... a:a,.otuttror;F0QOAl+-;udr'0n Choekxx0ale r�6�� /2/6j- Dis rd zscxota 10y«-`�. VTV� `r Ommo' n�`"wealth of�M,rassah set�s�' Y �iy r *n ,ty� p: ��b' p7,S�t�g�+"�1't�f � r � •3'tMY-i''� �MP�" r».bf d � �gfy T' � fF�:< _ n+�,.�������'n'�:r.,�} afimp�`c Aaiun at�e>. �r aCity of Salem `Boardof Health"tt .' '^Jat'q,, .`x, .' irk ,,� .' r�G`"uSr+� l4}; x�.r- eney Driscoll ° k f20 Washing tou Street,4hFloorMayof SALEM,MA `01970 Food/Retail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Leslies Retreat Grub & Pub File Number:BHF-2004-000008 96 North Street Salem MA 01970 LOCATED AT: 0096 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0182 Dec 20,2006 Dec 31,2007 $150.00 ESTABLISHMENT Total Fees: $150.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 11 of 18 R >. 0096 North Street Leslies Retreat Grub & Pub City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-9495 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:The Hotpoint refrigerator/freezer has an accumulation of food debris. Thoroughly clean both compartments. Yukers Bright Spot Inc. PIC: Claire Chalifour GENERAL COMMENTS: Inspector: 1028:All other violations cited in the 11/15/06 inspection report have been corrected. David Greenbaum Date Inspected:Correct By: 11/29/2006 Risk Level: Permit Number: BHP-2006-0297 j Status: SIGNED OFF #of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 ) Page I oft a 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®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 ) Page 2 oft 0096 North Street Leslies Retreat Grub & Pub City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-9495 Separation/Segregation/Protection FAIL Critical ❑d RED Owner: C menta Orange juice found stored in the ice for customer drinks at the bar. O not store any items in the ice for customer drinks Yukers Bright Spot Inc. prevent cross contamination. PIC: �Tlhe freezer in the basement has potentially hazardous food stored over other foods. Store all PHF below other foods to prevent Claire Chalifour r scontamination. Inspector: Food tact Surfaces Cleaning and Sanitizing FAIL Critical RED David Greenbaum Date Inspectelcorrect BY: mment:The meat slicer has an accumulation of grime. Thoroughly clean and sanitize the meaT slicer after each use. Date Inspected:Correct By: 11/15/2006 Kni s and utensils found stored between equipment. Properly clean and sanitize all knives and utensils and store in an Risk Level: propriate storage rack. Permit Number: BHP-2006-0297 Status: PARTIAL COMPLY # of Critical Violations: 2 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 15,2006 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Equipment and Ut nsils FAIL Non-Critical BLUE Foodborne Illness Interventions and Risk Factors (Require C menta The ice cream freezer needs a thorough cleaning. . immediate corrective action) `opener has an accumulation of grime. Thoroughly clean and scour the canopener. T re is an accumulation of food debris on the top of the Bakbar oven. Thoroughly clean this oven. vBoi�he microwaves in the cookline need a general cleaning. ,7 Sta-Kold reach in needs a thorough cleaning. The e Hotpoint refrigerator/freezer has an accumulation of food debris. Thoroughly clean both compartments. e KJenmore freezer in the basement has an accumulation of food debris. Thoroughly clean this unit. L TSF e E freezer in the basement needs a general cleaning. Physical Facili FAIL Non-Critical BLUE mment:There are water stained and missing ceiling tiles in the basement. Investigate the source of the leak and repair. Repair Physical replace all stained/missing tiles. T asement stairs need a thorough cleaning. GENERAL COMMENTS: 985:Reinspection on Monday, November 27, 2006, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 15,2006 ) Page 2 of .-Massachusetts Depr�artment of Public Health Salem Board of Health F' y f,, 4 120 Washington Street, 4'" Floor Division of Food and Drugs /.,,. ' . a Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 ' Name Dat Type of Operation(s) Type of Inspection �I - , E J,,,Eood Service ELRoutine Address V Rid 0 Retail V Re-inspection 6.7- Level ❑ Residential Kitchen Previous Inspection Telephone ❑ -Mobile Date: Owner HACCP YM El El Owner / ❑ Caterer ❑ Suspect Illness Person in CEI( I ) Time El Bed&Breakfast ❑General Complaint ❑ HACCP In: Inspector / py '(n Permit No. ❑ Other Each violation c eca req Yes an Txplanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. i „'FOOD PROTECTIONMANAOEMEN7A El12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 'I [113. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMIC ALS 3 ,`n" i rtla , "� Zn, ` a F12. Reporting of Diseases by Food Employee and PIC - 21 • ❑ 14. Approved Food or Color Additives ❑ 3.. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals 1 [ FOOD FROM APPROVED SOURCE a.,„""`,�,,,�„ @,„6.,,t;°m,..,,.®n� w71MEtTEMPERATURECONTROLS(PotentiallyHazardousFaods) ��j F] 4. Food and Water from Approved Source ro y ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures (PROTECTION 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating7 Conformance with Approved Procedures/HACCP Plans 16.Cooling FROM CONTAMINATION , `"'�„� q �_' .[] 19. Hot and Cold Holding .«s d .x b-[-•i ..J c ,.;�..R x ,I+1`a ham` I. 4w �.aG v i''S A ❑ S. Separation/Segregation/Protection El 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing '�REGUIREMENTS FOR HIGHLY SUSCEPTI@LE POPULATIONS(HSP)'„;;, [121. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing F] 11. Good Hygienic Practices `CONSUMER ADVISORY,°`'m"°'' t�`.'". ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected ` Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below O N{` by a Board of Health member or its agent constitutes an 23. Management and Personnel, .(FC-2)(59order of the Board of Health. Failure to correct violations _ 24. Food and Food Protection (FC-3)(590..004)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)(990.009) establishment operations. If aggrieved by this order, you !27. Physical Facility (FC-6)(590.067) 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:501nspecfFo,m 14C I Inspector's Signature: l f Print: PIC's Signature: -'� /�"' .'/'- Print: Page V of r Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(A) Assignment of Resonsibilit * 3-302.1](A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of ,ledge* Cooked and RTE Fm)ds* 2-103.11. Person in charge-duties Contamination from Raw ingredients 3-302.1 l(A)(2)•• Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) I Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables E 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(6) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501-111 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermeticall •Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.1.3 Shell Eggs* Sanitization Temperatures* 3-202.14 F.<s and Milk Products.Pasteurized* 4-501.11.4 Chetnical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water" concentration and hardness. * 5-101.1.1 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingCleaning Utensils Crean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4 602.11 Cleaning Frequency of Equipment Food - 590,006(B) and Fish From an Approved Source Contact Surfaces and Utensils* 4-7o-2.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-IlotWaterand 7201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2.301.11 Clean Condition-Hands and Aims* 3-202.18 Shellstock Identification Present* 2-301.12 Cleanin Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11 Eating,Drinkin or Using Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11. Food Safe and Unadulterated* 3-301..12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004Q Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* - Employees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402. 5-203.11 Numbers and Capacifies* Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(4(1) Labeling of Ingredients' 9 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability y 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision *Denoles critical item in the federal 1999 Fond Code or 105 CM1 590.(100- r { CITY OF SALEM a BOARD OF HEALTH ` Establishm � le � � Date: Pageofy� T E Item =Code C-Critical Item -. DESCRIPTION'.OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified r PLEASE PRINT CLEARLY -Ga r S, 5c7 -PTA _/ c Pa :l C 14 6 L E � J (l E 9 0 o, n (0 1 I �( 4 - K >ad '( 41" ( D < c +� I Y�l. ✓!l Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes,, have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ' . p o " Re-inspection Scheduled ❑ Emergency Suspension comply with all\rnandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures r Violations Related to Foodborne Illness Interventions and Risk According,to tuw Cooled to Factors(items 1-22) (Cont.) 4PF145'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFB 14 Food or Color Additives 19 PHF Hat and Cold Holding 3-501.16(B) Cold PRFs Maintained at or below 3-20'2.12 .Additives* 590.004(1) 41"/45"F" 32302.14 Protection from tjnapprovod Additives* 3-501-I6(A) Hot PHFsMai ntained at or above LL-Ia Poisonous or Toxic Substances 14WF- 7-101.11 Identifying Irrformamon-C)','cal 3-501.16(A) Roasts Held at or above 130°F. Containers" 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage" 3-501.19 Time as a Public Health Control* 004fi) Variance Requirement Restriction-Presence and Use* 5 7-202.12 Conch tionsaf Use* ' 7-203.11 'toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanittz rs,Criteria Chemicals' POPULATIONS(HSP) 7=„(}�4.12 Cheturcais far W tehnte Prodnve,Criteria" 21 3-801.11(A) Unpasteutized Pre-packaged Juices and 7-204 *.14 Devin A ants.Criteria'p Beverages with Warning Labels* 7-205.11Incidental Foal Contact, Lubricants* 3-801.t 1(B) Use of Pasteurized E(es* 7-206.11 Restricted Use Pesticides. Criteria* 3-801,11(D) Raw or Partially Cooked Animal Foodand Raw Sced S vrouri Not Served." 7-206.12 Rcxlcen Bait Stations* 3_801.11(C) Unopened Pa>d Package Not Re-served. 7-20613 Tracking Powders,Pest Control and Monifarrng` CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.1 I Consumer Advisory Posted for Consumption of Annual Foods'Phat are Raw.Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs Pathogens. F#1111 rnranai 3-401.1 1A(i)(2) Lg&i- 155"F 15 Sec. * 1:ygs-hnniediate Service 145°F15sce* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comrninuted Fish,Meats&Game Eg s* Animals- 155'F 15 see. s 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. r catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed P1 Fs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'P 15 see. r above if related to foodborne illness 3401.11(C)(3) Whole muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail. 3-401.12 Raw Animal,Foods Cooked in a practices should be debited under#{29-- Microwave 165'F* Special Requirements. 3-40 1.11(A)(1)(b) All Other PHFS-145'F'15sec, 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1](A)&([)) PHFB 165'F 15 sec. " (Items 23-30) _ 3-403.11(B) Microwave- 165'F2 Minute Stand inu Critical and non-critical violations, which do not relate to fire Time" foodborne illness interventions and rlsk jizctors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1.40°F* .590.000. 3-403.1.I(E) Remaining Umliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts„, 23. Management and Personnel FC-2 .008. 1g Proper Cooling of PHFB 24. Food and Food Protection FC--3 .004 25, ___ Equpment and Utensils FC 4 .005_ 3-501.14(A) Cooling Cooked PHFB from t40°F o 26. _ Water, Plumbin and Waste FC 5 006 _ 70'F Within 2,flours and From 7WF 27. Ph sical FacilltFC-6 .007 to 41°F/45°F Within 4 Homs. * 28, Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFB Made From Ambient 29. S ecial Re uiremonts _ .009 Temperature Ingredients to 41 017145°F 30. _Other ---- ----------- Within 4I°Iours^` s4;ionvmn,a:�zmm ''-Denotes�incal itean in the Cederal 199Y Pood Coda or 105 CMR 5909(10. CITY OF SALEM e BOARD OF HEALTH E Establishment Name: 1crSU5 J Date: Pager of A Item Code C-Critical Item :` DESCRIPTION OF VIOLATION/PLAN OF CORRECTION f Date `F No. Reference R-Red Item - Verified .' PLEASE PRINT CLEARLY n �,5z- r t lccn-Io^ - J r3:' t. S d✓ � NX) f x 0 ,4 Discussion With Person in Charge: Corrective Action Required: ❑ No Yes { I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo, ❑ Emergency Closure your food permit. , ❑ Voluntary Disposal ❑ Other: F 3-501.1.4(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Loy Cowled to Factors(items 1.22) (Cont.) - 41`F/45`F Witten 4 Hours. PROTECTION FROM CHEMICALS 3,}01.15 Coofirr,Methods for PRFs 19 14 Food or Color Additives PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-302.12 ProtecAddifition 590.004(F) 41`/45`F* 3-302.'L4 Protection frau tins i rp ata Additives* 3-501.1(i(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 4WE * 7-101.11 C Identifying IoR>nnatiiai-Original 3-501.16(A) aRciasts Held at or above 130°F. • -v-. CDtlCatner5* 7-102.11 Common Name--Working Containers` 20 Time as a Public Health Control 7-201.11 Se.aration-6toraiW 3-501-19 Time as a Public Health Control* 7-202.71 Restriction-Presence midOse` 590.004(1-1) Variance Re uirement 7-202.12 'Conditions of Use- 7-203.I I se*7-203.11 ) 'Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 7-204.11 ). Sanitizers,Criteria-C'.hemicals�; 7-204.1.2 Chemicals for Washine Produce,Criteria* 2t 3-801..1 1(A) Unpasteurized Pie-packaged Juices and 7-204.14 Beverages with Warning L bets* 3-901.11(B) Use of Pasteurized Egos' 7-205-11 Incidental Food Contact,Lubricants' 3-801.11(D) Raw or Partially Calked Anima]Food and 7-20fi.1 1 Restricted U'se Pesticides.Criteria* Raw Seed Sprouts Not Served. '" 7-20b.13 `Cracking Powders,Pest Control and 7-206.12 Rodent Stations" 3$0'1.11(7) Una eneci Food Package Not Re-served. Monitorin,* CONSUMER ADVISORY TiMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Prager Cooking Temperatures for Animal Foods'1'hat are Raw.Undercooked or PHFs - Not Otherwise Processed to Eliminate 3-401.LIA(lr(2) Figs- SSi'F 75 Sec. Patho enl*red... rroeom Eggs-thanediate Service 14501715sw 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3-401.1].(A)(2) Comminuted Fish,Meats&Came E gs*� , Annuals- 155°F 15 sec. *- 3-401.11(B)(1)(2) Pork'.and Beet Roast - 130°F 121 mini, SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F I5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering,mobile food,temporary and 3-40 1.11(A)(3) Paultrr, Wild Game;S ufted 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 a 590.009 violations relating to good retail 3=401.12 Raw Animal Foods Crooked in a practices should be debited under##29- ` Microwave 165`F* Special Requirements. 3=401.11(A)(1)(b) All Other PRFs- 145°F 15 sec. * 17 Reheating for Hot Holding �. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES. 3-403.11(A)&(D) PHFs 165`F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minnie Standing, Critical and non-critical violations, which do not relate to the Time* ,foodborne illness interventions and riskf actors listed abovecan be 3-403.11(C) Commercially Processed RTE Fond- found in the fWoe-ing sections of the Food Code and 105 CMR - 140°F* 590.000. 3-403.11(E) Remaining,Unsliced Portions oPBeef Item Good Retail Practices I FC 50 0-00---- Roasts* 23. man a ement and Personnel _ FC--2 .003_ lg Proper Cooling of PHFs 24. Food and Food Protection FC--3 004 F_ 3-501,L4(A) Cooling Cooked PHFs from t40`F to 25 Equipment and Utensils C 4 .005 26 Water_Plumbin and Waste FC 5 7006 70°F Within 2 Hours and From 70°F 27 Physical Facility __ FC -6 D to 41`�F/45`F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PRFs Made From Ambient 29. S ectal Requirements _ .008 Temperature higredients to 41`F/45o17 r 30Other Within 4 Hours* s:a,mW­bx. 6w 2 k Denotes critical item in the f,feral 1999 Food Code or 105 CMR 590.000. x - . CITY OF SALEM BOARD OF Establishment Name: I o ( (�29f HEALTH i h/ Date: Page: of t Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - Verified PLEASE PRINT.CLEARLY U CAOCl I 3r2pT �rl QX 1-k Lelf /v 5 J 7 / o, r n IL 4_0 n&3 t rr ylc) € b J X3 ce 4 ,� r , ,k- F. - o � — jc n_, l J _ Q C s S cAb, L i It f Discussion With Person in Charge: Corrective Action Required: i] No Yes ❑ Voluntary Compliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to 4-<e-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 ElOther: - i� t r 3-501,14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to Iaw Cooled to Factors(items 1-22) (Cont.) 4t°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-3TCoolin,Methods for PHR 14 Food or Color Additives 19 PHF Hot and Cold HOItlIng 3-202.12 Additives' 3-50L16(B) Cold PFIFs Maintained at or below 590.004(F) 41"745°F* 3-302.14 Protection from Lina t.roved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F. * 7-101.11 Rontainers,Information-Or9ginal 3-501.1.6(A) Roasts Heid at or above 130°F. " Containers* 20 Time as a Public Health Control 7-1.02.11 Gammon Name-WOrkinr Containers* g_507.19 Time as a Public Health Control" 7-201.11 Se aration-Sfot >?e* 590.004(H) Variance Rc ulremcnt 7-202.11 Restriction-Presence and Use* 7-202. OOndTtio,,of Us,- T203. s, - ?• 'REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 "Ionic Containers Criter -Prohibitions* 5 POPULATIONS(HSP)7-204.,11 :Samrzers,Cri lei is-Cheanicals* - ' 2T 3-801.11(A)_ Unpasteurized Pre-packaged Juiccsand 7-204.12 Chemicals for W asbin•Produce,Criteria* t, Beverages with Warning La6eis* 7-204.14 Dr iu r =tints,Galeria^` + 41-801,11(B) Use of Pasteurized Eggs* `1 1 7-205.11 - Incidental Food Contact. Lubricants' 7-206.11. . 3-801.11(D) Raw or Pat2ially Cooked Animal Food and Reatdeted Use Pesticides,Cntei ia* Y Raw Seed Sprouts;Not Served. 7-206.1'2 Rodent Bait'Stations' 3-801.1 l(C) Unopened Food Packa>e Not Re-served. 7-206.13 ;Tracking Powders.Pest Control and _ �i 'ModrtorinRM CONSUMER ADVISORY 22 3-603.1 I Consumer Advisory Posted for Consumption of TIMEtTEMPERATURE CONTROLS 16 Proper Cooking Temperatures for + Animal Foods'fhat are Raw,Undercooked or _ PHFs - Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Fggs- 155 i 15 S""tic. Patho,,enS.* OW91e rrvzoai F gs-hmnedrate Service 145`F15sec* 3-302.13 'Pasteunce d Eggs Substitute for flaw Shell 3-401.11.(A)(2) Comminuted Fish, Meats&Game E s* Annals- 155°F 15 see. * 3-401.11(B)(1)(2) Pork and Beet Roast- I10"F 121 min* SPECIAL REQUIREMENTS _ 3-401.11(A)(2) Ratites,injected Meats-155*F 13 590.009(A)-(D)f Violations of Section 590.009(A)-(,D)in sec.x catering,mobile food,temporary and 3-401.11(A)(3) .Poultry,Wild Game,Stuffed MIN, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr'or Ratites-165`F 15 sec. * .0 above if related to foodborne illness 3-40L11(C)(3) Wholemuscle,Intact Beet Steaks ' interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Anirmtl Foods Cooked in a practices should be debited under 1129- Microwave 163'F* Special Requirements. 3-401.11(A)(I)(b) All Other PH'Fs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403A 1(A)&(D) MIR, 165°F 15 sec. * (Items 23-30)-P 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 tisk factors listed above can be 3-403.11(C) Commercially Processed RTE Food- ,found in the following sections of the Food Code and 105 CMR 140°F* 590.000. _ 3-d 03.I I(E) Remaining,Unsiiced Portions ofBeef item Good Retafl Practices FC b9tL000 ----' Roasts* ` 23. Management and Personnel FC--2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25. Equipment and Utensils FC 4 _ .005 3-5(}1.14{A} Cw6ng Cooked PHFs from 140°F to 26. Water,'Numbing and Waste . FC 5 .006 70°F Within 2 Hours acid From 70°F - 27 Physical Facility FC-6 .007 to 41".F/45°F Within 4 Hours. '" 28. Poisonous or Toxic Materials _ FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial'Re uiremenis .009 Temperature Ingredients to 41°F/45oF 30. _Other Within 4llours* cswm,,,:neaazm "Denotes mucal item in the federal 1999 Food Code or 105 CNIR 590.900. a d Massachusetts Department of Public Health Salem Board of Health a -- 120 Washington Street, 4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 7AAd�draaaq D to Tvoe of Operations) Tvoe of Inspection Apr L,41' FoodService ❑ Routine L RiskRetail [�Re-inspection Level ❑ Residential Kitchen Nevious Inspection Telephone _ ❑ Mobile [__1 Temporary Tem ora � a 6 Sf 'k Owner KP �7r i I_ HACCP Y/N El Caterer L3S Suspect Illness Person in Charge(PIC) T Time ❑ Bed&Breakfast ❑General Complaint In: I ❑ HACCP Inspector7, 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 Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT am- ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities EMPLOYEE HEALTH uP" a PROTECTION�ROMCHEMICALS.,;,;:�.m�.m..,at-�' .,.,..,.,,. s 4-0., ,..._....;a ❑ 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 Source It TIMEITEMPER-ATURE CONTROLS 06t_Iil H ' VVI ❑ 4. Food and Water from Approved Source f 1 ° "( h Hazardous F-4 Z ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans NX18. Cooling °-, �� N'- PROTECTION FROM CONTAMINATIOrx *t`�` El 19. Hot and Cold Holding 71 ,..1.�..,�.. ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing v itEOUIREIIII FOR HII SUSCEPTIBLE POPULATIONS(HSP)ion: El 21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ('CONSUMER ADVISORY;;' ! "�' ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below .0"' by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(5590.090.0 044))) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(sso.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(59o.o07) 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:SXMSp UFOm -14 JX r.- Inspector's Signature: ---� Print: / n PIC's Signature: /- Print: i J i ` C / /t Pag of D�Pages Violations Related to Foodborne Illness _ Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 1 590.003(A) I Assignment of Respimsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge*-- - Cooked and RTE Fci)ds* 2-103.11. Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the;person in charge to Contamination from the Environment require reporting by food employees and 3-302.1 t(A) Food Protection* applicants* 3-302.15 Washing Fruits and Ve etables 590.003(F) Responsibility Of A Find Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(0) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice,of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F,) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD_FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) _Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water - 3-201.12 Food in a Hermetically Scaled Container* Sanifization'reni ratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.1.3 Shell Eggs* Sanitization Temperatures* * 4-501.114 Chemical Sanitization-temp.,pH, 3-20214 Eggs and Milk Products,Pasteurized 3-202.16 lee Made From Potable Drinking Water* concentration and hardness. '" 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Equipment Foal Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean" 4-602.11 Cleaning Frequency of Equipment Food- 590 006(B) Water Meets Standards in 310 CMR 22.0"' Shellfish Surfaces and Utensils*fish and Fish Froman Approved Source 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 7201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11. Clean Condition-Hands and Ann;* 3-202.18 Shellstock Identification Present* 2-301..12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-30114 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices '$ Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.1.5 Package Integrity* Mouth* 3-101.11. Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tastin * 6 Togs/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* Ent to 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* 1I 1,ocation and Placement* 590.004(J) Labeling of ingredients' 7 Conformance with Approved Procedures 5-205.11 -Accessibility,Operation and Maintenance /HACCP Pians Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,.Availabilit 9-103.12 Conformance with Approved Procedures* 6-301.12 Hand.Drying Provision °Denotes critical item in the federal 1999 Forai Code or 105 CMR 590.000. F CITY OF SALEM _ 9 `� � /� BOARD OF HEALTH e Establishment Name: lI� I \ C c_� l `Yi�� �%,k> Date: C/ Page:_ of Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dat Verified S No. Reference R-Red Item PLEASE PRINT CLEARLY / L Lg . G °l r pea�nr0 v e z62 cli.,�Cae . t i � ! it Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I.,, t L I have Jead this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employee Restriction/ volations before the next inspection, to observe all conditions as described, and to Emersion Violations� ,. P C1 Re-inspection Scheduled ❑ Emergency Suspension 'comply with all mandates of the Mass/Federal Food Code. I understand that ;f noncompliance may result in daily fines of t�n -yfive dollar or spension/revocation of ❑ Embargo ❑ Emergency closure your food permit. (/ ❑ Voluntary Disposal ❑ Other: r w 3-501.14(0) 'PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to taw Cooled to Factors(items 1-22) (Cont.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.'15 Cooling Methods for PHFs 14 _W Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Addltiur° 590.004(F) 41°(45°F* 3-302.14 Protect from Una roved Additives'k Poisonous or Toxic Substances 3.501.16{A} loot PHFs Maintained at or above lg 7-101.11 Identifying Information-Original 140^F 20 3-501.1.6(A) Roasts Held at or above 130"F. Containers'" 7-102.11 Common Name_-Working Containers* Time as a Public Health Control 7-201.11 Se aration-Storaee" 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Ilse* 5}0,004(H) Variance Requirement 7-202.12 Condaim,4Use* 7.203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicats for Washin Produce,Criteria"` 2.t 3-801.1 1(A) Unpasteurized Pre-packaged Juices and Beverages with Warni 7-20ngl.;abels* 7-204.14 n IninAgents,Contact,L 3-801.11($) Use of Pasteurized Eees* 5.]1 Incidental Food Contact, 7-206.11 Restricted Use Pesticides.Criteria* 3-801A 1(D) Raw or Patiiaily Cooked Animal Food and 7-206.12 Rodent Bait'Stauom* Raw Seed Sprouts Not Served. * 7-?06.13 'Cracking Powders,Pest Control and 3-801.11(C) Unopened Food Package Not Re-served. Monitoting* CONSUMER ADVISORY TIMEffEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw, Ifndercooked or 1fi Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155'F 1.5.Sec. Pathogens.* Enecnre vr,eum E s-'hume<,batc.Service 145°F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish, Meats&Game Eggs* Animals-155°F 15 sec. * 3-401.11(B)(1)(2) pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-40 1.11 Ratites, Injected Nleats-155°F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. 'k catering. mobile food, temporary and 3-40i_11(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Rapres-165°F 15 seca' above if related to foodborne illness 3-401.11(C)(3) Whole-nmscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(ARI)(b) All Cher PHFs-145`F 15 sec. 19 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHF, 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F2 Minute Standing Critical and non-critical violations, which do trot relate to the Time c ,foodborne illness hererventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTF.Food- ,found in the following sections of the Food Code and 105 CMR '140`F* 590.000. _ _ 3-403.11(E) Remaining Ilnsliced Portions of Beef Item Good_Retail Practices FC 590.000 Roasts* 23. _Management and Personnel _ __ FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection ____ FC FC-3 .004 25_ Equipment and Utensils 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water,Piumbin and Waste FC-5___.006 70°F Within 2 Hours and From 70"F 27, Ph sical Facilit FC-6 .007 to 41°F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials, FG-7 1 .008 3501.14(3) Cooling PHFs Made From Ambiens 23 Spec Re uirements .008 Temperature Ingredients to 41 017/45°17 30. Other 1y Rhin 4 FIourS'e sswm�a,Nr zao< 'Denotes critical irtin in the federal 1999 FoodCode or 105 CMR 590.000. Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2006 WHO'S PLACE OF BUSINESS IS: Leslies Retreat Grub & Pub File Number:BHF-2004-0008 96 North Street Salem MA 01970 LOCATED AT: 0096 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0297 Jan 4,2006 Dec 31,2006 $150.00 ESTABLISHMENT Total Fees: $150.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 8 of 20 CITY OF SALEM, MASSACHUSETTS n BOARD OF HEALTH f 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 t� (7b' 2046 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT'I, Q r "7 u5`--,5i"7V5 NAME OF ESTABLISHMENT V V K er; 1Ryq k' r/ EL# 7l44 t_`4t Y7 R� �iy Y5- TJ ADDRESS OF ESTABLISHMENT (¢ CIQCZ-r MAILING ADDRES�S''S}�(if different) t, 1 1 .. OWNER'S NAM�.�VSA 1124 �,Y Ckj— 6 R))L`\ TEL# ct7 y ADDRESS U rt� S F CITY n S AT€ f3 ZIP CERTIFIED FOOD MANAGER'S N E(S) 1 � t Lek e CERTIFICATE#(s) (�I 7 i n�i2� h ciU -10-"o &z�z (required in an establishment where potentially hazardous fo Is pr@pared (✓'v6 �4FZtrrt (sc7ZF� 3US`57` '?' EMERGENCY RESPONSE PERSON j�tt� e 1 k t9 l( e HOME TEL# 7 k 7 y I (;13� HOURS OF OPERATION: Mon. Tue.%-( Wed.1"1 Thu. 'Z- Fri 7 J Sat.7 l Sun. -t-Z-- TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$50 1000-10,000sq.ft. =$100 more than 10,000sq,ft. =$250 _. .... .......... ......... ... ................................................................ ....................,- RESTAURANT YE NO less than 25 seats .4 25-99 seats more than 99 seats =$200 -................ ------........----..-.--------------------------*... ...-. . .................$10-- ..,---------------- BEDIBREAKFRST YES NO 0 ---------------------------*----------------------------.............. ,,................... .------*----------------------- ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best 4ionature dge and bei ve filed all state tax returns and paid all state taxes required under the law. 11-2$-05 0(-// 7 _q -tr Date Socia! Security or Federal Identification Number ------------------------------------------------ ------ TT AA___--____-_____--____-_____--_-___--_--_-__ Revised 11103105 FOODAP2,adm Check#&Late—�lv— r 'rh ;♦ >..r.arn , ,,.. '"�1YY+'.-w- Y..t"5.,,I,{+ -.I �/ � rY T..rY,w �.ry'rYa +wv .. , , IY .� � r Massachusetts rDepartment of Public Health Salem Board of Health 120 Washington Street,4`h Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name ' Datg Tvpe of 0 eration(s) Tvpe of Inspection I O /Q ��Food Service ❑ Routine Address / S / Risk ❑ Retail )Re-inspection Level ❑ Residential Kitchen -Previous Inspection Telephone / / ❑ Mobile Date: Owner / �F HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) / Time ❑ Bed&Breakfast ❑ General Complaint ^ In: �D.'G El HACCP Inspector Outil, 'ly Permit No. ElOther Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. �,()I 1 -S } / FOOD PROTECTION MANAGEMENT - `-_'+ u'f ym H r/� ,.J r _ _ ❑ 12. Prevention of Contamination from Hands r�, ❑ 1. PIC Assigned/Knowledgeable/Duties ((( EMPLOYEE HEALTH El13. Handwash Facilities PROTECTION FROM CHEMICALS s E] 2. Reporting of Diseases by Food Employee and PIC - -11, - a ❑ 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color A FOOD FROM APPROVED SOURCE - ­_ [:115.Toxic Chemicals ' TIMEITEMPERATURECONTROLS P " ❑ 4. Food and Water from Approved Source (Potentially Haiardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling ". PROTECTION FROM CONTAMINATION El19. Hot and Cold Holding . . : i u 14 El 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices ,,;CONSUMER ADVISORY.= " ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the BoaOfficial Order for Correction: Based on an inspection rd today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc-a)(sso.00s) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-4)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.00s) 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,SMnVwFol -10.tl /",) Inspector's Signature: Print: )^ _ li PIC's Signature:'// _ / Print: / Page / of iPages V P "r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Gross-contamination b 590.003(A) AssirnmentofResponsibility* 3-302-11(A(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge" Cooked and RTE Foods* L2-1 1 l Person in charge-duties - Contamination from Raw Ingredients 3-302A I(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other- , ther2 590.003(1:) ,Responsibility of the person in change to Contamination from the Environment require reporting by foot employees and 3-302.1 I(A) Food Protection* a >licants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Farad Employee Or An 3-304.11 Food Contact with Equipment and ,Applicant To Report'ro The Person fit Utensils" Contamination from the Consumer 590.003(6) Reporting by Person in Char pe* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.0 Y3(D) Exclusions and Restrictions Disposition ofAduiterated or Contaminated 590,003(E) Removal of Exclusions anti Rest efions Food 3-701.1 1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food„ 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501_111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container" Mechanical War'Ferngratings* 3-201.13 Fluid Milk and Milk Products* 4501.112 Mechanical Warewashing-HntWater 3-202.13 Shell Eggs* Sanitization Temperatures,' 3-202.14 _11%s and Milk Products,Pasteurized* 4-501.114 Chemical Stmftimbon-temp.,pH, concentration and hardness. 3-202.16 Ice Made From Potable Drinking Water* 4-601_11(A) Equipment Food Contact Surfaces and 5-101.11 Drhrkin Water from an A roved S•stem* Utensils Clean* 590.006(A) Bottled Drinkin Water* 4-602.1 t Cleaning Frequency of Equipment Food- 59().()()6(B) Water Meets Standards in 310 CMR 22.0" Contact Surfaces and Utensils'" Shellfish and Fish From an Approved Source .T702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water incl 3-207.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* ip Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301 1 i Clean Condition-Hands and Anes" Re ulafo Authorit 3-202.1 S Shellstock Identification Present', T301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals^ LI Good Hygienic Practices _ Receiving/Condition 2-401.11 Eatnrg,Drinking or Usin*Tobacco* 3-202.11 PHFs Received at Proper Temperatures 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity- Mouth* - 3-101.11 Food Safe and Unadulterated* 3-301.12 Prevention Contamination When Tasting* .6 Tags/Records:Shellstock :1.2 Prevention of Contamination from Hands 3-202.13 Shellstock Identification* 590.004(E) Preventing Contamination from Employees* 3-203.12 Shellstock Identification Maintained* Tags/Records:Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and(opacities* acities* 3-002.12 Records.Creation and Retention* Labeling of Ingredients' 590.904(7) 5-204.11 La afron and Placement* 7 Conformance with Approved Procedures 5-205.1.1 Accessibility.Ororationand Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 S eeializedProcessin Methods* Devices 3-5iY2.t2 6-301.11 Handwashi ng Cleanser,Avid lability 8-103.12 Conformance with A. roved Prwedures' 6-301.12 Hand Drying Provision "Denotes critical item in the federal 1999 Fail Code 111 105 CMR 590_000. - MassachusetWDepartment of Public Health Salem Board of Health 120 Washington Street, 4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name I ]� 'r ( Date Tvoe of Operation(s) Tvoe of Inspection Lt I P. ' r,L vJfE f�hT �1 lob OS Food Service [�ioutine Address �% , ,/ Risk ❑ Retail O Re-inspection C tl, t Level ❑ Residential Kitchen Previous Inspection Telephone _ El Mobile Date: ^I�I Owner 1 HACCP WN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Cha ge(PIC) Time El Bad&Breakfast El General Complaint El HACCP Inspector 1 90 Out:( - Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT E] 1. PIC Assigned/Knowledgeable/Duties E] 12. Prevention of Contamination from Hands 'EMPLOYEE HEALTH ' ' ' 4 . m -- ❑ 13. Handwash Facilities . . . . .. . . o. _.s 3, t - ,3 . 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, ' TIME/TEMPERATURECONTROLS P "` - ❑ 4. Food and Water from Approved Source (Potentially Hazaroous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperature es ❑ 6. Tags/Records/Accuracy of Ingredient Statements ,❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans j 18. Cooling ,'PROTECTION FROM CONTAMINATION)' " , , ,"- a 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good.Hygienic Practices CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories _ Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board of Health. today, the items checked indicate violations of 105 CMR G R-7 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an _ 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: ^ rQC a OOj sssamspecrFoms-,a.ex 1 r� Inspector's Signature: Print: O PIC's Signature: / Print: ld /fit (- U V Pagel of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Gross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Annual Foods Separated from 590.003(B) Demonstration of KIlOwled c* Cooked and RTE Foods* 2-103.11 Person in charge--duties Contamination fromr Raw ingredients 3-302-11(A)(2) Raw Animal Foals Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Veeetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11. Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590,003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition ofAdulteratedorContaminated 590.003(E) Removal of Exl"ItiSiOn9 and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources F9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.1.11 Manual Warewashmg-Rot Water 3-201.12 food in a Hermetically Sealed Container* Sanitization'Fcameratures' 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Hot Water 3-202.13 Shell Ea s* Sanitization Tem erah¢es* 3-202.1.4 E<I gs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinkin-Water* concentration and hardness. 5-101.1.i DrinkingWater from an Approved Svstem* 4-601.,11(A) Equipment Food Contact Surfaces and Utensils Clean, 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency ol'EquipmentFcxtd- 590.006(B) Water Meets Standards in CMR 22Contact Surfaces and Utensils* Shellfish and Fish From an Approved oved Sourccee 4-702.1 1 Food ocy of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed r Chemical 10 Proper,Adequate Handwashing Re u Re and Wild Mushrooms Approved 0y 2-301.11 Clean Condition-Hands and Awns* e lafo Atrthorit 3-202.18 Shellstock.Identification Present* 2-301.12 Cleaning Procedure* 590.004(0 Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eatin ,Drinking or Usin Tobacco* 3-202.11 PI-IFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 7202.15 Package Integrity* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting"' 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Ent to•ees* TagslRecords:Fish Products 13 Handwash Facilities 3A02.11 Parasite Destruction* Convenienry 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 5-205.11 Accessibility.Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.1112 Hand Dr inR Provision S ecialized Processing Methods* Devices 3-S criteria-- 6-301.11 Handwashin - Cleanser Availability 9-103.12 oxygen packaging,w 8-103.12 Conformance with Ai roved procedures*oczdures* 6-301. °Denblrs critical item in the tedertl 199q fond Cwle or 105 CMIt 590.000. CITY OF SALEM L BOARD OF HEALTH. � Establishment Name: I t 'C� T tT�tcF �� �y Date: 1,2 OT Page: a— of Item Code C-Critical Item - DESCRIPTION OF VIOLATION/PLAN OF CORRECTION - Date No. Reference R—Red Item Verified r {� PLEASE PRINT CLEARLY C 1 / r r My �� i 'C4 C.1L1. A n0-9-le O �. A f- C7 AJ ce r � a-("52 N L-i7 e O Q. ,/1G l� ��f� t 0 vl , re ' SSI e. I 0\1 AO I e �A � 7 S ✓i � r , f ! I �/f• // ��✓, P r - r r S k a 7 I nC v; Id-1 /e01 7 IC/111 P dO Ste- nll V1)t �QQ /fr I t itr Ai .i l ACG _i`I, r &Afx�lti(inr X Sans 41 7O Discussion With Person in Charge: Corrective Action Required: ❑ No Yes .k I have read this report, have had the opportunity to ask questions and agree to correct all ° v untary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P Re-inspection Scheduled Ll Suspension Zi comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of tw7;� dollars or suspension/revocation of 11 Embargo ❑ Emergency Closure` your food permit. / ❑ Voluntary Disposal, ❑ Other �, :�f• +r 3-501,14(C) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to law Cooled to Factors(items 1-22) (Cont.) 41".F745°F Within 4 Houes. PROTECTION FROM CHEMICALS 3-501.15 CaolintrMethods for PHFs 14 Food or Color Additives 19 PHF Hat and Gold Holding -"" 3-50'1.16(B) Cold PHFs Maintained at or below 1. 3 202.12 Ad sectio* 590.0�(F) 41"/45° 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 Ictentityine,Information-OrSginal 3-501.1.6(A) Roasts Held at or above 130`E Containers* 7-10211 Common Name-Working Containers* 20 Time as a Public Health Control 71-01.11 Sepal ticlon-Storaze* 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 Ilse* 7-203.11 Toxic Containers-Prohibitions REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11. Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washine Produce,Criteria* 21 3-801.'11(A) Unpasteurized Pre-packaged Juices and 7-204.14Dmg Agents,(.utero* Beveraees with k u nine,Labels' 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Bets* * 3-801.1.1.(D) Raw or Partially Cooked Animal Foul and 7-206.1 1 Restricted Use Pesticides,CrSteria Raw Seed Sprouts Not Served. .r 7-206.12 1 Rodent Bait Stations- 3-801.1 I(C Un t et5ed F65d Package ' 7-206.13 ']`racking Powders,Pest Control and ) < tNot Re-served. Monitoring* CONSUMER ADVISORY TIMEiTEMPERATURE CONTROLS 22 3603.11 Consumer Advisory Posted for Consumption of Animal Fouls"that are Raw, Undercooked or PHFs a6 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate 3-401.1 lA(ll(.2) Eggs- 155'F 1.5 See. Pathogens.*e"'"'0" Eggs-Immediate Service 1450F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Mears&Game Eggs* Animals- 155'F 15 sec. 3-401.tl(B)('i)(2) Pork and Beef Roast--130'F 1.21 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game, Stuffed P1 residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165"T 15 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 3-401.12 Raw Animal Fouls Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-4014I(A)(O(b) All Other PHFs - 145'F 15 sec. *, 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-t03.11(A)Rt(D) PHFs 165°P 15 sea. * (,Items 23-30) 3-403.11.(B) Microwave- 165°F 2 Minute Standins Critical and non-critical violations, which do not relate to the Time* foodborne,illness interventions and risk factors listed above, can be 3-403.1.1(C) Commercially Processed RTE Food- ,found in the failowing sections of the Food Code and 105 CMR 140'F* 590.000, 3-403.11(ri) Remaining Unsliced Portions of Beef 'tem Good Retail Practices FC 580.000 Roasts* 23. Mane ement and PersonnelFC 2 .003 18 Proper Cooling of PHFs 24,--- Food and Food Protection _ FC-3 .004 25, menl and U _ 4 3-501..14(A) Coobng Cooked PHEquip tensils FC Fs from 140'F to 00 26 Water, umn and Waste PlbiFC-5 005 701-'Within 2 Hou1s and From 70'F 27. Physical Facility FC-6 M-7 to 41'7/45`15 Withinr4 Hours. * 28. Poisonous or Toxic Materials FC--7 .008 - 3-501.14(B) Cooling PHFs Made From Ambient 29. S eeial Re uirements _ I .009 Temperature Ingredients to 41017/45'F 30___Other ( _ _ Within 4 Hours* *'Dlnl,Ales critical item in the tuleral 1999 Food Code or 105 C p1'R 590-000. CITY OF SALEM BOARD OFF HEALTH Establishment Name: Ilei L?c (, -r Date: L7 Page: 3 of Item Code C-Critical Item - DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date _ � No. Reference R–Red Item Verified f f\ PLEASE PRINT CLEARLY i -IL ` A bn1 •7 - C 7 Y Op 'VA r ar • CU In �v reC(f o1(iS gS71 M /7 Gr7J ✓1 �4 cr - vj - G [1 Kkk,6 RAJ 2', ^tom (2 lo_"r n 4 1p—. S \ C �/ ^ J LIZ z I ' Q - U 16Ar 7t 4p S (/ rt " � SrYIC. f Discussion With Person in Charge: Corrective Action Required: ❑ No Ur Yes ❑ voluntary I have read this report, have had the opportunity to ask questions and agree to correct all Compliance ❑ Employee Restriction/ Exclusion Ff violations before the next inspection, to observe all conditions as described, and t0 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 coorrr suspension/revocation of ❑ Embargo ElEmergency Closure € your food permit. ❑ Voluntary C !/ Disposal `� 3 0 Other: 3-50i.14(t:) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) _ 41°Fi /45`P Within 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 1=414 19 Food or Color Additives PHF Hot and Cold Holding 3-202.12 Additives' 3-501.16(B) Cold PHFs Maintained at or below 590.004(F) 41°/45° F* ?-302.14 Protection Prom Una r roved Additives* 3-501.16(A) Hot PHFs Maintained at or above I5" Poisonous or Toxic Substances - t40"F " 7-101.11 Identtiying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Contaiucrs" 7-102.11 Common Name-Workln0 Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage" 3-501.19 Time as a Public Health Control* 7-20111 Restriction-Presence and Use'' 590.004(9) Variance Requirement 7-202.12 Conditions of Use* 7-20311 Toxic Containers-Prohibitions'' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanmcers,Criter is-Chemicals' POPULATIONS(HSP) 7-204.12 Chenucals for Washing Produce,Criteria" 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning I,.abels* 7-204.14 Drm r ents,Crtteua` 3-801.11(B) Use of Pasteurized E= s* 7-205.11 Incidental Food Contact.Lubricants* 7-206.11 Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or Pmtizflly Caikad Animal Faxl and Raw Seed Sprouts Not Served.'* 7-206.12 Rodent Bait Stations"` 3-801.11(C) Unopened FWd Package Not Re-served, 7-206.13 Tracking Powders,Fest Control and CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Fails'That are Raw.Undercooked dr 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.1.1 A(1)(2) Eggs- 155'F 15 Sec. Paths ens """ "/"Pool E "s-lmmedt ne Service 145°PlSsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(tl)(2) Comminuted Fish,Meats 8-,Game Eggs* Animals- 155°F 15 sec.* 3-401.11(B)(1)(2) Pork and Beef Roast-13WF 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 sem, * catering, mobile food,temporary and 3-401.1i(A)(3) Poultry,Wild Came, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry er Ratites-165or 15 sec. * above if related to foodborne illness 3-401A 1(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk:factors. Other 145,E* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Micruwave 165`F* Special Requirements. _ 3-401.11(A)(1)(b) All Other PHFs -145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165`F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time" foodborne illness insetvention.s and risk factors listed above, can be t 3-401 11(C) Commercially Processed RTE Fail- found in the following sections of the Food Code and 105 CMR , 140°F`s 590.000. 3-403.1 I(E) Remaining Unsliced Portions of Beef Item 1Good Retail_Practices � FC 590.000 Roasts* ' 23. - [-Manaslement and Personnel _ _ FC-2 .043 18 Proper Cooling of PHFs 24. Food and Food Protection _ _ FC-3 O(Y. 25 Equipment and Utensils FC 4 .005 :1-501..14(A) Coolhtg Cooked PHFs from 140°F to 26 Water, Plumbin and Wasie FC 5 . .006__ 70°F Within 2 Hours and From 70'F 27. Ph sisal Facili FC-6; .pp7 to 4PF(45°F Within 4 Hours. * 28. Poisonous or Toxic Materials_ _ FC-7 1 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements _ .009 Temperature ingredients to 4lor/45°17 30 __._.Other __ -------„,,,,,,,,,,,,,,,,-__ Within 4llours* ss�ommnaeezuo� *Deholes critical item in the federal 1999 Mood Code or 105 CMR 590P00. t. 1 F T 0096 North Street Leslies Retreat Grub & Pub City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE REINSPECTION Inspection HACCP: ❑ Telephone Item Status Violation Critical Urgency Nature of problem or correction .744-9495 Non-compliance with: Not Done Owner: Anti-Choking PASS ❑ Yukers Bright Spot Inc. Tobacco PASS ❑ PIC:' w Michael CIUke FOOD PROTECTION MANAGEMENT Not Done y= - w� PIC Assigned/Knowledgeable/Duties PASS RED Inspector: David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 9/15/2005 - - Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level:' `= r 'FOOD FROM APPROVED SOURCE Not Done Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2005-0085 �' Receiving/Condition PASS RED Status: Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNED OFF N Conformance with Approved Procedures/HACCP PASS ❑d RED #of Critical Violations Plans 1 PROTECTION FROM CONTAMINATION Not Done Time IN: Time OUT: Separation/Segregation/Protection PASS ❑o RED Notes: Food Contact Surfaces Cleaning and Sanitizing PASS ❑Q RED 297. Proper Adequate Handwashing PASS ❑d RED Urgency Description(s): Good Hygienic Practices PASSd❑ RED BLUE: 1 ( Prevention of Contamination from Hands PASSd❑ RED Violations Related to Good a Retail Practices (Critical' Handwash Facilities PASSd❑ RED violations must be corrected immediately or within 10 days)(Non-critical violations.. GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 16,2005 ) Page 1 of t 0096 North Street Leslies Retreat Grub & Pub must be corrected Immediately PROTECTION FROM CHEMICALS Not Done or within 90 days) Approved Food or Color Additives PASS RED RED: Violations Related to Toxic Chemicals PASS RED Foodborne Illness Interventions TIMEITEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASSd❑ RED immediate corrective action) Reheating PASSd❑ RED Cooling PASSd❑ RED Hot and Cold Holding FAIL Critical 0 RED The beer/produce walkin had a temperature of 46°F. Repair unit to maintain a temperature of 41°F or below. The dessert cooling unit has a temperature of 50°F. Repair unit to maintain a temperature of 41°F or below. Time As a Public Health Control PASS ❑d RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories PASS RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection PASS ❑ BLUE Equipment and Utensils FAIL Non-Critical ❑ BLUE The Ansul system needs to be professionally cleaned. Cleaning is sceduled for the end of September. Owner will notify the Board of Health when cleaning has taken place. 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 GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 16,2005 ) PaQe 2 o{3 I 0096 North Street Leslies Retreat Grub & Pub GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 16,2005 ) Page 3 of 0096 North Street Leslies Retreat Grub & Pub City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Telephone: . Item Status Violation Critical Urgency Nature of problem or correction 744-9495, Non-compliance with: Not Done :Owner: _ Anti-Choking PASS ❑ Yukers Bright Spot Inca Tobacco PASS ❑ PIC FOOD PROTECTION MANAGEMENT Not Done Michael ClUkey Michael PIC Assigned/Knowledgeable/Duties PASS ❑J RED Inspecto David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED .9/8/2005 ': 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-2005-0085 Receiving/Condition PASS ❑d RED Status: - Tags/Records/Accuracy of Ingredient Statements PASS ❑J RED VIOLATION #Of CfIYIC81 VIOIatIOnS - �- Conformance with Approved Procedures/HACCP PASS J❑ RED Plans 3 Time IN: Time OUT: Notes: 283:Reinspection in one week. All Items to be corrected. Urgency Description(s) A BLUE: Violations Related to Good Retail Practices (Critical"; violations'must be corrected immediately or within 10 . GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 08,2005 ) Page I of 0096 North Street Leslies Retreat Grub & Pub days)(Non-critical violations PROTECTION FROM CONTAMINATION Not Done must be corrected immediately, Separation/Segregation/Protection PASS RED or within 90 days) � RED: °' � >: Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑� RED /scored. cutting boards are stained and Violations Related to /scored. Resurface or replace the cutting �. boards. Foodborne Illness Interventions Them slicer has an accumulation of and Risk Factors (Require fo debris. Thoroughly clean and sanitize immediate corrective action) a meat slicer. Proper Adequate Handwashing PASS ❑d RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS ❑J RED Handwash Facilities PASS ❑d RED NOT Dedicate one bay in the 3 bay sink `a handwashing sink. PROTECTION FROM CHEMICALS Not Done Approved Food or Color Additives PASS ❑d RED Toxic Chemicals PASS RED TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done Cooking Temperatures PASS ❑d. RED Reheating PASS RED Cooling PASS 0 RED Hot and Cold Holding FAIL Critical ❑ RED �,e The beer/produce walkin in the basement has a temperature of 48°F. Repair unit to maintain a temperature of 41'F or below. aThe dessert cooling unit in the kitchen has a temperature of 587. Repair unit to maintain a temperature of 41°F or below. Time As a Public Health Control PASS 0 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 FAIL Non-CriticalJ❑ RED VProvide a consumer advisory regarding the consumption of raw or undercooked foods. *Information regarding the advisory given at time of inspection. GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 08,2005 ) PaQe 2 of rOO96orth Street Leslies Retreat Grub & Pub Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE vere is food stored directly on the floor of oth the beer/produce walkin and dry storage. All food must be kept at least 6-8 inches off the floor. Equipment and Utensils FAIL Non-Critical ❑ BLUE ,��interior panel of the ice machine has van accumulation of grime. Thoroughly clean and sanitize the ice machine. Howard walkin in the basement has an cumulation of food debris on the floor. horoughly clean the floor including under --*,Xe yal(lleacks. Sharp microwave in the basement needs a thorough cleaning. e sides of the griddle is encrusted in rease. Thoroughly clean the sides of tje Nddle. e Sta-Kold cooling unit needs a thorough cleaning. . The Ansuk system needs to be professionally cleaned. canopener needs a thorough scouring. e ice cream freezer in the kitchen needs a thorough cleaning. ._r he shelving where the plates are stored eeds to be thoroughly cleaned. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non-Critical ❑ BLUE dere are open spaces in the kitchen ceiling. Replace all missing ceiling tiles in Vth kitchen. pair the back screen door to close and eal tightly. Provide a sweep at the bottom of the doors. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE 4IOTE: Provide several spray bottles of sanitizer in the cookline. GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 08,2005 ) Pave 3 of 0096 North Street Leslies Retreat Grub & Pub GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 08,2005 ) Page 4 of �" mY X ..4 zTY...{' e.r"C;." ,..ic?::r�...s,{..N wai wn ,"° .+ 1L ».,iJ39•.a',TSy,�" "` "Z'wdPa.> i' `" ' . +" t'z^�.r.�.� a..:+,... CITY OF SALEM9 MASSACHUSETTS 5 ' Q-S��Ww - BOARD OF HEALTH -. . 120 WASHINGTON STREET, 4TH FLOOR 1 SALEM, MA 01970 TEL. -741-1800 FAX 97878-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Leslies Retreat Grub & Pub Address of Establishment: 96 North Street Owner's Name: Claire Chalifour Restrictions: Application Date: 11/18/04 Permit for Food Establishment 28-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, orequipment chan es are made, all plans for such must be P9 submitted to and approved by the Salem Board of Health. Vx-o- t� 'N tc-�i(-- HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH b n 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT YUKERS BRIGHT SPOT INC . TEL# D . A LESLIES RETREAT GRUB & PUB ADDRESS OF ESTABLISHMENT 6 NORTH ST . SALEM, MA , 01970 MAILING ADDRESS (if different) OWNER'S NAME Claire D. Chalifour TEL#978 745 5745 ADDRESS 96 North St . CITY Salem, Ma. STATE Ma . ZIP01970 CERTIFIED FOOD MANAGER'SNAME(S) Clsire Chalifour CERTIFICATE#(s) Michel Clukey 714156 (required in an establishment where potentially hazardous food is prepared.) Gell Z Claire Chalifour 978 745 5745 q7Y 4j° EMERGENCY RESPONSE PERSON Michel C lukey HOME TEL# 978 744 _8138 Ce-, 97Y-3 fr VfS HOURS OF OPERATION: Mon. X Tues-1 Wed.7-1 Thu. 7-1 Fri.7-1 Sat. 7-1 Sun.7-2P•M TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 .5 more than 10,000sq.ft. =$250 RESTAURANT 9YE NO less than'25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my besyk ledg d b ii f ave ile I1st to tax returns and paid all state taxes required under the law. 041-997-455 Signature Date,,/17�O&ocial Security or Federal Identification Number ------------------------------- ------------= ----------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date -61 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 3 ® 120 WASHINGTON STREET, 4TH FLOOR f SALEM, MA 01970 TEL. 978-741-1800 ' FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Leslies Retreat Grub & Pub Address of Establishment: 96 North Street Owner's Name: Claire Chalifour Restrictions: Application Date: 12/4/2003 Permit for Food Establishment 148-04 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. HEALTHGES N u CITY OF SALEM, MASSACHUSETTS ' v� BOARD OF HEALTH 3 • 120 WASHINGTON STREET, 4TH FLOOR a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT�O OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ro�C�GGe A77�61.1 12 id EL# q 7 �n7YL/ 4r p ADDRESS OF ESTABLISHMENT CT_ MAILING ADDRESS (if different) 11 l OWNER'SNAME 0gtihLRL 2k1I ll�c�W� TEL# Z Z S"J�7ys ADDRESS 1 4 I l L,9Z r5_T_ CITY A- STATE /V-1 ZIP oI rt ?v CERTIFIED FOOD MANAGER'S NAME(SF_4,, e ( k._V(- CERTIFICATE#(s) -71 I (required in an establishment where potentially ly hYLIV'rrdoo�us food is prepared.) 1 EMERGENCY RESPONSE PERSON M\eA r_P 1 HOME TEL# 91 Y 7 4 N HOURS OF OPERATION: Mon. LoSIlue.1 Wed.�_Thu. 7_1'r Fri.7+^ Sat. a- Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 1 0,000sq.ft. =$250 RESTAURANT ES NO 0 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES N $50 ALL NON-PROFIT(such as church kitchens) YES $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my be wle eief, afiled all state tax returns and paid all state t xes required under the law. �i. f.�fi / -3-rtigy3 G'�l -977 �fS nature Date Social Security or Federal Identification Number ----------------------------------------------------------------/---------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date �fSa — Salem Board of Health Massachusetts Department of Public Health 120 Washington Street,4�' Floor Division of Food and Drugs Salem,MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978)745-0343 Name Date Type of Operation(s) Type of inspection '5- f �T/tv ?Food Service ❑ Routine Address Risk ❑ Retail taRe-inspection O Level ❑ Residential Kitchen Previous Inspection Telephone A ❑ Mobile Date: HACCP Y/N E-1Temporary ElPre-operation Owner l tF r1� C3 Caterer (] Suspect Illness Person in Charge(PIC} Time ❑ Bed&Breakfast El General Complaint /Xt- eecjed El HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 59o.o09(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13,Handwash Facilities EMPLOYEE HEALTH - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE. TIMEtTEMPERATURE CONTROLS(Potentially Hazardous Foods). ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18, Cooling PROTECTION FROM CONTAMINATION [119. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ., ._. ❑ 11. Good Hygienic Practices ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions d' immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N ` by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Faod and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 28. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address j 29, Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 9.-5 InVwrofm-14tl Inspector's Signature: ' Print: !! YIC's Signature:/ Print: �� �C / Pagel of Pages i Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT R Cross-contarination 1 590,003(A) Assignment of Responttbthty" 3-102.11.(A)(1) Raw Animal Foods Separated fi'am 590.003(B) Demonstration of Knowledge* Cooked unit RTE Foods* Ll-103 11 Person in cha ge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Otber* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1 t(A) I Food Protrxtion* a licants* 3-30215 Washing Fruits and Vegetables 59(ww(F) Responsibility Of AFood EmployeeOrAn 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(1)) Exclusions and Restrictions" Disposition ofAdukerated or Contaminated 590.003(E) Removal.of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCEFood* 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 590.004(A B) Compliance with Food Law* 4-501.111 Manual Warewashing- Hot Wates 3-20112 Food in a Hermetically Sealed Container* Sanitization rem eratures* 3-201.13 Fluid Milk and Mill:Products* 4-501.112 ivlechanicl Warewashing-Hot Water 3-20213 Shell Eggs* Sanitization Temteramres* 3-202.14 E=*s and Milk Products.Pasteurized" 4-507.114 Chemical Sanitization-temp.,pH, 3-202.16 Icc Made FromPotable Drinking Witterconcentration and huchicss * " 5-1.01.11 Drinking Witter from an Approved System* 4-601-'1l(A) Equipment Frxxi Contact Surfaces and Utensils Clean' 590.006(A) Bottled Drinking Water* 4-602.11. Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 31.0 CMR 220* Contact Surfaces and Utensls* Shellfish and Fish From an Approved Source 4-702,11 Frequency of Sanitization of Utensils and :3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui ment* Shellfish* 4-703.11 Methotis of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2301.11 Clean Condinon--Hands and Arens* 3-202.15 Shellstock Identification Present"' 2-301.12 Cleaning Procedure* 590.004(C) Wild Muslacoms* 2-301.14 When to Wash" 3-201.17 Game Animals* 1t Good Hygienic Practices 5 Receiving/Condition 2-_401.11 Eatin , Drinkin orUsin>Tabacco* 3 202.11 PHFs Raceived at Pro rer Tem reratures* 2-401.12 Discharges Frorn the Eyes.Now and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* fi Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202,15 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* l.nt 1p res'" Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 ,Parasite Destruction* Conveniently Located and Accessible 5-203.11 Numbers and 3-402.12 Records.Creation and Retention* mens*t* 590.004(.l) Labeling of Ingredients' S-20<t.l t Location turd Pllaacemen 7 Conformance with Approved Procedures 5-205.1.1 Accessibilit , O eration and Maintenance MACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processin>Methods* Devices 3-502.12 Reduced oxygen 1acka<dn ,criteria* 6-301.11 Ilandwashiug Cleanser.Availability v ' rv• icedures* tr301.12 Hand Drying Pcotiision 8-103.12 Conformance vtthA>>r< e.dPu "Denotes critical rent in the federal 1999 Food(lode or 105 CMR 590.060. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: /11-46/sy Page: Z of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY t£tli✓ cu�t �zr� P CONK t a� t Discussion With Person in Charge: Corrective Action Required: ❑ No o Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P ❑ Re-inspection Scheduled ❑ Emergency Suspension 1 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 13 Emergency closure your food permit. C3Voluntary Disposal 0 Other: 3-501-14(C) PHFs Received at"Temperatures Violations Related to Foodborne Illness Interventions and Risk According to 1xiw Cooled to Factors(Items 4-22) (Cont.) 41°F/45;F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 9 PHF Hot and Cold Holding k 3-501.16(B) Cold PIIFs Maintained at or below 3-20114 Aotecti s' 590.004(F) 4P/45° F- 15 f;,o coon from Unapproved Additives* '_i-501.16(A) Hot PHFs Maintained at or above i$ Poisonous or Toxic Substances 140'F. * 7-101.11 Identifying 1'nfonnation-Ocigina( 3-501.16(A) Roasts Held at or above I30-F. Containers'" 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Se <'uation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(Ii) Valiance Requirement 7-202.12 Conditions of Use•" 7-203.11 Toxic Containers-Probibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanlnzers,Criteria-Chemi als POPULATIONS(HSP) 7-204.12 Chemicals for Washm�Produce,Criteria* 2'i - 01.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Dain Agents.Criteria" Beverages with Warning labels* 7-205.11 Incidental Food Contact,Lubricants" 3-801..11(B) Use of Pasteurized EI,, 7-206-1 l Restricted Use Pesticides.Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.'t 7=206.12 Rodent Bait Stations" 3-80t.I l(C) Unopened Food PackaLt Not Re-served. 7-206.13 Tracking Powders,Pest Control and Momtorina* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 V 3-603-.11 Consumer Advisory Posted for Consumption of Animal Foods'1'hat are Raw.Undercooked or I6 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.1IA(1)(2) Fogs- 155 F 1.5 Sec. Pi tho Tens en cAv r nanm E E rs-'hnmediate Service 145'Fl 5see* 3-302.13 Pasteurimcl Eggs Substitute for Raw Shell 3-401.11.(A)(2) Comminuted Fish, Meats&Game E s* Animals-155°F 15 sea 3-401.11(B)(1)(2) Pork and Beef Roast - 130°F 121 rnrn* 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 3-401.1 I(A)(3) Poultry, Wild Game,StuffedP[IFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-]65°F 15 sec. above if related to foodborne illness 3-401.1 l(C)(3) Whole-masele,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)(I}(b) All Other PHFs --145°F 15 sec 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 7403.11(A)&@) PHFs 165°F 15 sec. * (Sterns 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403 11(C) Commercially Processed RTE Food found in the following sections of the Food Cade and 10.5 CMR 140°6'* 590.000. 3-403.I.1(E) Remaining Unsliced Portions of Beef Item Good Retail Practices _ _ _FC 590.600 23. Management and Personnel FC-2 _.003 _1 Roa.,ts" ---.- IS Proper Cooling of PHFs 24. Food and Food Protection _- FC-3 .004 25 E uipment and Utensils FC_4 .005 3-501.14(tl) Cooling Cooked PHFs from 14WE to g 26 Water, Plurnbin and Waste 70"F Wit hin 2 Hours and From 70°F 27. -Physical Facility FC-6 .007 -- to 41°FI45"F Within 4 Hours. ` 28. Poisonous--or Toxic Materlais _ FC-7 .008 3-501.14(6) Cooling PHFs Made From Ambient 29. 5 ecial R ulremeints .009 Temperature ingredients to 41°F/45°F 30. ____ Other Within 4 Hours'., 15114r ,nlds2'd" "'Denotes critical item in tae raloal 1994 Food Code or 105 CMR 590.000. Sal Massachusetts Department of Public Health 120 W Board SHealth M 720 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tei. (978)741-1800 Fax(978) 745-0343 Name Date 'f / T €of O eration,� T of Ins ction Ld xu r Q� �I>Br 6Ru /'. 44YO5� Food Service ORoutine Address Risk ❑ Retail ❑ Re-inspection 91 Level ❑ Residential Kitchen Previous Inspection Telephonefit( ❑ Mobile Date: -7H'1`9W9� ❑ Temporary ❑ Pre-operation OwnerC s HACCP Y1N ❑ Caterer ❑Suspect Illness Person in Charge(PIC)-G Time ❑ Bed&Breakfast El General Complaint In: ❑ HACCP Inspectorp rP N Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC [114,Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15,Toxic Chemicals FOOD FROM APPROVED SOURCE - TIME(TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION - ❑ 19. Hot and Cold Holding ❑ 8i eparation/Segregation/Protection ❑20.Time As a Public Health Control JZ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(MSP) ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY , ❑ 11. Good Hygienic Practices ❑22. Pasting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report,when signed below 'C _N__1 by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.o04) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S'S901nspecHorm610.0oc Inspector's Signatur - Print: PIC's Signature: �, Print: Page-/ ofPages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contar'nination 1 590.003(A) Assignment of Responsibility* 3-302.11.(A)(1) Raw Animal Fads Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTF Foods* 2-1.03.11 Person in charge- duties Contamination from Raw ingredients 3-30111.(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other` 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require rcporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Wxshin,Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.1.1 Food Contact with Equipment and Applicant To Report To The Person hi Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting bPerson in Charge* 3-306.14(A)(B) Returned Food and Rewrvice of Food* 31 590.003(D) Exclusions and Restrictions" Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Ulisafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources BE Food Contact Surfaces 590.004 A-B) Com Bance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Tcm erannes* 3-20]13 Fluid Milk and Milk Produc s* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13Shell Eg s* Sanitization Temperatures* _ 3-203.14 Eggs and Milk Products.Pasteurized" 4-501_]14 Chemical Sanitization-temp.,pFl, concentration and hardness. * 3-202.16 Ice Made From Potable Drinkin Water* 5-101.11 Drinking Water from an A roved System* `1-6011 I(A) Equipment Fad Contact Sarfaces and Utensils Clean' 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006($) WaterMeets Standards in 310 CMR 220* Contact Surfaces and Utensils" Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-20t.14 Fishand RecreationallyCaught Molluscan Food Contact Surf ices ofF-uinneral Shellfish's 4-703.11 Methods of Sanitization-Hot Water and 3-20115 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Came and Wild Mushrooms Approved by Regulatory Authority 2-30L 11 Clean ConditionHandsand Arms* Urania,Procedure*301 2- .12 Ur 3-202.18 Shellstock Identification Present"' .,..._�_..,.._�_.. 590.004(C) Wild Mushrooms* 2-301.14 When to WaS114= 3-201..17 Game Anunals"' 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eatin ,Drinking or Ushre Tobacco, 3-202.11 PHFs Received at Proper Tem peratures* 2-30112 Discharges From the Eyes.Nose.and 3-202.15 Paekage Inte it'"` Month* 3-101.11 Fad Safe and Unadulterated * 3-301.12 Preventinzz Contamination When Tasting* 12 Prevention of Contamination from Hands 6 Tags/Records:Shellstock s90.004(E) Preveming Contaminadon from 3-202.18 Shellstock identification* e 3-203.12 Shellstock Identification Maintained" Em Flo gees* TagslRecords:Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3=102.11 Pat asiteDestruction* 3-40212 Records.Creation and Retention* 5.2Numbers and addles* 590.004(7) Labeling of Ingredients" 5-2203.11 04.11 Location acid PlacemeaY* 7 Conformance with Approved Procedures 5-205.11 Accessibility,O erasion and Maintenance /HACCP Pians Supplied with Soap and Hand Drying 3-5102.11S ecialized Processin,Methods- Devices 3-502.12 Reduced ox sten ackamug,criteria'" 6-301.11 llandwashina Cleanser. Availability 8-103.12 Conformance with Approved Procedures* 6-301.72 Hand Dryin=Provision Uenota9 ecitical 91xan in the federal 1999 ptxd Codc or 10504R 590.000. S CITY OF SALEM 3 BOARD OF HEALTH Establishment Name: t,&.rt/!f S R-&"44'- AXAT4 Date: /2�f� v Page: 2 of i Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified .PLEASE PRINT CLEARLY to W /n1 /d►414&w rfj P-dal A4-0- dde J1 r 2 r; /fv a IM Al- r 96 drr K-Cdd dN0 A4 v /!`r 5 efd p re- 2l+' � d A Y U /hOt' rtN tti✓�1 v d rt! S. .l-�.r�'7.dK. IDiLBU sL - 1.1&,r rry sAa of d YWAr.Pw &KF` t G�ePd s lia C t a A.4 6&4 ,n/ ,/i r4�P ZSR 0 fZty 9&* 2.Ic`� I`� G h.►?i� �r��-' I'e,�dJByt C.t.cSnrt+! Discussion With Person in Charge: Corrective Action Required: -❑ No ❑ Yes t I have read this report, have had the opportunity to ask questions and agree to correct all 13 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 dol ar or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 13 Voluntary Disposal ❑ Other: 3-503,I4(C) PHFs Received.at'Temperatures Violations Related to Foodborne Illness Interventions and Risk According to how Cooled to Factors(items 1-22) (Cont.) 4t017I45'F Witbia 4 Hours. " PROTECTION FROM CHEMICALS 3-501.15 Cooling Metbods for PHFs 14 Food or Calor Additives I9 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or beton- 3-202.32 Addtuion 590.004(F) 41`145° F` 3-302.14 Poisonou from txic Substances Additives* 3-501.16(A) 11ot PHFs Maintained at or above Ig Poisonous or Toxic Substances 14WK 7101.1 l Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F.x Containers" 7-1.02.11 Common Name-Working Containers'* 20 Time as a Public Health Control 7-201.11 Separation-Stora e* 3-501.19 Time as a Public Health Control* 7-202.t Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Ilse* 7-203.1.1 Toxic Containers-Prohibitions REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sattitlzers,Criteria-Chemicals°' POPULATIONS(HSP) 7.204.12 C:benucals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning labels- 7-204.14 Drviu Agents,Criteria'" 3-801.11 B Use of Pasteurized E s' 7-205.11 Incidental Food Contact-I abricants* ) gg 7-206.11 Restricted Use Pesticides.Criteria* 3-801.1 t(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served. 7-206.12 TraRodci Bait dens, e 3-801.11(0 Unopened Food Packa>e 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 Animal Foods That are Raw. Undercooked or 1fi Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.1 IA(l)(2) Eggs- 155F 15 Sec. PathO�cI1S''ena�n�e�n�ooi b rs�s-Inune<batc Service 145°F75sec' 3-302.13 Pasteurized Eggs Substitute for Raw She11 3-401.,11(A)(2) Comminuted Fish,Meats&Came E> s* Animals- 155°F 15 sec. r 3-001.11(13)(1)(2) Pork and Beef Roast- IffF 121 min* SPECIAL REQUIREMENTS 9-401.11(A)(2) Ratites;Injected Meats-155°F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.„ catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165"17 15 sec.+' above if related to foodborne illness 31401A 1(C)(3) Whole-muscle,Huact Beef Steaks interventions and risk factors. Other l45°F* 590.009 violations relating to good retail 3401.12 Rate Animal Foods Cooked in a practices should be debited under 9Y'9- Micmwave 165`F* Special Requirements. 3401.11(A)(I)(h) All Other PHFs- 1.45°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165F 15 sec.x (Itenes 23-30) 3-40111(B) Microwave-165°F 2 Marne Standins Critical acid non-critical violations, which do not relate to the Time* foodborne illness interventions and risk fiwto s listed above, eon be 3-403.11(C) Commercially Processed RTE Food- ,found in the following sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remafuing Unsiiced Portions of Beef Item Good Retail Practices FC 580.000 Roasts" 23. Mani ement and Personnel _ FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection _ FC-3 .004 25. ___ Eclui ment and Utensils FC 4 .005 3-501..14(<A) Cooling Cooked PHFs from 1.40`F to 26 Water,Plumbing and Waste FC5-t .006 70°F Within 2 Hours and From 70'F 27. Ph sical Facility _ FC-6 .007 to 41"F745°F Within 4 How's. * 28. Poisonous or Toxic Materials __ FC-7 .008 3-501.14(13) Cooling PHFs Made From Ambient 29_ Special Requirements .009 Temperature btgredients to 41°F/45°F 30 Other Within 4 Hours* sssorn,�.,nees-a.un� °Denotes critical item in tha rcderai 1999 Food Code or 105 CNIR 590900. CITY OF SALEM BOARD OF HEALTH t Establishment Name: Ldr4 gal Date: 4-y-_ Page:_ of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified - PLEASE PRINT CLEARLY 74 f4ttf OA/ ' r Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twee,y-fiv dol ars of suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. / f/ ❑ Voluntary Disposal ❑ Other: r 3-501.H(C) PRFsReceived-atTemperatures Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to Factors(items 1-22) (Cont.) 4l'F/4S'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cool ng Methods for PHF1 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 AddiBves" 3-501,16(13) Cold P1Ifes iMaintained at or below 590.004(F) 4P/45°F* 3-302.14 Protectant from Ihta t roved Additives* 3-501.16(A) Hot PHFs Maintained at or above 1.5 Poisonous or Toxic Substances 40°F. * 7-101..11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers" 7-102.11 Common Name--Working Containers* 20 Time as a Public Health Control 7-201.11 Sete ration-Storage* 3-501.19 Time as e Public Health Control* 7-202.11 Restriction-Presence and rise* 590.004(H) Vari:mce Requirement 7-202.12 Conditions of Use` 7-203.11 Toxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.71. Smtitizers,Criteria-Chemicals* POPULATIONS(HSP 7-204-.2 Chemicals lot Washing Produce,Criteria" 2Y 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Davin A*guts,Cri[eriBeverages with Warning Labels* a" .._._ 7-205.11 Incidental Food Contact.Lobrricrtnts* 3-801.11(B) Use ofPasteufrzed EeTs* 7-206.1 t Restricted IT Pesticides.Criteria* 3-801.1 I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.,x 7-206.12 Rodent Bait Stations* 3-80'1.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.1 I Consumer Advisory Posted for Consumption of 16 Proper Conking Temperatures for Animal Foods That are Raw.Undercooked or PHFs - Not Otherwise Processed to Eliminate i 3-401.17A(U(2) Eggs-X155°F 15 Sec. Pathogens.* 6tl"cove 0v200f Eggs-Ltunediate Service 145'Fl 5sec'^ 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(11)(2) Comtninuted Fish,Meats&Game Eggs* Animals- 155'F 15 sec. ,n 3-401.11(8)(1)(2) Pork and Beef Roast - 130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3-40111(A)(3) Poultry, Wild Gante,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr,or Ratites-165".F 15 sec. " above if related to foodborne illness 3.401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under 7/29- Microwave 165°F* Special Requirements. 3-401.11(A)(I)(b) All Other PHFs.- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°P 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165'F 2 Mlnttts Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk ftrctors listed above, can be 3-403.11(C) Commercially Processed RTE Food- ,found in the following sections of the Food Code and/OS CMR 140°F* 590.000. 3-403.11(E) Remaining-Unsliced Portions of Beef Item Good Retail Practices FC 680.000 __ Roasts' 23. Management and PersonnelFC-2 _.003 F,_8 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 4 3-501,14(A) Cooling Cooked PHFs f am 25. Egui ment and Utensils FC-140°F to 26. Waterlumbin and,PWaste FC- _.005 70"F Within 2 Flours and From 70"F 27. Ph sical Facility___ FC-6 .007 to 41'F145°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PRFs Made From Ambient 29. _ S ecial R ulrements .009 - -�- 'Femperaurre Ingredients to 41"F145°17 30 Other � Within 4 Hours'r i 119aR111u11.10 &" Denotes critical item in iha federal 1999 Food Cure or 105 CMR 590,000. C Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4`h Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date T e.of 0 eration s Tvpe of Inspection Sh r eeW ii Pd8 B I9 r ood Service ❑ Routine Address '79S Risk E] Retail e ' spection Telephone Level ❑ Residential Kitchen Previous Inspection _ 9C M ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation L,41 AX L' AL- ejwc- ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: ElHACCP Inspector va A G C.itB Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. .'FOOD PROTECTION MANAGEMENT '- - ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities _ EMPLOYEE HEALTH _ ,... . PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC El3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE ❑ 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source _ TIMENEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [1 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ' ": ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ,:REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY.. . . ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions v' immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health.Nth. 590.000/federal Food Code. This report, when,signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils cited in this report may result in suspension or revocation of (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 3590Ine ctFo m 10 as Inspector's Signature: Print: PIC's Signature: / Print: Page I of2-Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT8 Cross-contamination 1 590.003(A) kmininentofResponsibility"4 3-302.11(7)(1) Raw AnimaIFoods Separatedfiom 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods" 2-103.t 1 Person in charge- duties �� Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other= 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(x) Food Protection* applicants* 3 302.15 Wsshine Fruits and Ve.etables 590.003(F) Responsibility Of A Food Employee Or An 3-3171-1.1 Food Contact with Equipment and Applicant To Report To The Person hi Utensils* Charge* Contamination from the Consumer 590.003(G) Re ortina by Person in Charge* 3-306.14(A)(13) Returned Food and Reservice of Foal* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrigtions Food 3-701.11 Discarding or Reconditioning Lrrsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Cam Bance with Food La 4-501.111. Manual Warewashing-flot Water 3-201,12 Food in a Hermetically Sealed Container* Sanitization'rerareratures* 3-201.13 Fluid Milk and Milk Pr(yducts* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell;Bees* Sanitization Temperatures* 4-507.114 Chemical Sanitization-tem 1 3-203.14 Fees toil M.i(k.Products,Pasteurized' 4-501,114 PIT, concentration and hardness. * 3-202.16 Ice Made From Prom a DrinkingWater* 4-601.11(A) Equipment Fuad Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Lltensits Clean* 590.006(A) 'Bonded Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590A06(B) Water Meets Standards in 310 CMR 22.01,' .Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.1 1 Frequency of Sanitization of Utensils and .3-201.14 Fish and Recreationally Caught Molluscan Food Contact Snrfa(xs ofF m anent* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources'" 16 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authorityan2-301.11 Clean Condition--Hands d Arms* 3-202.16 Shellstock Identification Present* 2-307-12 Cl=ung Procedure" 590.004(0) Wild Mushrooms* 2-301.14 When to Washs` 3-201.17 Game Animals" 11 Goad Hygienic Practices 5 Receiving/Condition 2-407.11 Eatmj Drinking m Usine.Tobacar* 3-202.11 P1TF's Recei veil at 1'ro x1,Tem)eratures* 2-401.12 Discharges From the Eyes.Nose and 3-202.15 Packaee'I'nte¢ri.t * Mouth* _ 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing 0ontaminatinn When 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.13 Shellstock Identification* 590.004(E) Preventing Conumunadon from 3-203.12 Shellstock ktentification Maintained" Em lovees* Handwash Facilities Tags/Records: Fish Products 13 3-402.11 Parasite Destruction* NumbeienttytocatedandAccassibte 3-402.12 Records.Creation and Retention* 5-203.11 Nnmbeas and Capacities* 590.004(q Labeling of Ingredients' 5-204.11. Lavation and Placement* 7 Conformance with Approved Procedures 5-205.11 Aucessibilit% O eration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying ;-50111 Methods* Devices 3-502.12Reduced ox >en acka�*ine,criteria" 301.11 Handwashhtg Cleanser.Aaailabilit 3-103.12 Conformance with Approved Procedurts* 6-301.12 1-landDtvin>Pro cion ,z Denotar'critical 1103n in the federal 1999 Food(lode or 105 CN11,59f(,900. CITY OF SALEM BOARD OF HEALTH Establishment Name: L&XL.I tIC S Raw-osAr 6f-cw s t Rrd Date: (e �ey Page: 2 of 2 Item Code c-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 44- ✓1()(�4f lu s o Al ANS f Discussion With Person in Charge: Corrective Action Required; ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: it � r 3-501 J,I(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont) 4FF/451F Within 4 Hours. PROTECTION FROM CHEMICALS3-507.15 Co zlim Me hods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-50116(12) Cold PRFs Maintained at or below _T_20212 Adds" 590.004(F) 41'/45' F* 3-302.14 Protection from Ana z roved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. 7-101.11 'Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. C.ontalnera" 7-102.11 Common Narne-Workin.Containers* 20 Time as a Public Health Control 7-20'111 Se ararion-Stora,c 3-501.19 Time as a Public Health Control* ' - _ 590.004(H) Variance Requirement 7-202.11 Restriction-Presence and Use's 7-202.12 Conditions of Use* 7-203.1.1 Toxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals,' POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce,Criteria" 21 3-801A I(A) Unpastem"ized Pre-packaged Juices and '�Beveraees with WatvineLabela 7-204.14 Drviu eats.Criteria* 3-801.11(6) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact.Lubricants* 7-206.11 Restricted Use Pesticides.Criteria"" 3-801.11(D) Raw or Partially Calked Animal Fail and Raw Seed S gouts Not Served. 'x 7-20612 Rodent Bait Stations" 3-80'1.11(C) Unopened Food Package Not Re-served. 7.206.13 Tracking Powders,Pest Control and Monitoring" CONSUMER ADVISORY TIME{TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Elinunate 3-401.1 IA(I)(2) Eggs- 155°F 15 Sec. PathoRcns.*EOoc"vd vr,aoor E es-Itmtediate Service 145°F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* 3-401.11(A)(2) Comminuted Fish,Meats&Game Animals- 155'F 15 sec. * ,401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec,* catering. mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed P1lFs, 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 3-401.1 I(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 Fax1s Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401Al(A)(1)(b) All Other PHFs- 145'F'15sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) P1IFs 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 r-elate to the Time* foodborne illness interventions and riskfrrctors listed above, can be 3-403.11(C) Comrnerciaily Processed RTF Food- ,found in the fallowing sections of the Food Code and 103 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Bee( Item Good Retail Practices FC 590.000 Roasts* 23. Manarjement and Personnel _. FC-2 .003 18 Proper Cooling of PRFs 24. Food and Food Protection FC--3 .004 25 Equipment and Utensils __FC 4 005 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. Water, Plumbing and Waste FC-5__ 006 70'F Within 2 Hours and From"WF 27. Ph sical Facility FC-6 ( .007 to 41'F/45'F Within 4 Hours. '" 28. Poisonous or Toxic Materials _ 7-C-7 .008 3-501.14(13) Cooling P1IFs Made Front Ambient 29, s ecial R uirements _ .009 Temperature Ingredients to 41'F/45``F 30, Other NVithin 4Hours* ^`Denotes critical itGn in the rdu'al 1999 Food Code or 105 Cb1R 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Dateof erotion s Type of Inspection s GR-d/J r/Log- 5� ov T e ood Service g!4 Fl5utine Address Risk ❑ Retail ❑ Re-inspection Telephone Level El Residential Kitchen Previous Inspection _ S �j ❑ Mobile Date: OwnerHACCP Y/N ElTemporary E] Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time L1Bed& Breakfast ElGeneral Complaint IVIC&A412- g In; ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ' ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities (2) ` EMPLOYEE HEALTH d" PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC [-] 3. Personnel with Infections Restricted/Excluded El 14. Approved Food or Color Additives FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals_� ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION'S 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(21 REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) / ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY_ , m ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions 3 immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofHealth., 590.000/federal Food Code. This report, when signed below R. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 419�a� S,5901nVWFOl -14.do Inspector's Signature: Print: PIC's Signature: // Print: t Lel C/U I Page/of-ypages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination I 590.003(A) Assignment of Responubdtty" 9-302.11(A,)(1) Raw Animal Foods Separated from i90.003(B) Demonstration of Knowledge* Cooked and RLE l-oods"` 2-103.11 Person in charge--duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-30215 Washing Fruits mud Vegetables 590.003(F) Responsibility Of A Fexxt Employee Or An 33-304.11 -' Food COntaeL with Equipment and Applicant To Report To The Poison In Utensils'" Charve* Contamination from the Consumer 590.003(C) Re ort9nR b Person in Char e*" 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) I Exclusions andReshictions* OispoMtonofAdulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Nlanuat Warewashing-Hot Water "'- Sannizauon rem eraarres* 3-201.12 Food in a Hermetically Sealed Container* 3-20113 Fluid Milk and Milk Products* 4-501-112 Mechanical Warewashino Hot Water 3-202.13 Shell Egos* Sanitization Tem>eramres* 3-202.1.4 E gs and M lk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness.* 3-202.16 Ice Made From Potable Drinking Water* 5-101-11 Drinkin-Water from an A moved System* 4-601.11(A) 'Equipment Food Contact Surfacesand 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(13} Water Meets Standards in 310 CMR 22.0* 4-602.11. Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils' Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces cif E 2u ment* Shellfish" 4-703.11 Methods of Sanitization --Hot Water and 3-201.15 Molluscan Shellfish from NSSP listed Chemical* Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Pa'mO' 3-202.18 Shellstock Identification Present* 2-301.12 Cleanim, Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-20117 Garne Animals* 11 Good Hygienic Practices S Receiving/Condition 2-401-I1 _ P.aYin , Drinkin or Using Tobaccn* 3-202.1 1 PHFs Received at Proper Temperatures* 2401.12 Discharges Fiout the Eyes.Nose and 3-202.15 Package Into it * Mouth* 3-101.11 Food Safe and Unadulterated3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* -Enn ln'ees* Handwash Facilities Tags/Records:Fish Products 13 Conveniently Located and Accessible 3-402.1 I ,Parasite Destruction"' 3-402.12 Records.Creation and Retention* 5-203.11 Numbers aad Ca collies` 590-0040) Labeling of Ingredients' 5-204.i'l. Location std Placements 7 Conformance with Approved Procedures 7-20511 Accessibility,Operation and Maintenance MACCP Plans Supplied with Soap and Nand Drying 3-502.11 S ecializedProcessin>Methods* Devices 3-502.12 Reduced ox en racks«ing,criteria* 6-301.11 Handwashing Cleansci Availabilit 8-103.1.2 Conformanee with Approved Procedures* 6-301.12 Hand Drying Provision '"Denotes critical item(n the ielaral 1999 hood Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:49,_Tu 96"9- j;Auo i A&W Date: f,20zPage: 2 of q Item Code C-Critical nem .DESCRIPTION OF VIOLATION/PLAN OF CORRECTION _ Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY N tV, L t,fatlLS Cc�AMrr✓(C O SrIN+ 2, 6, ,0,4#0- t,Nrr ro , a/ M 'F- o� l3fcce / G APS'r f r r✓ . rt eSM of rf 'r; R wig C R N Qpr q/,, al- 161LIL.CAAA N Stif6 JAS AN c., +e v 60 l/S AXV AW, !�D C CL N S rrr7� ,J aJ"6N�i�• N le. NrvL r &rrs m4- Arm A.4 Ane.•. ut.4 .xn/ 36 • �fvkbu� c� �/ F rr r , - 9 C v0 of `it.G� B r A F Let A cry &Czsu✓: q mar su ,� Ns mor o e a ,7 k y- Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes ,g 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 i .•, noncompliance may result in daily fines of twenty-five dollars resuspension/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 According to Iaw Cooled to Factors(items 1-22) (Cont.) 41°Fl45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 1=414 19 Food or Color Additives _ PHF Hot and Cold Holding 3-501.16(11) Cold PHFs Maintained at or below 3-202.12 Addection 590.004(F) 41`/45° F` 3-302.14 Protection from I is Substances Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140'F. Containers 7-101.11 Identifying ere*Information701 ninal 3-501,16(A) Roasts Held at or above 130°F. * 7-102-11 Common Narita-Workne,Containers* 20 Time as a Public Health Control 7-20'1.)1 Separation-Storage* 3-501-19 Time as a Public Health Contra!` 7-20211 Restriction-Presence and Use'" 790.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce. Croona' 21 3-801 11(A) Unpasteurized Pre-packaged Juices and Beverages with Waning labels* 7-204.14 Drvina, ents,Crneria° - - 7-205.11 Incidental Food Contact. Lubricants* ;-80 Ll I(B) Use of Pastennzed Eg„s�: 7-206.11 Restricted Use Pesticides, Criteria* 3-80 IA I(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations` 3.8(p.H(C) Unopened Food Package Not Re-served- " 7-206.13 Tracking Powders,Pest Control and Monitorine* CONSUMER ADVISORY TIMEiTEMPERATURE CONTROLSConsumer Advisory Posted for Consumption of nim Aal Forxts'lltat are Raw.Undercooked or PHFs 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate 3-401.tggs-1A(1)(2) E155°F 15 Sec. 703.11 Pathogens.*=r�crra rnrzom Ergs-hmnediate Service 145°F15sec*' 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11.(A)(2) Comminuted Fish,Meats&Game E gs* Animals-155°F 15 sec. * 3 401.11(B)(1)(2) Pork and Beef Roast- 13WF 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-1550F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec, * catering, mobile food, temporary and 3-401.1.1(A)(3) Poultry, Wild Game,Stuffed PRK residential kitchen operations should tie Stuffing Containing Fish,Meat, debited under the appropriate sections Point or Ratites-165°F 75 sec. ,. above if related to foodborne illness 3-401.11(,C)(3) Whole-muscle,httact 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 165'17* Special Requirements. 3-401A I(A)(l)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 13 sec." (items 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* ,foodborne illness intetventions and riskfac'turs listed above, can be 3-403.11(C) Commercially Processed I2TE Food- found in the following sections of the Food Code and 105 0412 '140'F* .5.90.000. 3-403.1.1(E) Remaining Unsliced PortioBf ( Item _ Good Retail Practices FC 590 000 Roasts` 23. Management and Personnel 3 ---_ FC--2 .00 18 Proper Cooling of PHFs 24. Food and Food Protection __ FC-3 .004 25 Equipment and Utensils FC 4 .005 3-501.14(.A) Cooling Cooked PHFs from HOOF to - -- 26 Water, Plum bing and Waste FC 5 .006 7 P Within 2 Hours olid From 70°F 27. Ph sical Facilit}r_ _ _ FC-6 .007 to 41.'F145°F Within 4 Hours. ` 28. Poisonous or Toxic Materials FC- 7 .008 3-501.14('B) Coolim,PHFs Made Frons Ambient 29 S ecial Re uiremonts __ __ .009 --- Temperature Ingredients to 41`F/45oF 30 Other k S590rpmbxkG ..-.-.---'- -. Within 4I-Iours' "'Denotas critical item'n the rMeral 1999 Food Cade or 105 CMR 590.000. h CITY OF SALEM _ BOARD OF HEALTH Establishment Name:L&Y arz j?9X"14r- &htis t- Oc!$ Date: �S- JoC./ Page: 3 of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item PLEASE PRINT CLEARLY Verified 113 le, r 64,1 Q i Id A t4 NX - / C S d Fib t/t V/S` ?l/ r AW Aee,&AtoLw.-dW a rs Ar+n r14 t£ 436511115- 44 a �t c :221 [ r UN/ra Ao m&Av— entj Fwnt ff*4-6 t V F 19 f ,a/ wip 47oF AgA1tA vN r '� o i f Atr•f Fr °� off-- t.ew✓• /3 fit, 0041"sR SINK— 1 0 Sly1►4otiq ' 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 L] 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 suspensi n/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: i 3-501.1.4(C)- PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to haiv Cooled to Factors(items 1-22) (Cont.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cowling Methods for PHFs i4 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(13) Cold PHFs Maintained at or below 3-202.12 Addutves'r 590.004(F) 41'!45° F" 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above 1S Poisonous or Toxic Substances 140'F. * 7-101.11 Identifying Info rmanon-Original 3-501]6(A) [toasts Held at or above 130'F. Containers* 7-102,11 Common Name-Working*Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora e"` 3-O 4( Time as a Public Health Control" 7-202.11 Restriction-Presence and Ilse* 19 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7.203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanrtizers,Criteria-ChcmicaNs POPULATIONS(HSP)3-801.11( HSP) 7-204J.2 Chemicals for Washin Produce,Criterias: 2.t 3-$01.17(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 7-204.14 Drying encs,Criteria* 3_gOL11(B} Use of Pasteurized'Eggs '' 7-205.11 Incidental Food Contact,Lubricants* 7-206.11 Restricted Use Pesticides-Criteria* 3-801A 1(D) Raw or Partially Cooked Animal Foorl and Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations" 3-801.11(C) Uno.used F<xxi Parka to Not Re-served. �` 7-206.13 Tracking Powders,Pest Control and Monitorino� CONSUMER ADVISORY TIMEfrEMPERATURE CONTROLS 22 3-603-11 Consumer Advisory Posted for Consumption of Anhnal Foods'llnat are Raw.Undercooked or I6 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs � Eaecere rntznm 3-401.1 IA(i)(2) F,,s- 155 F 15 Sec. I atho*ens* E p-Immediate Service 145°1715sce 3';02.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11.(A)(2) Comminuted Fish,Meats&Game Eggs* Animals- 155'F 15 sec. 3-401.11(B)(1)(2) Pork and Beet'Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,injected Meals-155'F 15 590-009(A)-(D) Violations of Section 590.009(A)-(D)in sec. " catering,mobile food,temporary and 3-401..11{A)(3) Poultry,Wild Game,Stuffed PHFs, residential.kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec, * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145'F 590.009 violations relating to good retail 3-401.12 Raw Amond Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401_11(A)(1)(b) All Other PHFs--1.45'F 15 sec. * I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(I)) PHFs 165'F 15 sec. (Items 23-30) 3-403.11 B) Microwave-165°I^2 Minute SCanding Critical and non-critical violations, which do trot relate to the Time' foodborne illness interventions and risk.factors listed above., con be, 3-403.11(C) Conmrercially Processed RTE Food- found in the follon•ing sections of the Food Cade and 105 CMR 140'F* .590.000. 3-403.11(F) Remaining Unsliced Portions of Beef Item Gaod RetaU Practices FC 59Q.000 Roasts* 23. Mane ement and Personnel FC-2 .003 Ig Proper Cooling of PRFs 24. Food and Food Protection_ FC-_3 .004 25Equipment and Utensils F.. __.. 4 .005 - C 3-501.14(A) Cooling Cooked PHFs from 1 ___ 4WF to 28. W ater,Phil mbinq and W aste FC-5 F .006 70'F Within 2 Hours and From 70'F 27. - Physical Faclil _ _ FC-6 007 Lo 4 t°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC -7 .008 3-501.14(B) Cooling PHFs Made From Ambient _29- Special Requirements .009 'temperature Ingredients to 41'F/45'F 30,_ _ Other Within 4llours:: .1110F rm,,E6 2d- *IJeroles critical item in the,federal 1994 Food Code or 105 CNIR 592000, CITY OF SALEM BOARD OF HEALTH Establishment Name: CA SL4 X-S U "A It" (rRt,a r PAIR Date: Sr '��np_ Page: of Hem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY.. . r ly !\ Gt71 W Wtr tt� n -- auto s r tfs P OV1 S I - Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction inspection, to observe all conditions as described, and to Exclusion P L3 Re-inspection Scheduled Z1 Emergency Suspension violations before the next ins comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twe ve dollars or nsion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal 0 Other: 3-501.14(C) PHFs I2eceivedI t'1"emperatures Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to Factors(items 1.22) (Cont) _ 41°F/45`-F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12Adcli[ives" 3-501.16(13) Cold PEIFs Maintained at or below- 590,004(F) elow590.004(F) 41 V45°F* 3-302.14 Protection fiomUno roved Additives" 3-501.16(A) I1ot 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)' 7-102.11 Compton Name-Workinm Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stoeatie* 3-501.19 Time as a Public Health Conu'ol* 7-202.11 Restriction-Presence and Use 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals^` POPULATIONS(HSP) 7-204.12 Chemicals for Washin-Produce,Criteria* 21 3-80'1,'1I(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drvino vents,Criteria* Beverages with Warning Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-501.A I(B) Use of Pasteurized Eg� 7-206.11 Restricted Use Pesticides, Cnteria* 3-801.11(D) Raw or Partially Cooked Animal Fond and 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 TIMEIrEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of l6 Proper Cooking Temperatures for Animal Foods flint are Raw. Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.t1A(7){2) Eggs- 155'F 1.5 Sec. Pathogens.*s"L'r veom Eat InitnedrateService 145921 sec: 3-302.13 Pasteurized Pigs Substitute for Raw Shell 3=101.11.(A)(2) Comminuted Fish,Meats&Game Eggs:r Animals- 155°F 15 sec. .* 3-401.11(11)(1)(2) Pork.and Beef Roast- 130"F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Came,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,intact'Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-- Microwave 165'F* Special Requirements, 3-401.11(A)(1)(b) All Other PHFs-145°F15see. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165=F 15 sec. (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate io the Time" foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTF Food- finnrd in the following.sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining UnsHced Portions of Beef Item Good Retail Practices FC -500.600 lioas, 00 600Roasts* 23. Management and Personn_e_I_ _ FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC -3 .004 25 __Equipment and Utensils _ FC 4 3-501.14(A) Cooling Cooked PHFe from 140`F to 26 Water,Plumbin and W asie FC 5 .008 70°F Within 2 Flours and From 70".F 27. PhysicalFacil�__ __ FC-6 .007 to 41"F/457 Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 ' .008 3-501.14(13) Cooling PHFs Made From Ambient 29_ Special Re uirements _ .009 Temperature Ingredients to 41`F145'F 30.... _Other Within 4 Hours* s, brk6n.a« "Denotes critical item in the federal 1999 Food Code or 105 CMR 596000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'h Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 i Name Date / T e of O eration s Type of Inspection -,c Q w ,� /"cZ /' 6Y Food Service Routine Address Risk ❑ RetailRe-inspection ^�� Y^ r� Level ❑ Residential Kitchen Previous Inspection Telephone IMobile Date:/-/ 0 aGl �r u. . do Z ❑ Temporary ❑ Pre-operation Owner (- n/ /i�n / HACCP Y/N ❑ Caterer p _ El Illness Person in Charge(PIC) / Time ❑ Bed& Breakfast ❑ General Complaint P Let// Ce In. E] HACCP Inspector / 1 vd/Ssrt klS Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. _ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [118. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health/Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ El 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices -CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR o_C Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc-4)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:5901ne cfFcrm MCoc Inspector's Signature: '!ti✓e j ,j / Print: PIC's Signature: / ,1-�_ A i !Y' Print: (�.I �� /' I Page of Cppages I Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cmss-conta nlrratlon 1 590.003(A) Assignment of Responsibility' 302.11 NO) Raw Animal Foods Separated from 590.003(_B) Demonstration of Knowledge* Cooked and RTL Foods' 2103.11 Person in charge-duties Contamination from Rawingiedients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-30211(A) Food Protection* t. applicants* 3-302.L-5- 590.003(r) -302.15590.003(F) Responsibility 01 A Food Employee Or An 3-3(}1.1.1 Foal Contact with Equipment and Applicant To Report To The Person In Utensils'" Chaff ge" Contamination from the Consumer 590.003(0) Reporting by Person in Charge* 3-306.14(AI(B) Returned Food and Reservice of Foorl* 3 590.003(D) Exclusions and Restrictions" Dsposlfion afAduiterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning tinsafe FOOD FROM APPROVED SOURCE I Food" 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compluntce with Food Law* 4-501.11 I. Manual Warewashing-Hot Water 3-201_t2 Food in it Flennetically Sealed Container* ._,- Sanitization Tem.eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing--Hot Water 3-202.13 Shell Eggs* Sanitization Teraperafures" 3-2-02.14 'Eggs and Milk Products.Pasteurized'" 4-501.114 Chemical Sanitization-temp.,pFI, 3-202.16 Ice Made From Potable Drinking Water" concentration and hardness. 5-1.01.11 Drinking,Water from an A roved System" 4-601.11(A) Equipment Fond Contact Surfaces and Utensils Clean- 590.0064A) Bottled Drinking Water* 590.006(8) Water Meets Standards in 310 CMR 22.W 4-602.11 Cleaning Frequency of Equipment Food- 590.006(R) Surfaces and Utensils FishaShellfish and Fish From an Approved Source 4-902.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Fa d Contact Surfaces of E ui ment* Shellfish', 4-703.11 Methods of Sanitization--Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed - Chemical^ Sources' 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11. Clean Condition- Hands and At 3-202.18 Shellstock Identification Present" 2-301-12 Cleaning 11rmeduie* 590.004(C) Wild Mushrooms* 2-301.1.4 W1nea to Wash/` 3-20117 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-40 1.1 1Fadi ,Drink,in or Using TobaccoT 3-202,11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes.Nose and 3-202.15 Package hrtes3itv'" Mouth* 3-101.11 Food Safe and Unadulterated 'r 3-301.12 Preventing Contamination When Tastln** 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.13 Shellstock Identification* 590.004(E) Preventing Contaminadon from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records: Fish Products 13 Handwash Facilities 3=10211 Parasite Destruction" Conveniently Located and Accessible 3-402.12 Records.Creation and Retention" 5-20111 Numbers and Ca aciucs" 590.004(7) Labeling of Ingredients' 5-204.11. Location mid Placement* 7 Conformance with Approved Procedures 5-205.1,1 Accessibility, 0 erasion and Maintcnmua lHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Ruluced oxv=en paekagLne,criteria* 6-301.1.1 Ilandwaehin*Cleanser.Availahi1it 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Diving Provision "Dmolc Critical/Pent in the federal 1949 Food Code or 105 CMR 5C)OM . CITY OF SALEM BOARD OF HEALTH Establishment Name: >°lY7(__ Date: /-A/_oe Page: of t. Item Code C—Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - Verified PLEASEE P—.RRIINT CLEARLY- , U f 't I t F pl F Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion } P ❑ Re-inspection Scheduled ❑ Emergency Suspension cdmply 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: i a.: 3-501.14(C) I'HFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk Accordin;to La1v Cooled to Factors(items 1-22) (Cont.) 4 1`F/45`jLWfflan 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding --------- 3-50L16(B) Cold PI1Fs Maintained at or below 3-202.12 Adchttsesr .- 590.004(F) 41745°F* 3-302.14 Protection from Una}1ploved,ldditiees'r 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 140 F. 1-101.11 ldentifying Information-Original 3-501.16(A) Roasts Held at or above 130'-. * Containers" 20 Time as a Public Health Control 7-102.11 Common Name Working Containers"` 3-501.19 Time as a Public Health Control" 7-'_01.11 Se.aratiation-Stot rgc 7-202.11 Restriction-Presence and Use 590.004(H) Variance Re uiaetnenl' 7-202.t2 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions' REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanidzers.Criteria-Chemicals* POPULATIONS(HSP) 7-204-12 Chemicals for Washin>Produc Criteria* 21 3-801.11(A) Unpastcurizud Pre-packaged Juices and 7-204.14 Diving Agents.C itena" Beverages with Warning labels* r706 05.1.l Incidental Food Contact,Lubricmus* 3-801A1(B) Use of Pasteurized Eg'g's* 06.]1 Restricted Use Pesncldes,Criteria" 3-801.1.1(])) Raw or d Sprouts Animal Food and Raw Seed S gouts Not'Served. .12 Rodent Bait Stations* 3-801.11(C) Uno ened Food Pucka>e NoC Rc-served. 0fi.13 Tracking Powders,Pest Control and Monitoring" CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for .Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155'F 15 Sec. Pathogens.* "`'°1aY t2001 -cgs-Immediate Service 144;°1715sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shelf 3-401-11(A)(2) Comminuted Fish.Mcats&Game Egs+ Animals-I55'F 15 see. " 3-401.11(B)(1)(2) Pork and Beef Roast- 1.30'F 121 min* SPECIAL REQUIREMENTS 3=401.11(A)(2) Ratites,Lrjected Meats- 155'F 15 590.009(A)-(D) Violations of Section 590,009(A)-(D)in sec. * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-1651- 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 ora practices should be debited under#29- Microwave 165'F* Special Requirements. 3-40 1.11(A)(1)(b) All Other PHts-- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-40111(A)&(D) PFIFs 1651-15 sec. '7 (Items 23-30) 3-403.1 I(I3) Microwave- 1651 F 2 Minute Standing CG-itical and non-critical violations, which do not relate to the 7Tme* loodhorne illness interventions and risk{actors listed above, can be 3-403A l(C) Commercially processed R"PE Food- ,found in the following sec tions of`the Food Code and 105 CMR 1400F* 590.000. 3-4013.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts"` 23. Mana eeno nt and Personnel FC-2 .003 1g Proper Cooling of PRFs 24 Food and Food Protection FC 3 004 25. E m ment and Utensils FC 4 005 3-501-14(A) Cooling Cooked PHFs from 140'F fo - ----- _ 05 26 Water, Plumbing and Waste FC-5 -006 70'F Within 2 Hours and From 70°F 27 Physical FacilityFC-6 .007 to 4l."Fl45'F Within 4 Hours.* 28- Poisonous or Toxic Materials FC-7- .008 _, 3-501.14(6) Cool ing PHFs Made Flom Ambient 29. Special Requirements _ _ _,00i 1 'Temperature Ingredients to4ff/-15°F 30. 1 Other _ Denotes critical item in the federal 1999 Food Gnfe or 105 CMR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4t' Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Tvtfe of ODeration(s) Te of inspection r Gvl3r UB Food Service Routine Address ' Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone / _ y 9S / EI Mobile Date-.-4-;R 9-a3 Owner HACCP YIN ❑ Temporary ❑ Pre-operation p 1 , V,Q El Caterer E] Suspect Illness Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint Inspector) �� In Permit No. ❑ Other T Out: ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provisions) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. `FOOD PROTECTION MANAGEMENT ❑ . Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/Duties �/y2 IJ 13. Handwash Facilities EMPLOYEE HEALTH - ' PROTECTION FROM CHEMICALS d ` ❑ 2. Reporting of Diseases by Food Employee and PIC r ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE ;, ❑ 15. Toxic Chemicals / ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE.CONTROLS(Potentially Hazardous Foods) w ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions ' t immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR o-C 7V -, 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations ✓ 25. Equipment and Utensils cited in this report may result in suspension or revocation of (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:5901ns dFmm 14400 ctor§ gnat Print: PIC's Signatu Print: A C ,,-e l Ul�, Pagei of Pages t .t Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT L8 Cross-conrem an tion 1 590.003(A) Assignment of Responsibility''` 3-302.11(x(1) Raw Animal Fords Separated from 590.003(B} Demonstration of Knowledge* Cooked and RTE Foods" 2-1.0311 Person in charge -duties Contamination from Raw Ingredients 3-30211(x)(2) Kao Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibi lity of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits said Vey*etables 590.003(F) Responsibility Of AFood Employee Or An 3-304.1.1 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Re.ortin b Person in Charge* 3-306A,l(A)(3) Returned Forxl and Reserviceof F(xxl* 3 590.003(1)) Exclusions and Restrictions* Disposition ofAdutteratedorContaminated 590.003(1:) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590,004(A B) Cam lianas with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hetnneticall y Sealed Container* Sanitization Tent>ei atures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Wm-ewashrn�]lot Water 3-202.13Shcll'Eapv Sanitization Tem aeratureS- 3-202.14 I5*gs and Milk Products,Pasteurized" 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water's concentration and hardness. ,: 5-101.11 Drinking Writer from an Approved System" 4-60Lt1(x EquipmentContact Surfaces and 590.006(A) Bottled Drinking Water` Ltensils Cleean"an* 4-602.11 CleaningFrequency ofEquipment Food- 590.006(,B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces anti Utensils' Shellfish and Fish Froman Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of F.quipmem* Shelltish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources' 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re2uldrory Authority 2-301.11 Clean Condition-Hands and Arms" 3-202.19 Shellstock Identification Present* 2-301.12 Cleanin Procedure" 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* - 11 Good Hygienic Practices 2-401.11 Faring, orU�in Tobacco* Receiving/Condition ,.�__�.-_. 3-202.11, PI-IFs Received at proper Tem erantres:' 2-401.12 Discharges Froin the Eyes.Nose and 3-202.15 Package Into it * Mouth* 3-101.LI Food Safe and Unadulterated 3-301.12 Preventing Contamination When Tastin 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.13 Sbel,lsrock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained`" Ent lovees* TagsiRecords: Fish Products 113 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.1.1 Numbers and Ca acities* 590.004(() 1 Labeling of Ingredients` 5-204.11 Location and Placement* 9 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenanec IHACCP Plans Supplied With Soap and Hand Drying 3-502.11 Specialized Proees'sin>Methods* Devices 3-502.12 Reduced oxv>en Packaging,criteria* 6-301.1.1 Handwashing Cleanser.Availability 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Dryin�Provision *Denote,Critical item in the federal 1999 Food Code or 105 C6tR 590A00. CITY OF SALEM BOARD OF HEALTH Establishment Name: l F.SG/,nc "1, 7— Date:i--13—e Page: 62 of 12_ Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY ll Ni/.Q,e SA7/H7�07L 0?7 .P/ N /i/I eo 7 - 4. as '/S7O� oo//v 7- tii� Pri / r/ _ F , s �. ✓ P i z a 7 7V/VA— w as- - -7as- Z��17tAlogioYs 44=4r ..t ' /3 ✓JP — /P P r . 2 r- e —�.> , �r_l AMT Exrre�, A1Ink —/ e-We_ 104719 a aCfdW /ti L'HO yr r rDiscussion With Person In Charge: 'Correcti a Acfion Required: ❑ No ❑ Yes e read this report, have had-the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee RestrictionExclusion ions before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension g ly with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twen y=five dollar or suspension/revoc tion of ❑ Embargo ❑ Emergency Closure your food permit. Li Voluntary Disposal ❑ other: t 3-5n114(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to 1..,2ia Cooled to Factors(Items 1-22) (Cont.) 4'FF145'Within 4 Hours.' PROTECTION FROM CHEMICALS 3-501.15 Conlin Methods for PHFs14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PIiFs Maintained at or helow 3-202.12 Additives* 590.004(F) 4117450 F* 3-302.14 Protection from Una roved Additives* 3-501.16(A) Hot PFIFs Maintained at ra above 15 Poisonous or Toxic Substances I40'F 7-101-I1 Identifyinglnfonnaton-Orignal 3-50L16(A) Roasts Held at or above 130°F. * Containers* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora>?e* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use" 590.004(H) Variance,Requirement 7-202.12 Conditions of Use* 7-203.11 '1oxieContainers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washing Produce; Cciteriu' 21 3-901,11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels*3-801.1 I(B) Use of Pasteurized Eggs* 7-2067-206 ,11 Restricted Use Pesticides,Criteria*.1.1 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sp ours Not Served 7-206.1.2 Rodent Bait Stations" 3-801.11(C) Unopened Food Packa�e NoC Rc.-served. 7-206.13 Tracking Powders,Pest Control and Monoorinv* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw, Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogenscr -aye i,.7001 Immediate Service t4�, F15secw 3-401.11A(1)(2) E>;I,g- meF 15 Sec. 3-302.13 Pasteurized Fobs Substitute for Raw Shell 3-401.'1l(A)(2) Comminuted Fish.Meats&Game Egz'* Animals- 155'F 15 sec. 3-40111(11)(1)(2) Pork and Beef Roast-'130'F 121 rninib SPECIAL REQUIREMENTS 3-40L11(A)(2) Ratites, Injected Meats- I55'F 15 590-009(A){D) Violations of Section 590.009(A)-(D)in sea catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game.Stuffed PHFs, residential kitchen operations should be Stuffing Contain9ng Fish,Meat- debited under the appropriate sections Poultr or Ratites-165'F 15 sec. * - above if related to foodborne illness 3-401.'1.1(0(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under 1129- Microwave 1 WF* Special Requirements. 3-401..11(A)(1)(b) A(I Other PHFs-145°14 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1I(A)&(D) PHF, 16-5'F 15 sec. * (Items 23-30) 3-403,11(13) Microwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time'` foodborne illness iriementions and risk factors listed above, can be 3-403.1.1(C) Commercially Processed RTE Foott- found in the following sections of the Food Code and 105 C19R 140-F* 590.000. 3-403II(E) Remaining Unnliced,Portions of Beef Item Good Retail Practices FC 590.000 , Roasts* 23. Management and Personnel F1-2 .003 g Proper Cooling of PHFs 24. Food and Food Protection _ _ FC--3 .004 25. ' 26. Water, Plluumbidnq and Waste FC -007 { _ _ FC 4 .005 cilit 3-�01.14(A) Cooking Cooked PHFs from 140°F toFC-5 _ 70 f Within 2 Hours and From 70'F to-11-1145"F Within 4 Hours. * 28. 1 Poisonous or Toxic Materials FC- 7 008 3-501.14(B) Cooling PRFs Made Front Ambient 29. _ Spec(al R ulrements .009 _ Temperature Ingredients to 41'F/45' 30. Other ______ _ _ -_ Within 4 Hours* *Denoles o i7 ical item in the Pedual 1999 Fwd Code or 105 CNIR 590.9017. Y, a ' CITY OF SALEM, MASSACHUSETTS .� BOARD OF HEALTH - • • 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 If COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Owner' s Name : Claire Chalifour Name of Establishment : Leslies Retreat Grub & Pub Address of Establishment : 96 North Street Type of Establishment : FOOD SERVICE Application Date : 12/10/2002 Restrictions: Permit for Food Establishment 19-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of . ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT t r 0'` r d, 'kri� f•r t yyh�IZAR tr 9•-a,,'"i, ri'r:`.r '+3#' ,�k �}`', ,J'uYba. . y t *4x 7, tse ''}� } .� CITY OF SALEM, MASSACHUSETTS e}' BOARD OF HEALTH 1"? 3 120 WASHINGTON STREET, 4TH FLOOR - SALEM, MA O1970 DEC 5 " 2002 71� TEL. 978-741-1800 FAX 978-745-0343 _ STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HBOARD t,.}F HEALTH HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD,ESTABLISHMENT NAME OF ESTABLISHMENT . INC . TEL#978 744 9495 D B A SLIES RETREAT GRUB & PUB ADDRESS OF ESTABLISHMENT 9b NORTH ST SALEM,MA of 97()--i, MAILING ADDRESS (if different) OWNER'S NAME CLAIRE D , CHALIFOUR _TEL# D7t3 745 5745 ADDRES� 96 NORTH TT . CIT"_ MA. STATE_pgA ZIP 01970 CERTIFIED FOOD MANAGER'S NAME(S�LAIRE CHALIFO CERTIFICATE#(s �41TCHE� - UKGL—Eye ) - 7 (required in an establishment where potentially hazardous �food lIis prepared,) EMERGENCY RESPONSE PERSON P�ICHEL CLUKEYOUR HOME TEL#_M3 AM h.n fiM n.ct nrt hnf HOURS OF OPERATION: Mon. 77=1 Tue.7 Wed. 77=1 Thu.7-1 Fri.7-1 Sat. 7-1 Sun, -2 TYPE OF ESTABLISHMENT 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 NO `S 3 less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES (0 $5 TOBACCO VENDOR YES $50 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 location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signatur Date ocial SC,--4v or F deral Identification Number -r. _ - _1 /!�/02S9 k1 91) Revised 1125/02 FOODAP2.adm Y Check#&pate .J: /sQ- i b t �1 fl f�"�`�t t�� f; , I f�h^'�u ik•. 1��+j £'j s�ttY��{S ('.._I / {�5'4��i tf �1ji �f`! �% }l ��i�t�' i prS�, r .,k�1 I�i �}�� !S,� �-.11�i�4 `�i;i3; .., ° t�T "`1 i,n SIR AM vow ry(v{' ��'� r` `�T ,,¢qV��fi,J. a f !I �ti�l. � �n� � } 4�f�teT"1� �1h7 r ,y �'� �APogPM MgPgPdPAPPAA£Aq AFlP9vPA6LBPPPPgOAPAFl A PtIVPPM q9 £OPggd PIIIPAVPVAPFlMfl PI VPflMP onOA OvvFlltPFlogN OyllOOgvAgA OI Oq P P MA ( ^ f � i {f • • - : • F TMI fe1f� I1 I �3-,/)�C�77y '•n yah y, �\., G.L..0 • _ - - • i � ' o � Y MWDILWAwt • AVIL I/' c�a • • " •wil _ • a fir'}�ai�� a1�4 F x��Y tr • . . rho _ UUM, • F p F F y4 m .............................. fl d..�a _ _F �- •--'-•• r:..,-a......�. �.,en, v+w.. .-�r�..,rv�+h.w»r..++m,.re+s(�W.f."+4'sGln�^w^r-f"*'V'+-�iwesw.-.+c.-..�,;`..,.»-.r.....':A THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date Tvoe ofOperation(s) Tyne of Inspection / ,� �"� � �q Food Service Routine Address /, / Risk ❑ Retail Re-inspection /V Level ❑ Residential Kitchen Previous Inspection Telephone _ - n ❑ Mobile Date: Owner ACCP Y/N ❑ Temporary ❑ Pre-operation v 2f ❑ Caterer ❑ Suspect Illness Person In ChWe(PI Time ❑ Bed& Breakfast ❑ General Complaint In: ElHACCP Inspector Out: Permit No. ❑ Other /. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded ❑ 14. Approved Food or Color Additives FOOD FROM APPROVED SOURCE El 15. Toxic Chemicals El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/Records/Accuracy of Ingredient Statements El 17. Reheating El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding El8. Separation/Segregation/ Protection El 20. Time as a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 10. Proper Adequate Handwashing ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 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 N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations / 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: Print. r D� PIC's Signature: PriWn . Page/of Pages FORM 734A HOBBS&WARREN - B STON t Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1' 590.003(A) Assi nment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2$ 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and 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 in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3)1 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE g Food Contact Surfaces -:4:; Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products,Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 16• Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* .11x.. Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* ''.`12': Prevention of Contamination from Hands 6Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* '13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7' Conformance with Approved Procedures Supplied with Soap and Hand Drying HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM / BOARD OF HEALTH Establishment Name: L ��// �S �/� Date: O3 Page: of I, Item Code C-Critical ItemDESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified '. PLEASE PRINT CLEARLY H Or R 1 t -� 0 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 a P ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: c r I 3-50114(() PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) -(Cont.) 41'F145'F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs lq Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additves 3-501.16(B) Cold PIIFs Maintained at or below 590.004(14) 41°245'S* 3-302.14 Protection from Una. .roved additives'r 3-501..16(4) 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, 7-102.11 Common Nam *e-Working Containers*_ �� Time as a Public Health Control 3-501.19 Time Its a Public Health Control 7-201.11 Separation-Stotagt; _ c 7-202.11 Restriction-Presence-and Use" S>0.004(H) VarianceRecuiremert 7-202.12 Conditions of(Jse" 7-203,11 Toxic Containers-Prohibitions* i REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Saiitlzers.Criteria-C'hemieais* POPULATIONS HSP _ 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.i 1(A) Unpasteurized Pre-packaged Juices and 7-204.14 Dr ing Agents.Criteria* / Beverages with Warning Labels* 7-205.11 Incidental Food Contact,Lubricants" 3-$01.11(6) Use of Pasteurized E&as* 7-206.11 Restricted Use Pesticides,Criteria" 3-801..11(D) Raw or Pmtially Cooked Animal Food and Raw Seed S gout's Not'Served. 7-206.L2 Rodent Bait Stations* / 3-80111(C) Unopened Food Pucka>e Not'Re-served. 7-206.13 Tracking Powders,Pest Control and r - Monitoring" CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consulter Advisory Posted for Consumption of 16 Animal Foods nature Raw, Undercooked or Proper Cooking Temperatures for PRFs Not Otherwise Processed to Eliminate 3Pathogens.* -401.11.A(1)(2) EFgs- 155°F 15 Sec. Eizs-Immediate Service l45°Ff Sseccx 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155'F 15 sea " SPECIAL REQUIREMENTS 3-401.11.(6)(1)(2) Pork and Beef Roast- 130'5 121 min' - 3-401.11(A)(2) Maims,Injected Meats- 155 F 15 590-009(A)-(D) Violations of Section 590.009(A)-(D)in ec catering, mobile food, temporary and 3-401.11(A)(3) Pooltfy,WSId Game. Stuffed PHFs, residential kitchen operations should be ;ituti)ng containing Fish,Meat ...a,lw .ndel'the Poultry or Ratites-]WF'15 sec. *, above if related to foodborne illness 3-401A I(C)(3) Whole-muscle, Intact Beef Steaks interventions and risk factors. Other 145'5"' 590.009 violations relating to gaxl retail 3-401.12 Raw Anitnal Foods Cooked in a practices should be debited under#729- Microwave 165`17* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145°F'15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.1.1(A)&(D) PFIFs 165°F 15 sec. * (Items 23.30) 3-403.11(13) Microwave-165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* foodborne ithress interventions and risk,factors listed above, can be 3-403.1.1(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 C1IR 14WF* 590.000. 3-40;Al(E)1(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roasts" 23 Management and Personnel FC 2 003 18 Proper Cooling of PHFs 24 Food and Food Protection FC 3 004 t FC 4 005 3-501-14(4) Cooling Cooked Pl-IFS from 140`17 26. Equipment matt and Utensils Co 26. Water. Plumbin .00 and Waste FC-5 6 70°F Within 2 Hours and From 70'F 27. Physical Facility FC-6 .007 to 41.°F145'F Within 4 Hours. * 28 Poisonous or Toxic Materials I FC-7 ,008 1 3-501.14(B) Cooling PHFs Made From Ambient (29 S ectal Requirements � .009 Temperature ingredients to 4I'F745"F 30 Other _ _ ------- Within _Within 4 Hours* `Denote,;critical item In(lie federal 1999 Food Gtde or M CMR 590.000. f i_ j Salem Board of Health Massachusetts Department of PugIlcHealth t„ Division of Food and Drugs Sal Washington Street,4 Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name )l _ ) 1�� f- �> // Dat T e of 0 eration s Type of Inspection { E I C S (Q d'/ ✓Vi 7 I)r,/)2 ood Service ❑ Routine Address S ! / ,/_ RIs ❑ Retail ®zRe=inspection b 'tel Level ❑ Residential Kitchen Previous In pection Telephone _ ❑ Mobile Date: la�I Owner t( U 1/_ �S ) r "ACCP YM ❑ Temporary ❑❑ Pre-poperatio, Y f�f! ❑ Caterer Suspect Illness Person in Cha rg (PIC) Time ❑ Bed&Breakfast E] General Complaint In: ❑ HACCP inspector �� t �I Op �� Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action.as determined by the Board of Health. J f L L1 c FOOD PROTECTION MANAGEMENT"" A 2 `_` `s°,r s 9; ( ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties El 13. Handwash Facilities ?r �.EMPLOYEEeP a €.� ,a_ Z.. PROTECTION FROM bHENGCALS I,tir a i c� r + ❑ 2. Reporting of Diseases by Food Employee and PIC t r»-�- - -�� --ars �•-ea.tz�'� F$ w +- a _ L F-1,1 4.Approved Food or Color Additives El 3.. Personnel with Infections Restricted/Excluded [115.Toxic Chemicals .FOOD FROM APPROVED SOURCE ,, !, �.. ,!�"zr" TIME/TEMPERATl1RECDNTROLS-(Potemtall'y Hazardous Fo3tl ❑ 4. Food and Water from Approved Source fi) ❑ 5. Receiving/Condition W ❑'16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION `3; r 1, x' =� "'"" ., El 19. Hot and Cold Holding 1 ... . .�i.d �..�,.�,,,,.,..; i.6 c 0;�i I, i .,.Gmum+i:i•a w�. t_ 14i tiv. % ❑ 8. Separation/Segregation/Protection El20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing 'El210IRFood Nand Food Preparation for HSP POPU}A7tON9(H$P) ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices 4, ;CONSUMER ADVISORY;' Z=2 � y i270 � ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days•as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. x 590.000/federal Food Code. This report, when signed below C N 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S.5501nsp ctFo 614.Ca Inspector's Signature: Print: PIC'sSignature: -�A� Print: F_ �� �c ���n� Page of Pages V - Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT $ Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11. Person in charge--duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foals Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Pow Protection* applicants* 3-302.15 Washin Fruits and Ve enables 590.003(F) Responsibility Of A Food Employee Or An 3-3(A.1 I Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(0) Reporting by Person in Charge' 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Scaled Container* Sanitization Temperatures* 3-20'1.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashinn Hot Water 3-202.1.3 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitisation-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water'° concentration and hardness. * 5-1.01..1.1 Drinking Water from an Approved System* 4-601.11(A) Equipment Foot Contact Surfaces and Utensils Clean- 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 3 10 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* - 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Cantact Surfaces of Equipment* Shellfish* ff 11 ;; Authority Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 1p Proper,Adequate Handwashing Game and Mushrooms Approved by 2-301,11 Clean Condition-Hands and Arms* Idents Re ulato 3-202.18 Shellstack Identification Present* ?r301.12 Cleaning Pnkedtue* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2401.11 Eating,Drinkin or Using Tobacco* 3-202.11 PLIFs Received at Proper Temperatures* 7401.12 Discharges From the Eyes, Nose and 3-202.1.5 Package Integrity* Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 PreventinE Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventhtg Contamination from 3-203.12 Shellstock Identification Maintained* Em alo gees* 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* Location and Placement* 590,004(7) Labeling of Ingredients' 7 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance lHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxy gen packa&ing_criteria* 6-301.1101.1 - Handwashin Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-32 Hand Drying Provision Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. J 6 Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4th Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name I / v Date -/,I Type of Operations) Type of Inspection S t CS ('�e ✓, -1- JIr 11 J ? ` Food Service 'Routine Addressn 1�1 Risk El Retail El Re-inspection A Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: / / HACCP Y/N 11 Temporary ElPre-operationOwner (( ,JVQ I 1 � h Y S r 4% 1 El Caterer El Suspect Illness Person in Chargee(PIC) Time ❑ Bed&Breakfast ❑ General Complaint C(J In:r [IHACCP Inspector rA OutVl� Permit No. ❑Other Each violation checked reiluirei an explanation on the narrative'page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGENiENT�"��M 70 :„�„„ El12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities ALTH r EMPLOYEE HE �'li i�-ff n w` 'ci"' 1 "- '.„i'w„,li9i C� �,.�'.RIM __ �"„a� E.. PROTECTION WiOM CHEMICALS u2H + ! t z' , e §� „r i t�iF ss Tq ❑ 2. Reporting of Diseases by Food Employee and PIC hi�,,.�...,.�iro ,�m�,.�:,.»,»u».�.»..�.m.�a,,...,i kt�e..,ua ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals „FOOD FRO APPROVEDSQURCE * El 4. Food and Water from ApprovIad Source k,TIME(tEMPERATURE CONTROLS(Potemlally Hazardousfoods) ❑ 5. Receiving/Condition P❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION , � t f 1 s r „ d �-q [119. Hot and Cold Holding Q S:,i ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing [REQUIREMENTS FOR HIGHLY'6USCEPTI6I.E Pl]PULAT(QN$ ❑21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing El11. Good Hygienic Practices [CONSUMEf ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below c by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fo-z) .0 4) order of the Board of Health. Failure to correct violations h 24. Food and Food Protection (FC-3)(559090cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-a)(sso.00 )oos) 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 M'X127. Physical Facility (FC-6)(590.007)' have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this ordeffr. 30. Other DATE OF RE-INSPECTION: 5:5X?nspe Fomi14.do Inspector's Signature:- Print: PIC's Signator///� /fid/ Print: C��r ! L ( q1t t���L Paged of Pages V Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination I 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated frau -590.003(B)_. Demonstration of Knowledge* Cooked and RTE Foods* 2 103.11. Person in charge--autres - Contamination from Raw ingredients 3-302,t I(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other' 2 590.003(,0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* _ applicants" 3-302.15 Washing Fruits and Ve. etab'les 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Char*e* Contamination from the Consumer 590.003(0) Reporting by Person in Charge* 3-306.14(A) ) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated- 590 003(F) ontaminated590003(F) Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding orReconditioning Unsafe FOOD FROM APPROVED SOURCE Fri* 4 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501..1.1'1. ManualWarewashing-Hot Water 3-201.1.2 Food in a Hermeticall•Sealed Container* Sanifization'rem eratures* - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.1.3 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101..1.1 Drinking Water from an Approved System* 4-60 LI I(A) Equipment Food Contact Surfaces and 590.006(A) I Bottled Drinking Water* Utensils Clean* 590.006(13) Water Meets Standards in 310 CMR 22.04' 4-602.11. Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source 4-702.11. Frequency of Sanitization of Utensils and 3-20114 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-20115 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulato Authority 2-301.1 I. Clean Condition-Hands and Arens"` 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* 1.1 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Usin Tobacco* 3-202.11 PHFs Received at Proper Temperatures* X1.12 Discharges From the Eyes,Nose and 3-202.15 Package Inte it * Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventingsti Contamination When Tan * 6 TagstRecords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shelistock Identification* 590.004(E) Preventing Contamination from 3-203.12 Sheilstock Identification Maintained* Employees* TagsiRecords: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(7) Labeling of Ingredients* , 5-204.11 location and Placement* 7 Conformance with Approved Procedures 4 5-205.11 Accessibility, 0 Aeration and Maintenance 1HACCP Plans ` Supplied with Soap and Hand Drying 3-502.11 Specialized Processing,Methods* Devices 3-502.1.2 Reduced ox gen packaging,criteria* 6-301.11. Handwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301.12 Hand Dryin Provision * Demes critical item in the federal 1999 Foal Caleor 105 CN9t590-(1(1(1. . CITY OF SALEM 1 I BOARD OF HEALTH t Establishment Name: L o c�i r/ s c O l`r r��14 Date: Ir� /I o J Page: Z of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY Lit V1 cs ( n' r � - - - - l - - r U ? v l\ x_ A C �nrn I r I s O i I r r lZ A)0,o ),.r-., ko(orl 1 0 7A�'J P 4 ( _ U e S I 0n A -il .t/f JA{�� .LC C (f ill' � �7. + Th) L // ,� / (� ( / l AJ 1_DXJrtar (SII I- ..n< -� Vt�S( i S - - _ I 1 U LO ,O I _,�l_ - e✓� _rkn, f f n 1 r i V O� 1 I _ .1 0 t /7. ' I Discussion With Person in Charge: Corrective Action Required: ElNo X Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Emersion P ❑ Re-inspection Scheduled ❑ Emergency Suspension 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. �j ��j/ Ll Voluntary Disposal ❑ Other: - v ----- ---- - — [" -730Tf,T 4(WPI II Rec�ived of Temj;Ja res g to Law Cooled Violations Related to Foodborne illness interventions and Risk Accordin 'r Factors(items 1-22) (Corn) "I�F145'F Within-1 HottrS PROTECTION FROM CHEMICALS Conlim, Methods for PRFs 14 Food.or Color Additives Lj-9- PHF Hot and Cold Holding 3-201,12 A(Utive"* 3-50!.16(B) Cold PHFs Maintant"I at or below 590.004F) 4101,450 F. 3-302,14 Protect on froffulkhra)Lrovto �ddihvcil' -------4- - L 3-501.16(A) flot PHFsMairrunned at or aterve 15 -- — � Poisonousor oxc Substances 140'F. 7 1(Ft.I I Identifying l"foi ination-- Original Rousts Held at or above T30 1, Time as a Public Heafth Control 7-102 It (ormaonNarne ---------- leahl, In, )ubd�� 3-501,19 ni, 7-20 L 11 7-201 T icuon-Prf-wirce and Use* 011 iy) Varian(e 7-202.12 Coaifitiopn of US0, REOWREMENTS FOR HIGHLY SUSCEPTIBLE 2 20111 Toxic Conlarnop,---Probibvioni* ...... POPULATIONS QHSP _ 7-204.11 sanuizers,CrIterw-chcnricRls* 21 3-801�I I(A) Untni�ncurizrd Pre-pa6.agcdR;i---] 7 "(K 1, Chernicak for Was4m ,Ln2e!tu�,(,'tite(ia* Bt ter with Warvil S 14' ia'� 714 _ _ I.--— 21 i---k�il!? 3-8 '31-t,'of_p"t"'n" 0 4220,�,I I Inviderval 1-oIA Contact�LAIN icanIs' [_7-206.11 ko4lvcld U'sv pe'lhides.Criteria, 3-801.1 I(D) Raw or Parit.ittv Gx* d Animal Food and Raw Sr ed S Ironer Not Served 7-4106 12 RM10111 B�it SW Aanrol and CONSUMER ADVISORY 22 3-6W II Corrsuraer An"isory Nroed for Coustimption ot TIMErrEMPERATURE CONTROLS Animal ft"Kos Tbart are Raw.Unden:�)Kcd ci 16 Proper Cooking Temperatures for PHFs OflNot rerwke Proceqsed to EIinwrare 3 40i I I A(I Fgg.+- 15,S'F 15 5'c. 1 -302.13 Egg-Substitutehn w Sirell -401.1-1t S)(2) f 0,mountood Fith, Meat,& GaiT Animus- 1,5t 15%'ex'L" PoBeet Roast 1W'F 121 rainySPECIAL REQUIREMENTS 3-401.111(A)Q� -1�1`tlke'-S,11)jeLl�',d Meme 155�F 15 -'5-90�009(m (557 Violations of Section 790.009(A)-(D) in cateringarrobile hood tenspurary residenlial kitcheir opentions Should he -1-46i I—1(.A:(3 lrouhry, A ild Game,,Stuffed PKF g Corvauing Fish,Ment, 1 dehited under the appropriate sections Poultry or Ranter 165`1 15 Sen. alrove if ielated to fax)dhorne illness 3-401AI(C)(3) Whole-muscit,InuIct Beef Steaks litter ventioni and risk ftictors, Other t0l; 590.009 violations rehoinlo to�uod retail 3-401.12 Raw Aroural Fcxxfs 0xik(A is practices should)v debited under#29 - Micfowave­105'F'- ----] Special RCqLIircnncnts- 3-461,71iAr(10)) Ali Other Pllf> - 145�'F'I Lg Reheating for Hot Holding VIOLATIONS RELATED-fO GOOD RETAIL PRACTICES 3-463,11 (15) Pill;, 165'B 15 wc, — (Rears 23.30) A-403.13 b) Vfi Crow aw-165° 2 mi .n tT,stcZi ne Critical and non-crincal viotalwns, uhich do nn;rotate to tate Time" roodhorne iflncms ns ventioand ri,�kpaors Lord abol,c, avpl(1, 1403.1 IT(7) I C0noWTtia[lV Paxessed RTE Frx)d found in Ihefallowing sections 0,01n;Food Cade and 105('1IR 140'F 3-403,11(r) RearInjong OvUced Portiom(if Boof Roasl'* t nq.!j�rF.,qnnq!. FC -P �003 Proper Cooling of—PHFs 24 RM not nRxId Prolecoo� FC 1 3 004 —181-- f-4 --- -L - !LtartdALerrL,1s. 1 -:4 ; 005 -501,14(A) CM441E Ox&,d PliFs froto t _---- 1-1------ Met,Plurribina and W uste FG-5 X006 70'F Within 2 flounq and From 70'Jo 27 1 Phfsiral FadliltL C-6 '007 io410FA5'F1,VithhI4Rouc�. * 28, Poisonous or Toxx MateriMs I FC-7 '008 3-501.14(B) _g PHF�Made From.Arnbient ---29� ----------- Terrrperatkne lniredicrn:s to 411-'145`F 30, other W thin 4 HouW Denoto's C'ItIcal]rom in Ire r'it 1979 Fol l('xfc'e 105(:,.,4R 570 000 CITY OF SALEM BOARD OF HEALTH Establishment Name: �I Date: Page: of lltemp� Codei,,­,�,Z, C 7 Critical lte�m"� -'D DESCRIPTION OF VIOLATION Date jj;� 1 .1 Pvg'�k'40& i�� 1� E N PLAN OF,CORRECTION,,,, Reference led No.,�, R "o *�# R Red item tt"i L!'-'; L,PL c -,EASE PRINT CLEA�L'Y ".7 daqd4 -4v Lw �i�u L,�,4 0 C> oe 'sy'oj 15 0 k blop I C4 4C -tz'. L A.ke,J4 Discussion With Person in Charge: Corrective Action Required: ILI e I have read this report, have had the opportunity to ask questions and agree to correct all I Voluntary Compliance J 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 2K Re-inspection Scheduled Ll Emergency Suspension noncompliance may result in daily fines of twenty-five dollars orsuspension/revocation of c3 Embargo LD Emergency Closure your food permit. Ielary 0 Voluntary Disposal z Sal Q Other: Pa ­50!,)4(Q PHFi;Received at T;mwraiur;;s Violations Related to Foodborne Illness Ino-mentions and Risk s .According to lav Cooled Factars(lleatts 1-22) (Cont,) 41'F/45'F Widaril Hovis- PROTECTION FROM CHEMICALS L19 PHF Hot and Gold Holding 14 Food or Cl..Adddi!!t_=� I soL 15(ll) Cold PHFll Maintained at or ttelow 3-202,12 Additivc,'" 590,004F) 4!`145°F* 3-302,14 Protection from ttnappurved � — ----4 Poisonous or Toxic Substances 9-501,16(A) 1.11A PFII"q lfaintailled;if or above 7-101.1 F Original14O'E.,L___ 1-501 161 Rousts field at or above 130°F. Time as a Public Health CowboL--� a Publb�I feahir Control, I l0i I IRaynctioni ommon Narset-- works -C 7-20LI 1 and Lie"7.202.1-1 -Pre'se'rico [-2-202.12 TM Conditions of Uw* 7-20111 Toxic Conuarwo;-RroI,,1w.,lwW REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sarlili7eN,Criteria-ChCUACAS* POPULATIONS 21 3-SO 1,11(Aj' Juices and 7-20,k 12 Chaniical�for Was ce7 fi dial' 7 204,14 es with io�ria� — 11 Incidental Foort Contact.Lubricati 1, :Skl1 I(BL—!Le_("'A'I c Llf!/—e -W I IIIJ) Raw or Parualiv Cooked At olid Frxxf ane} Raw sceLs 7-ZO6.12 R(Xlf at 13�it scitiole,' 3-K 01,11(C) Ureaned Food Pace 7."06.12 Trickna;Po%%dts�;,PeiaCoiatrol and a, ............... I n7L CONSUMER ADVISORY -T2 --i7),—OIT 111 ('01),urier Aciviloi y flcstud f4 Coullemption of TIMErrEMPERATURE CONTROLS Anwad Fooc[�Thtaarc Raw, Undcrcxx>kod o Proper Cooking Temperatures for HFs Not Of ice Proce5sed to Flimiraae PHF _TT __ _ [�s llatho,�ern (;i t I I 55'F 15'S H�Y'F'15cec. llomeurj7od Fgt.:Substitute to) Sew shell 1-401.11(A)(2) cotrawynocd Fols, "'fellis&Gault 40130F 121 riun� li-ef Roari SPECIAL REOUIREMENTS 3-401.11(A)Q) Raines, lnicccoi ,%Ieats - 15s'F 15ae 590.009(A} (D) �iolanoos ciff'Seclion 59(k009(�,7)-`(D),n7 cateringmobile f(x.)d,unriporary and 3 40 1.11 W3) I Ponitir),VA ild Game,Stuffed llffs, i reNidendiial kitchen operations should be Sildifilla camsilang, F10t Nfear dcluled tinder the appropriate.sectioas Poultiv(a,leatites-165",P 15 see. above if related to ftxrelborne jlljwss Intact Reof Steaks interventions and risk factors Other 145F 590.009 violaficao4 radatino to 000d retail 3-40L 12 Raw Anitrad Fcixl. Cooked in it practices should be debited under#29 - Micicava" 105'F Special Perleirernents. 7 T46 i I I(,T�FIf fil Allth'iteF11 145'F 15se,; L17Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-;OTI I(A)&(D) Pill;, 165°b to - (Items 23-30) 3-403.11(B) Microwave- 165F 2 Minuie, Standing Ct itirai and non-(ruical viokilwits, which do Part relate to lee Time" foodhorne ilhe.,vv huet verniow and rok,(wiars Vvred above, can be 403.11(C) I Conatelcially Prtx eised R'II,`Fvwld- fintild it,drejolhia-ing se(nous o f the Food Code and 10-5 CA4R 140'F* J90,0(& 3-403-1 1(E) Rem irate, Umiii.�ed Portions of Beef Retail Practices FC 59iraftis tvSanagt meat and persoripp! FC -2 003 d F d F 24 ooanoad"Pncjectloil art at PHFs --Ft� 1­-"-­­ 25, 1,merit and Utensils FC 4 5 W ter rnbin wid`Nast© F .006 3 5kIA4(A) Cool Ing C Cooked PHIs bum 14WF 14) i 70�17 Within 2 Fkxu�and From 7,)'I' 27. Pte5cai Facilftv F0-6 it,41'F145'F sVithin 4 Finnic. DOS 413) Cool ng PHF�Made From Ambicat Pericurementr, 3—501 1 Tempirrainre Ingredients to 411745'I't L i0 _Other ------------ within 4 fjours* *Uemxcs critical herr,ollhrIeAm,! 19)9 Foci Cate cr 105 Choi{590000, `Iy it Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,41"Floor Division of Food and Drugs 1 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name ID Date Type of Operation(s) Type of Inspection l PAJ f' ( � 000d Service ❑Routine Addr s Risk E IJ Retail ❑ Re-inspection r Level ❑ Residential Kitchen Previous Inspection Telephone + ❑ Mobile Date: Owner HACCP YM El Temporary ElPre-operation Un p ❑ Caterer ❑Suspect Illness Person In CVharge(PIC) Time ❑ Bed&Breakfast ❑General Complaint Inspector In. I Permit No. [IHACCP Out: ❑Other Each violation checked requires an explation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) Lg-�-i9o.009(F)�fp action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT _ ❑ 12. Prevention of Contamination from Ha ❑ 11. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ; , �.sr,: ,3y - - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVE D_SOUR CE El 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition El 16. Cooking Temperatures _ -- ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 16.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding El B. Separation/Segregation/Protection El 20.Time As a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing 16EQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP), q:❑ 10. Proper Adequate Handwashing [121. Food and Food Preparation for HSP 0 11. Good Hygienic Practices rp-6NSUMER_ADVISORY- _ _ _ _ _ , X142. Posting of Consumer Advisories Violations Related to Good Retail Practices b Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of c Health. 590.000/federal Food Code. This report,when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc•a)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. (o 30. Other DATE OF RE-INSPECTION: sv l�ail c-� 7 c� a3 Inspector's Signature: l) Print: PIC's Signata": Print: l h _ ( f Page ofages- F t 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) Assignment of Responsibility* Cooked and RTE Foals* 590.003(B) Demonstration of Knowledge" Contamination from Raw Ingredients 2-1.03.11 Person in charge-duties 3302A I(A)(2) Raw Animal Foods Separated from Each Other" EMPLOYEE HEALTH Contamination from the Environment 2 590.(X)3(C) Responsibility of the person in charge to 3-302.1 l(A) Food Protection* require reporting by food employees and 3-302.15 Washing 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 in Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003((3) Reporting by Person in Charge* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Ftwd* FOOD FROM APPROVED SOURCE 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501..111. Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sy caled Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Temperatures* 3-202.14 Eggs and Milk Products. Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.1.1 Drinking Water from an Approved S^stent* 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 Contact Surfaces and Utensils* Food- Shellfish and Fish From an Approved Source 4-702,11. Frequency of Sanitization of Utensils and - 3-201.14 Fish and Recreadonally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild f tushrooms Approved by Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-20117 Game Animals* 1.1 Good Hygienic Practices g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and 3-202.15 Package htte it .* Mouth* 3-10111 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification a 590.004(6) Preventing Contamination from 3-203.12 ShellstoekTdentificationMaintained* - Employees* Tags/Records:Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 3-402.12 RecorLabeling of Ingredients' and Retention* 5-204.11 Location and Placement* 590.004(J) Latreiing of Ingredients' 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized ProcessingMethods* Devices 3-502.12 Reduced oxygen anka - q ncriteria* 6-301.11 Handwashin Cleanser, Availability 8-103.12 Conformance with A.. roved Procedures* 6-301.1.2 Hand Drying Provision Denotes cridan item in the federal 1999 Food Cale or 105 CMR 590.000. CITY OF SALEM pr BOARD OF HEALTH Establishment Name-&L -AY) �Io. Rte-- Date:A�� Page: Q' of 3 Item Code C-Critical Item !` DESCRIPTION OF VIOLATION/PLAN OF CORRECTION DaW No. Reference R-Red Item ' Verified PLEASE PRINT CLEARLY 41�l ) -YiI A N-.`�Ai,f.fiflL�i �J_ - _ � I`� ��✓'1�hn, , y .t��e'n l ����Ue1ni� YY�h� '_�"��f /'•z.., ��� -' il ni.E'1 C / � Y t -h - Q ^^cO VnoCtA_— \AJ `7I \ Y/ � /MV /1n. 171 d N VLA, Fn n a, (9,. i i - ) q-lana i 6 iZ co -0 �.l°p�-Eo-7fi , ,.: Ol Discussion With Person in Charge: Corrective Action Required: ❑ No YYes I have read this report, have had the opportunity to ask questions and agree to correct all g/Votuntary Compliance ❑ Employee Restriction/ I 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 (J ? p ,noncompliance may result in daily fines of twenty-five dollars oVsuspens �ion/revocation of mb rgo+`, T i� ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: y t i r , 3-501.14(C) PHFs Received at Temperatures Violshons Related to Foodborne Illness lnferrenfions and Risk According to Law Cooled to Factors{ffems 1-22) (Cant.) _ 41aF/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Ctrolin Methods for PHFs 14 - Food or Color Additives 19 - PHF Hot and Cold Holding ditives*' 3-501.16(B) Cold PITF%Maintained at or below 3-202.12 Ad 3-302.14 Protection from Una roved Additives* 590.0016( Hot P F* 15 Poisonous or Toxic Substances 3-501.16(A} Hot PHFs Maintained at or above 140°F. * . 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held of or above, 130'F, Containers* 20 Time as a Public Health Control 7-102.11. CormuonName-Working Containers* 7-201.11 Separation-St o 3-501;19 Time as a Public Health Control* 7-202.11 .Restriction-Presenceand Use* 590.004(H) Variance Requirement 7202.72 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanifti rs.Criteria-Chemicals* 7-204.1.2 Chemicals for Washin Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged 3uices and Bevcra.ges with Warning Labels* 7-204.14Drying' Agents.Criteria" 3-801.11(B) Use of Pasteurized Eggs* 7-205,11 Incidental Food Contact Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served, 7-206.12 Rodent Bait Stations* 3$01.11 C Unopened Food Package Not Re-served. 7-206.13 Tracking Powders, Pest Control and Monitoring' CONSUMER ADVISORY TIMEtTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Tem{�ratttres lar Animal Fouls`chat are Raw,Undercooked or PropHFs Not Otherwise-Processed to Eliminate 3 401.I1A(1}(2} Eggs- f55`F 15 Sec. Pathogens.*"'" E -immediate Service 145°Ft5 ec* 3-302.13. Prized Eggs Substitute for Raw Sheil 3.401.11(A)(2) Comminuted Fisb.Meats&Game E;:: Animals-155°F l5 sea. 3.401.11(B)(1)(2} Port:and Beef Roast- 130°F'121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.049(A)•(D) Violations of Section 590.009{A}-(D)in sec.* catering,mobile foul,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing-Ash,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec.* - above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F<_ 590.009 violations relating to good retail 3-401.12 Raw Animal Fiords Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3401:1 I(A)(1)(b) All Other PHFs-- 145°F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRAC77CES 3-403A I(A)&(D) PRFs 165°F 15 scc. * (Items 23-30) 3-403.11(B) Microwave--165`F 2 Minute Standing Critical,mid non-critical violations,which do not relate to the Time* - foodborne illness interventions and riskfactors listed above, canhe 3-403.11(C) Commercially Processed RTE.Food- found in the following sections�gf the Food Cade and 105 CMR 1400P 590.000. 3403.11(E) Remaining Unsticed Portions of Beef err+ I Good Retail Practices FC 690.000 _ Roasts* 23. 1 Management and Personnel ( FC 2 .003 !. 18 Proper coo0ng of PHFs 24. i Food�and Food Protection FC 3 Wet 1 25 1 Equipment and Utensils 1 FG 4 .005 3-501.14(A) Cooling Cooked PRFs from 140°F to ! 26, Water.Plumbing and Waste FC-5 'M 70°F Within 2 Hours and From 70°F , 27. Physical Facility to 410F/45°F Within 4 Hours.* 1.2_8. ' Poisonous or Toxic Materials FC-7 .008 3-501.14(8) Cooling PHFs Made From Ambient 29. _Special Requirements .009 TempestureIngredients to4l°F/45`F 30, 1 Other Within 4 Hours` s:ssnr,mam:<t c: . Denotes anical wmn in the£.deral 1999 Food CW v or 105 CI IR 590900. CITY OF SALEM p nBOARD OF HEALTH (- Establishment Name:r� P ')(> ' a �, Y�1 _ , - ', PiON' Date: Page: 3 of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Item Verified PLEASE PRINT CLEARLY D Dn _>s} t 1) Did 2A��, _ (vL, - cYJ U � d> � L _ kri n(` on e Cl S E \ 1x4 in n S P U i� c o \I t/\ �rt_ J f�F' ,.'✓ :ril...°/ 7nA , , on �) 7P �l1 A-1 LDssion With Person in Charge: Corrective Action Required: ❑ No O-'Yes e read this report, have hk�d the opportunity to ask questions and agree to correct all p/Voluntary Compliance ❑ Employee Restrictiontions before the next inspe$ ion, to observe all conditions as described, and to Exclusion L � e-inspection Scheduled ❑ Emergency Suspension ply with all mandates of the Mass/Federal Food Code. I.understand thatP�ompliance may result in dailyBines of twenty-five.dollars,or suspension/revocation of mbargoq� 3 ❑ Emergency Closure food permit. /n G /s, ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne fitness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'F/45°F Within 4 Hours, PROTECTION FROM CHEMICALS 3-501.15 CoolingMethods for PHFs 14 Food or Color Additives 19 PHF Slat and cold Holding •- ----- 3-501..16{B) Cold PI-IFs Maintained at or below 3-202.12 I Additives* 590.004(F) 410 45'Ft. 3-302.14 Protection from Un roved Additives" 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances . 140'F. 7-101,11 Identifying Information-Original 3.501.16(A) Roasts Heid at or above 130'F. Containers* . 7-102.11. Comutmr blame-Working Containers* t ZO 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* - 5W.004(H) Variance Re uirement 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 Washin Produix,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* .Bevrra>es with Warning Label s* 3-F{01.11tB) Use of Pasteurized E * 7-205.11 Incidental Food Contact, ,Criteria* 3-801..11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides;Criteria* y Raw Seed Sprouts Not Served. 7-206.22 Rodent Bait Stations* 3-801.11 C Unopened Food PackageNot Re-served. 7-206.13 Tracking Pmvders, Pest Control and Monitoring* - CONSUMER ADVISORY TIMEII EMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Funds That are Raw.Undercooked or PRFs _ _ Not Otherwise Processed to Eliminate Pathogens,'tY,bcnvc rnrrxi 3-401.I IA(l)(2) Eggs- 155'F 15 Sec. Eggs-.Immediate Service 145'F15sec" 's 3-302.13 Pasteurized E g& Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game Eggs' Animals-155'F 15 sec:. SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* 3-401A I(A)(2) Ratites Injected Meats-155'F 15 590.009(A)-(D) Violations of Section .590.009(A)-(D)in see. * catering,mobile food,temporary and 3-401.1 f(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites4650F 15 sec, * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145OF 4' 590.009 violations relating to goal retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401,11(A)(1)(b) All Other PRFs--145'F 15 sec.* 17 Reheating for Hot holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave- 165`F 2 Minute Standing Critical,mid non-critical violations,which do not relate to the Time* foodborne illness interaentions and risk factors listed above,cart-be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. . 3-403.11(E) Remaining Unsliced Pottiots of Beef P Item j Good Retail Practices I FC 690A0o Roasts* _ 23. 1 Management and Personnel FC-2 .p03 18 Proper Cooling of PHFs 1 24.. 1 Food and Food Protection FC-3 .004 1 25. Equipment and Utensils I FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140`F to26. W ater.PlUmbinq and Waste 1 FC-5 .005 70*F Within 2 Hours and From 70*F 27. Physical Facility FC-6 .007 to 41`F/45'F`.i ithin 4 Hours. * f 25. Poisonous or Toxic Materials E FC 7 .008 3-501.14(13) Cooling'PHFs Made From Ambient X29. SQecial Requirements ,008 , Temperature Ingredients to 41°F/45'F ' i Other i Within 4 Homs* 'Uznotcs critical hem in the federal 11,199 Food Code ui'105 CNIR 590.00 . l i Massachusetts Department of Public°Health Salem Board of Health 120 Washington Street,4th Floor DIVISIOn Of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Data Type of Operation(s) T f Ins ection k ( Food Service Routine Address Risk 0 Retail e-inspection n _ Level El Residential Kitchen Previous Inspection Telephone I El Mobile Date: Owner 1Q 7 HACCP YIN ❑❑ Catenary ElPre-operation Person I' Charge PI ❑ Suspect Illness `1 g (PIC) (J Time ❑ Bed& Breakfast ❑General Complaint ou Permit No. [I HACCP Inspector .�.V Out: El Other Each violation checked requires an ex la ation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT .. _ -. - [:112. 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 El14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded _ ❑ 15.Toxic Chemicals FOOD FROM,APPROVED SOURCE ❑ 4 Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous_Fo6ds) ❑ 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 _ - ti. - ba ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control G 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY_SUSCEPTIBLE POPULATIONS_(P ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices _I CONSUMER ADVISORY ^° y (/fy 22. Posting of Consumer Advisories Violations Related to"Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report,when signed below c x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations /1 24. Food and Food Protection (Fc-3)(5so.004)) cited in this report may result in suspension or revocation of (/ 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s=�, ,, Inspector's Signat6re: Print: / � ` Q✓ PIC'sSignatur : l Print: �, (J, �_ �\ Page oages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION Cross-contamination FOOD PROTECTION MANAGEMENT '1 590.003(A) Asia went of es onsibiliC * 3-302.11(A){t) Raw Animal Fonds Separated from Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw ingredients 2-103.11. Person in charge -duties 3302.11(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 3.302.1.1(A) Food Protection* require reporting by focal employees and 3-302.15 Washing 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 In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590,003(G)__ Reporting b Person in Char&e* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(F.) 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 Hermetically Sealed Container* Sanitization Tem eratures* 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 EMs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and . 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces ofEquipment*p Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by k240 ,.11 Clean Condition-Hands and Arms* Re Mato Authortt 3-202.1.8 Shellstock Identification Present* ..12 Cleanin Procedure* 590.004(0) Wild Mushrooms* 1.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 - Receiving/Condition 1.11 Eatin ,Drinkin or Usin Tobacco* 3-202.11 PHFs Received at Pro er Tem eratures* 112 Discharges From the Eyes,Nose and 3-202.15 Package Ince it * Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(F.) Preventing Contamination from 3-203.12 Shellstock Identification Maintained Employees* 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 5-205.11 Accessibility,O oration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with A roved Procedures* 6-301.1.2 Hand Drying Provision *Denotes critical item in the federal 1999 Pail Cade or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: DL oa'n �_2� ,4- ? Date:--?—, (Jl�/ Pager_ of _ Item Cafe C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item � Verlfled PLEASE PRINT CLEARLY A IlPr I �YV n <OV� n( axl , S - CJ� , rnm o hvn 1n . Old n aI / fUk Cr/L - syvex wl 6Q Cn� Yt v�c,�z.ri 7tM L4 A_ �!A A, 1 oto , c Q `v ppnn 77�� , vi 1 D M f M n n on ()A P -1yA � f� ._fes_ � S tU� l ' o f_/ 1 ,2A ff hT-z I Discussion With Person in Charge: Corrective Action Require ❑ 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 ❑ 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 r suspension/revocation of ❑ Embargo C) Emergency Closure your food permit. , i" � ❑ Voluntary Disposal ❑ Other: i 1 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(items 1-22) (Cont.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 - PHF Hot and Cold Holding 3-202.12 Additives* 3-501,16(B) Cold KfFs Maintained at or below 3-302-14 Protection from Unapproved Additives* 590,004(1•' 41°/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 140°F. * 7-101.11 I Containers* rs Information-Original 3-501,16(A) Roasts Held at or above 130°F. -Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Se aration-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 ,Restriction-PresenceandUse* 590.004H) 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 WashingProduce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged luices and Beverages with Warning Labels* 7-204.14 n encs.Criteria* 3-801.11(B) Use of Pasteurized E "* 7-205.11 Incidental Food Contaa Lubricant * 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria 7-206.12 Rodent Bait Stations* Raw Seed Sprouts Not Served 7-206.13 3-801..11 C) Unopened Food Package Not Re-sensed. Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEtTEMPERATURE CONTROLS 22 3-603.11. Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PRFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 See.-E "°v'nmr Eggs-Immediate Service 145°F15sec* 3-302.13 Prized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game EV Animals-155°F 15 sec. 3-401.11(B)(1)(2) Pork and Beef Roast-1.30°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.0(Y9(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 we. * above if related to foodborne illness 3-401.1.1(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401;11(A)(1)(6) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3.403,11(A)&(D) PHFs 165T 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 Titre* - foodborne illness interventions and riskfactors listed above, can:he 3-403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 140°F* 590.000, 3403.11(E) Remaining Unsliced Portions of Beef nem I Good Retail Practices FC 590.000 Roasts* - 23. Manmenrient and Personnel FC-2 .003 .i 18 Proper Cooling of PHFs 24. _ Food and Food Protection FC-3 7004 i 25. Equipment and Utensils I FC-4 .005,,, 3-501.14(,A) Cooling Cooked PHFs from 140°F to 26. Water.Plumbingand Waste FC-5 .0096 70'F Within 2 Hoursr, and From 70'F 27. -Physical Facility l FC-6 .007 to 41°F/450F Within 4 Hours. * 28. Poisonous or Toxic Materials : FC=7 .008 3-501.14B) Cooling PHFs Made From Ambient 29. S Special R uirements .009 Temperature Ingredients to 41°F/45°F 30. Omer _ Within 4 Hours* +:sant<xd 'Dmotes critical item in the federal 1999 Foal Code or 105 CMR 590.000. CITY OF SALEM n BOARD OF HEALTH Establishment Name: �Q� e� pl�e-e ��1,��Qr� Date: Page:_ Of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date, No. Reference R-Red Item Vernled PLEASE PRINT CLEARLY f d 1 .10. , La ff CLO -3 V _4� — x, 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 ❑ 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 tw ji five doll rrl uspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. Ila ❑ voluntary Disposal ❑ Other: i 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to law Cooled to Factors(Items 1-22) (Cont.) 41'F/45°F_Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 590A04(F) 41'/45°F* 3-302.14 Protection from Unapproved Additives* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 140'F. 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 1 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Rego 7-202.12 Conditions of Usc* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* pppULATIONS HSP 7-204.11 SanChemicalses.Criteria i Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels* 7-205.11 Incidental Fwd Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed S Served - 7-206.1 Not Serve 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders,Pest Control and 3-R01.1)(C). Uno tied Fwd Packs Not Re-served. Monitoring* CONSUMER ADVISORY _TIMEJTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 Sea Patbo ns.1"V°rnymi Eggs-Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3.40E I1(A)(2) Comminuted Fish.Meats&Game E Animals-155F 15 sec. * 3401.11(B)(1)(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering, mobile foal, 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(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 tinder#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 3-403.11(A)&(D) PRFs 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 Tithe* foodborne illness interventions and risk factors listed above, cart:be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item Good Retail PracticesFC 590 Roasts* 23. Manartement and Personnel 'FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 004 25. Equipment and Utensils FC-4 .065 3-501.14(A) Cooling Cooked PRFs from 140'F to 26. Water,PlUmbing and WasteFC-5 .006 70'F Within 2 Hours and From 70'F 27. - Physical Facili i FC-8 .007 to 41'F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials : FC-7 .008 3-501.14(B) Cooling PRFs Made From Ambient 29. Special Requirements ' .009 Temperature Ingredients to 4I'F/45'F 13a I Other _ Within 4 Hours* sdoni�.ic x 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000,