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LESLIE RETREAT GRUB AND PUB - ESTABLISHMENTS LESLIES RETREAT GRUB & PUB 96 NORTH STREET i x _ a � I �OOND1?•,��, City of Salem, Massachusetts 3 t Board of Health a 120 Washington Street, 4th Floor, Salem, MA 01970 P Tel. (978) 741-1800 Fax. (978) 745-0343 PI1I'th Prevent. Promote. Protect. Iramdin@salem.com Kimberley Driscoll Larry Ramdin RS/RENS, CHO, CP-FS Mayor Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 Permit Number: FM-15-47 Permit Type: Food Establishment 25-99 seats Goods &Services: Food Service: 25-99 seats Name of License Holder: Leslies Retreat-Yukers Bright Spot Inc. Name of Food Establishment Leslies Retreat Grub & Pub Address of Food Establishment 96 North Street Salem MA 01970 Restrictions: This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: $280.00 Issued: 1/1/2015 CITY OF SALEM, MASSACHUSETTS �uu�seaIth . BOARD or HEA1,11-t ��,.". 120 WAS]IING'rON SSnaurr,411 FLoot KIMBERLEY DRISCOLL TIS..(978)741-1800 FAx(978)745-0343 LARRY RAMDIN,RS/REI IS,CI 10,CP-FS MAYOR Iramdin(e salem.com HI:A1.I'1I AGG:NT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: L' V<-1 Q �GG_ ��/1 LC:Vk45 2) Establishment Address: psr let MA 01r7o 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: P- -/4 { Q-95— 5) Applicant Name&Title: LLA-11767' kltf1 ✓[ 6) Applicant Address: U ST- O 7) Applicant Telephone No: y 7�J`— 24 Hour Emergency No: Email: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address Q corporation An individual 04,A Ipt OwvPa� I D!L J Apartnership 1121,/G• .� Other legal entity 12 Person Directly Responsible For Daily Operations O ,er, Person in Char e,Supervisor,Manager,etc. Name&Title: I -L Address: tn1� � 4(y ? y Telephone No: Z Fax: (3Z�T 17 0 -1 tmail: Emergency Telephone No: dit -1e -)-to /.-z-"--7-- 13) LZz13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#:_� Date: Amount: Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) e, C° 16 Das and Hours of Operation - Y P o o.v 17) No. of Food Employees: �p 18) Name of Person in Charge Certified in Food Protection Management: -q-18,�S7 7 _ Required as of 101112001 in accordance with 105 CMR 590.003(A) L S 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): (3'Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) 0 Retail( Sq. Ft) 0 Caterer Permanent Structure 19"Food Service-( Seats) 0 Frozen Dessert Manufacturer Mobile Mlood Service-Takeout 0 Residential Kitchen for Retail Sale 0 Food Service-Institution 0 Residential Kitchen for Bed and ( Meals/Day) Breakfast Home 0 Food Delivery 0 Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments (check one) RETAIL STORE RESTAURANT ✓Annual 0 Less than 1000sq.ft. $70 0 Less than 25 seats $140 Seasonal/Dates: 01000-10,000sq.ft. $280 0 Residential Kitchens $140 0 More than 10,000sq.ft. $420 019-99 seats $280 0 More than 99 seats $420 Temporary/Dates/Time: ------------------------------- ❑ Bed S BreakfastlChildcare ServiceslNursing Home $100 ................... ................................ --------- ----------- ... ............................... - ADDITIONAL PERMITS 0 MAKE ICE CREAM,YOGURTISOFT SERVE $25 0 PASTURIZATION $25 0 ALL NON.PROFIT* $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF—potentially hazardous food(time/temperature controls required) ✓ Non-PHFs—non-potentially hazardous food(no time/temperature controls required) (check all that apply): RTE—read -to-eat foods Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs 1for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service., Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable lawL. I ha en instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: cltic 6 Pursuant to MGL Ch.62C, sec.49A, I certify under the peril ' of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. �G 25) Social Security Number or Federal ID: f- 26) Signature of Individual or Corporate Name: /�f/ Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax(978) 745-0343 City/Town of :W ejj4 Address: FOOD E$TABLISHMENT INSPECTION REPORT Tel. Name D t Type peraf/onls) Type of/ ection ood Service ine Address Risk ❑ Retail Re inspection Telephone Level E) Residential Kitchen Previous Inspection ❑ Mobile Date: Owner HACCP YM ❑ Temporary ❑ Pre-operation PO JjAP ❑ Caterer ❑Suspect Illness Person-in arge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint i/!✓I ❑ HACCP Inspector U Out: Permit No. ❑.Other Each violation checked requires an explan n on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness In en tions and Risk Factors_(Red Items) - - Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ Allergen Awareness 590.009(G) ❑( � corrective action as determined by the Board of Health. ""�\ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties E] 13. Handwash Facilities EMPLOYEE HEALTH PROTECTIONTROM'CH El ❑2. Reporting of Diseases by Food Employee and PIC . EMICALS- 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD'FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TwrrEMPERATURECONTROLS(PoteMlally Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑,8. Separation/Segregation/Protection ❑ 20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY-SUSCEPTIBLE-POPULATIONS,(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an ins ect on 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-zXsso.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-4X590.o05) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (rc5)(59o.om) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590,007) have a right to a hearing. Your request must be it writing 28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Heath at the bove address 29. Special Requirements (590.009) within 10 days of receipt of this or r. s. gp pthe \� n G � i^^ DATE OF RE-IPECT Inspector's Sig^nna�ture: •r�''nWn^v^`'^r^d Print:Vl\ [`It'tJ1n nom"_ J( / PICS Signature: CtLr Print: ZLHPage o>F ages Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g1 Grass-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal FtxKis Separated from 1 590.003(A) Assignment of Responsibility* Calked and RTE Foals* 540.003($) Demonstration of&towledge"' Contamination from Raw ingredients 2-103.11 Petxon in charge-duties 3-302.11(A)(2) Raw Animal Foals Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590,003(C) Responsibility of the person in charge to 3-3U2.11(A Food Protection* require reporting by foal employees and 3-3(12.15 Washing Fruits and Vegetables a rlie nns* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Foul 13rnployee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Char n* -� ?-306.14{A}(�) Returned Foal and Resevice of Foal* 590.003(Cr) Re otrin b Penson in C'har4e* (Disposition of Adulterated or Contaminated 31 590.003(0) Exclusions and Restrictions* Food 590.003(E) Removtd of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE _ Foal* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Fad p L Law* 4-5111 Manual Warewashine-Hot Water 3-2U1.1.2 Food in a Hermetically Sealed Container*--It"~- SanTemperatures* Teeratures* all 3-20113 fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell E- s* __ Sanitization Temperatures* 3-202.14 }' s cmd Milk Products, Pasteurized" 41-501.114 Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinkin�Water* - concentration and hardness. * 5-1.01.11 Drinking Water front an Approved System* 4-601.-'II(A) _ Equipment Food Contact Surfaces and 590,006(A) Bottled Drinking Water* Utensils CleatO 590.006{.B) bVatei Meets Standards in 310 CMR 27.0* 4-602.1 I Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils Shellfish and Fish From an Approved Source 4-702.1) Frequency of Sanitization of Utensils and 3-201.14 Fish and Reci caticsnally Caught Molluscan _ Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Ha Water and 3-201.15 Molluscan Shellfish from NSSPListed Chemical* Sources* 10 Proper,Adequate Handwashing Garne and Wild Mushrooms Approved by 2-301.11, _ Clean Condition-Hands and Arms- 3-202.18 nus"3202.14 Shelistock Identification Present* 2-301.12 Clennino Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-20117 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.1 1 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Tem ratttres:" 2401.12 Discharges From the Eyes,Nose and 3-202.15 package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated3-301.12 Preventin Contmnination When Tustin r. p Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.14 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 Shellstoek Identification Maintained* _ Em rlo•ees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 5-203.11 Numbers and Capacities* acities* 3-402.12 Records.Creation and Retention* 590.004(7) Labeling of Ingredients' `- 5-204.1 i Location and Placement* q Conformance with Approved Procedures P6_301' 1 Accessibilit ,Operation and Maintenance /HACCP Pians Supplied with Soap and Hand Drying Devices 3-502.11 S duce o gen p cl Methods* 1 Handwashin Cleanser,Availabilit 3-502.L2 Reduced oxygen ackaunq criteria* 4-103.12 Conformance with Approved Procedures* 2 Hand Drying Provision ''Devotees cridcal item in ttie federal 1999 Food Code or 105 CMR 596.000. M1400 / , C—Critical item • • • • • • • R—Red Item X101 W09 IM I NMI ���,.'[•��. la`s ��... ., ,. .z'! ':1�1 >>i_, ®� i�..}A!�C�hLIC N � M MEMO i�.1ir�i�li�I �S '�i► �....,_„-. ''_d�fl�! .;.. , : - Vic••..,,, _ � ��'�E'�!.►Ms"�i� ���V' - • ...-. -ems. : ,._ /.1., _,_ � . . - .. . . - .. . . . . • . . - _ � {.fin' . . . .'�-- - 3-501.14(C) PRFs Received at Temperatures Viotations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 417145'F Within 4 Hours. 3-501.15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS 19 PHF Not and Cold Holding Food or Color Additives 14 -,--- 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(17) 41°145°F* 3-302.14 Protection from Unapproved.Additives* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances WOR * 7-101.11 Identifying information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* - 24) Time as a Public Health Control 7-102.11. Common Nam-Working Containers* - 3-5Di.19 Time as a Public Health Contra(* 7=201.11 Soration-Stora e" 590.004(11) Variance Re 7-202.11 Restriction-Presence and Usc* turement 1.202.12 Conditions of Use* RE0UIREMENTS 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(.4} BeveUnparages wit Pre-packaged Juices and 7-204.14 in Agents.Criteria* Use of a with Warning Labels* 7-205.11 Incidental Forel Contact,Lubricants* 3-801.11(B)8A ( Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3 801.11@) Raw or d Sprouts uts Not S rvd.Animal Food and Raw Seed S s Not Served * 7-206.12 Rodent Bait Stadurs* 3-80I.il(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and - - Mrnutonn * -CONSUMER ADVISORY TIMEtTEMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs Patho '"eaecrve,nrnmr 3-401.IIA(1)(2) Eggs- 155F 15 Sec. Em.-Immediate Service 145°F15sec* 3-302.1.3. 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Cram * Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 31401.11(B)(1)(2) Pork and Beef Roast- I309F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.1 l(A)(2) Ratites,Injected Meats-155°F 15 sec.* catering,mobile food,temporary and 31401.1.l(A)(3) Poultry-,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-1650F 15 sec. * above if related to foodborne illness 3401..II(C)(3) Whole-muscle,Intal Beef Steaks interventions and risk factors. Other 145°.F* 590.009 violations relating to good retail 3-401.12 Raw Animal Fools Corked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 340LI1(,A)(1)(b) Ali Other PHFs- 145-F 15 sec. 17 Rettesitng for Hot Voiding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403;11(A)&(D) PHFs 165-F 15 sec.* (Items 23-30) 31303.11(13) Microwave-'165`F 2 Minute Standing .Critical,and non-critical violations,which do not relate to the Time* foodborne illness interventions and riskfactors listed above, can be 3-403A I(C) Commercially Processed RTE Food- found in the following sections of the Food Code acrd 105 CMR 1400F* 590.000. _ 3403.11(E) Retraining Unsliced Portions of Beef /Perri I Good Retail Practices .FC T 5905900w li 23, Mana ement Parsarrxd FC-2 .003 i Roasts* JFood and 24.. F�and Fel Protection FC-3 .004 18 ---^- Proper Cooling oP PHFs 2&- E ui rnent and Utensils FC-4 005 t 3-501.14(A) Cowling Cooked PHFs from 140'F to 26. 1 Water,Plumbing and Waste FC-5 F06-i 70'F Within 2 Hours and From 70'F 27. Physical Fac@ FC-6 .007 to 41°F/45'F Within 4 Hours.° 28. Pdsonous aTozic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ec al R uirements .009 Temperature Ingredients to 410F1457 30' ( Other -- ---- ----1 Within 4 Hours' *Dmotes crhial item in the federal 1 999 Frad Code or 105 CMR 590.000. CITY OF SALEM �,, BOARD OF HEALTH Establishment Name: Y PS �.t� Date: Page:_3 L= Hem -Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R—Red Item Verified PLEASE PRINT CLEARLY G 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 El Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal F 'd Code. I u nd that noncompliance may result in daily fine o enty- , e doll or'sus ension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. LiVoluntary Disposal L] Other: i 3-5D1.14(C) PHR Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) 41.017145017 Within 4 Hours. * 501.15 Cooling Methods for PHFs PROTECTION FROM CHEMICALS 19 PHF Not and Cold Holding 14 Food or Color Additives 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41'/45°F* 3-302.114 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140017 * 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130'F. Containers* ZD Time as a Public Health Control 7-102.11. Common Name-WorkingConminers* - 3-501.19 Time as a Public Health Control* 7-201.11 - Separation-Storage* - 7-202.11 Restriction-Presence and-Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.111 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Cheritirals* 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-8g1.11(A) Unpasteurized Pre-packaged Juices and Beverages with Warning Labels* 7-204.14 Drying Agents.Criteria* 3-601.11(B) Use of Pasteurized Eggs* E�,-2106_12 Incidental Food Contact,Lubricants* 3 801.11(D) Raw or Partially Cooked Animal Food and Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served Rodent Bait Stations° Uno ned Food Packa re Not Re-served. Tracking Powders,Pest Control and Mortitorin * CONSUMER ADVISORY TIME(FEMPERATURE CONTROLS 22 3-603.11. Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PHFs - rx.�Mn rrvrzooi P 3-401.11A(1)(2) Eggs- 155`F 15 Sec. 3-3D2.13. Pasteurized Eggs Substitute for Raw Shell Eggs-Immediate Service 143'F15&ec* 3.401.11(A)(2) Comminuted Fish.Meats&Game E * .Animals-155'F 15 sec.* SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 mite# 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 catering,mobile food,temporary and sec * 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165*F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145T^ 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. 3.401A I(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3403.1I(A)&(D) PHFs 165°F 15 sec.* (Items 23-30) 3-403.11(B) Microwave-'165'F 2 Minute Standing Critical,artd 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- fnund in the following sectiorm of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) Remaining Unsticesd Portions of Beef ± Item ' Goad Retail Practices .FC 53D.000 Roasts" 23. k4anatiement and Personnel I FC-2 I .oM 24.. Food and Food Protection I FC-3 ! - 004 ! 18 Proper Cooling of PHFs i 25. Equipment and Utensils �FC - -4 .005 3-501.14(A) Cooling Cooked PHFs from 140*F to t 26; Water,Plumbing and WasteIFC-5 .006 # 70'F Within 2 Hours and From 70'F 27. Physical FacilityFC-6 .007 to 41*F/45`F Within 4 Hours. *- 28. -Poisonous or Toxic Materials _ FC-7 .o08 3-501.14(8) Cooling PRFs Made FrornAmbient 29. S eclat R uhements 009 Temperature Ingredients to 4I'F/45*F 30. I Other .Within 4 Hours* *rhnotev critical herr in the federal 1999 Food title or 105 C,%4R 590.000. L "M *s1e." ~' T 3 WX Board of Health USAj i Kirtib8flE3y UriStollti � `�� ,� a 120 Wasli�ngton Street,4th Floor,' �a��g�gr ��>�,� FoodfRetad Establishment y"-T .�. ESTABLISHMENST NA, !Lesbes Retreat Grub`& pubQfy, ��� 4.f �8`i FAe NB umtiyr HF 2004-000008 _ ."g6 Noah Street w� �,s x y: Sa1Cm a � I�l0I9s � a WWI + a3 rc -f r =. 'mss r k s7c t� " I. % � LOCATED AT 009b NORTH STREETW - � e..�a* a. a u '°t � a � ,r^a r�'`.• "`y' '> '�,.m aea?dv '``'�'`, ^'; � w +s,�y� +-y �x s' �' SALEM; 1vtA `01970a � ' 4. PertType ? Permit No x Permit Issued Pergs►t roExpiresFee Restrcbons/Notes r FOOD SERVICES ' BHP 2014 00011 5 Jan 1,2014 Dec 31,2014 $280 00$ ESTABLISHMENT � gg� z . �e sr ` ' sz a � a � ' otal Fees $280 0 m , . ¢ r "t 3 "".,, 'au" a " x.*.�a z �.ta r- a'.x o^t9 4vy „aas as^� sF' eA yfv. f ^sex r r4 g.+s� mow. , -2"-r ��e n; '- ax' 'x a�r;,�uf��,p ' �� �;""a p }•z `Y t v v �' ra Sax FOLs" a• . s '= - 5 " '� � *� N` x, 'g �. #`'`-#'-*u ac ' ^rRTr3rR�""'� "*,r �"ay. n :r"i z .F^�` tow?rl h h,G �s:`RM4 3`� a�<; ?.1' g r fiy. 4 r+`�,:s r R d r+ ><xa, k. vE# e ✓ '' a "#s 3� a`wa 4 bra - a e`1`" ?� ,'0 �':� -2 as- a ., � ww �{ < "'fit " x "as '=aS+"y;m3,sr` o j r .� 0s . '"'xe PERMff EXPIRES ecember 31, 2014 Lmxa�e k � Board ofHealtb z�: 4 y a Q � .iz $r .,,' u 3' .` asp w; �# .o- i� ✓+.a+ 3 !* #, a v"•.& §k F`.v '#w^AA ^� fr rd•� �_ '"��„ K � � sh-ffi`.3�R+4j L� 5 3x S� �j''Sy2A �Si S�� '�[ +�..j r -xc Fr AX , 414 ik Tlns Permst is notttansferable and must be reissued upon change of ownership or loca4on The permit must beposted 1 in a prominent locatron'm the Establishment ,, ;., 'r, : t In-accordance mth the"State Sanitar Code beofre an `revonations im rovements or e w meat Caare made, i Y Y_ P 9 Phinges all plans for such u t tie submitted to and approved by the Salem Board of Health p =� page t � $ ,�x eje'a1 ��`,�6.� kts��'� `c,�^ r r 2 � ����<w a ro S gss d .,�*t, `t��'p�,✓'-a CITY OF SALEM, IV ,. RECENEDMASSACHUSETTS >? u, SOV 24 213 BOARDot,Hr•:,v;rH wo,... Z013120WASHINGTON S'nwi- ',4'T'FLOOR KIMBERLEY DRISCOLL _ - I. (978)741-1800 FAx(978)745-0343 • SLE �� Ixam � salem.com 1�\RRY Ite1MI)IN,RS/REI-[S,CHO,CP-};S MAYOR UOARD U(- HF- LTH HGAI:1'H AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: U , 1 n r (oaf } 5L-r v 2) Establishment Address: IJORI-k (— ti e- ,t 0C'-1,-7u 3) Establishment Mailing Address(if different): 4) Establishment Telephone No: R 1 7'!'t (Z"j 5) Applicant Name&Title: Ml�} r 1�wc 0 W� ) GvL, 6) Applicant Address: A,°}^ c, 2-ZZ/ 7) Applicant Telephone No:q l 8? r 24 Hour Emergency No: ,u� &.1mail: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address A corporation -*� An Individual n l l26 d W Q¢ }fin A partnership Other legal entity 12 Person Directly Res onsible For Daily O erationsOwln��err- rvi , Person in Charge,Supervisor,Manager,etc. 4N Name&Title: 7! l aC V �i 1�` Address: 5AYe1_ l} Telephone No: I V- 7N5 `J 7`15' Fax: 7 9'0 67f5-Email: Emergency Telephone No: 17( 210 4 ZL Z- 13) 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check* I Date: G/ / Amount: � J Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) C 16) Days and Hours of Operation: -1,A^ i 191VI 17) No.of Food Employees: 18) Name of Person in Charge Certified In Food Protection Managemen // Required as of 1011/2001 in accordance with 105 CMR 590.003(A) C U .q3 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑Caterer Permanent Structure ❑ Food Service-( Seats) ❑Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: Breakfast Establishments....... (check one) RETAIL STORE RESTAURANT Annual ❑Less than 1000sq.ft. $70 ❑Less than 25 seats $140 Seasonal/Dates: ❑1000-10,OOOsq.ft. $280 ❑Residential Kitchens $140 ❑More than 10,000sq.ft. $420 W2599 seats $280 ❑More than 99 seats $420 Temporary/Dates/Time: ... - - ------ ------_._.. - - ❑Bed&BreakfastlChildcare Services(Nursing Home $100 ---------------------------------------------•-•---••---•------------------------.._._....------------------------------------•---------- ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ALL NON-PROFIT' $25 1nicludln , church kitchens, state funded childcare 6 pofvate club 23) Food Operations: Definitions: PHF-potentially hazardous food(timdtemperature controls required) Non-PHFs-non-potentially hazardous food(no time/temperature controls required) (check all that apply): RTE-ready-to-eat foods Ex.sandwiches salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PH F Cooked and Cooled or Hot Held Pre-packaged Non-PHFs At .,_lot More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs LCeld Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for andior HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and i affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 10.5 CMR 590.000 and the Federal Food Code 24) Signature of Applicant: "u Pursuant to MGL Ch.62C,sec.49A,I certify under the pe ties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: - r`f J 26) Signature of Individual or Corporate Name: Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4" or Division of Food and Drugs Salem, MA 01970- 4 Tel. (978)741-1 0 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISH T INSPECTION REPORT Tel. Name Da T�yppe of Operation(s) Type of Inspection O t(o 1%1 L&Food Service ❑ Routine Address Risk ❑ Retail 10 Re-inspection Telephone Level ❑ Residential Kitchen Previous s ction _ l�t? ❑ Mobile Date: y r Owner �^ HACCP YIN ❑ Temporary ❑Pre tion i f� ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) Time ❑ Bed 8 Breakfast ❑General Complaint Inspector In: HACCP �� ❑ Out: w Permit No. ❑.Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑ FEl Violations marked may pose an imminent health hazard and require immediate Allergen Awareness 50.009 bacc5 .009(G) ❑ corrective action as determined by the Board of Health. FOOD.PROTECTION MANAGEMENT _ _- -_._ _ _ - _ _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties - _ - "'" _ ❑ 13. Handwash Facilities EMPLOYEE HEALTH ,PROTECTIONFROWC_ HEMICALS _ ❑ 2. Reporting of Diseases by Food Employee and PIC _ El3. Personnel with Infections Restricted/Excluded [114.Approved Food or Color Additives ❑ 15.Toxic Chemicals OMAP DSOURCE -FOl)DF.RodandWat rfromApp e ) :.TIMF1rEMPERATURE:CONTROLSi0iitenba'0kazaMous clods) _ ❑ 4. Food and Water from Approved Scarce ❑ 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 _ _ 1 ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time as a Public Health Control _ .' . 9. Food Contact Surfaces Cleaning and Sanitizing i REQUIREMENTS FOR HIGHLYSUSCEPTIaLE=POPULATICN$''(H&P);, El 21.Food and Food Preparation far HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADMSORY [122. 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. C N 590.000/federal Food Code.This report,when signed below 23. Management and Personnel (FC-2X590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3X590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4X590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc5)(59o.om) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30.Other DATE OF RE-INSPECTION: S: 4uox In Inspector's Signator .Print: PICS Signature: Print: L Page �fageS 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 R.esnsibilit * 3-302.11(A)(1) Raw Animal Foods Separated from Cooked and RTE Foods* 590.003(6) Demonstration of Knowledge" - Contamination from Raw Ingredients 2-10311. Person. in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated Tom Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590A03(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 Fund Employee Or An * Applicant To Report To The Person In Utensils Contamination from the Consumer Charge* 3-306.14(A)(B Returned Food and Reservice of Food* 590.003(G) Reporting b Person in Charge* 3 590.003(D) Eiclusions and Restrictions* DisposAionofAdufterated or Contaminated Food 590.003(E) Removal of Exclusions and Restr ct ons 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 14 Food and Nater From Regulated Sources 9 Food Contact Surfaces - - 590.004(A-B) Compliance with Food Law" 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3=201.13 Fluid Milk and Milk Products* 4-501.1 t2 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem ratures*- 3-202.14 Eggs and Milk Products.Pasteurized" 4'501.114 Chemical.Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101..11 Drinking Water from an Approved System* 4-601..1 I(A) Equipment Food Contact Surfaces and 590.006(A) Clean* 590.006(A) Bottled Bets ta*Standards Water* 4-602.11 Cleaning Frequency of 590.00F,(L') Water Meets Standards in 31.0 CMR 22.1;* g q Y Equipment Food-' Shellrsh and Fcsi-•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 NSSF Listed Chemical* Sources* 10 Proper,Adequate Harldwashing Game and Md Mushrooms Approved by Regulatory Authority 230].11 - Clean Condition-Hands and Alms*- 3-202.18 Shellstmk identification Presem" 2-301..12 CleaningProcedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* - 1.1 Good Hygienic Practices 3 ReceivinglCondliion 2-401.11 Eating,Drinking or Using Tobacco* 3-202.1 f PHFs Received at Proper Temperatures* 2-401.12 . Discharges.From the Eyes,Nose and 3-202.15 Package hue,it * mouth* 9-101.11 _ Foal Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Re=ds:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from - 3-203.12 Shellstock Identification A4aintained'* Employees* - - Tags/Records:'Fish Products 13 Handwash Facilities 3=402.11 Parasite Destruction* Convenient Located and Accessible 3-402.12 Retxrrds,Creation and Retention 5-203.11 Numbers and Capacities* 590.004(n 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 - 3-502.17. Specialized ProcessinMethods* Devices- 3-502:12 Reduced oxygen packilging criteria* 6-301.11 Handwashing Cleanser,.Availabilit 8-103.!2 Conformance with ArovedProcedmes* 6-301.1.2 HandD 'n Provision *Denotes critical item in the federal 1999 Ford Cade a105 CMR 5WOOli, CITY OF SALEM ARD OF HEALTH Establishment Name: 01 Date: 10 / Page:_ of Item Code C—Critical RemDate DESCRIPTION OF VIOLATION/PLAN F CORRECT ON No. Reference R—Red Item Verified PLEASE PRINT CLEARLY h L � f O Discussion With Person in Charge: Corrective Action Required: ❑ No es 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 L3 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 ty-five dollars s pension/revocation of ❑ Embargo ❑ Emergency Closure y-0ur food permit 0 Voluntary Disposal ❑ Other: Y 1 f 3-50I.7.4(C) PHFs Received at Temperatures Violations Related to Foodborne illness Interventions and Risk According to taw Cooled to Factors Memo'1-22) (Cont.) 41°F/_45`FWithin 4Hours, PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs Food or Color Additives 19 PMP Hot and Cold Holding t 14 3-50L16(B) Cold PHFs Maintained at or below 3-202.12 Additives*' 590.004{0 4101450 F* 3-302.14 Protection from Un roved Addiiives* 3-501.16(0 Hot PRFs Maintained at or above yg Poisonous or Toxic Substances 140°F. * 7-101,11 Identifying Information-Original 3-501,16(A) Roasts Held at or above 130°F. Containers* 2U Time as a Public Health Control 7-102.11. Common Name-WorkingContainers* - 3-501.19 Time as a Public Health Control'' 7-201.11 Separation-Stora e* 590.004(H) Variance Requirement 7-202.11 .Restriction-Presence and Use* 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPUi AT1DNS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washin Produce,Criteria* .Beverages with Warning labels* 7-204.14 Drying Agents.Criterium ,^_801.11(B) Use of Pasteurized Sg°s* 7-205-11 incidental Foal Contact,lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria'[ Rua Seed Sprouts Not Served. 7-206.I2 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 1 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEMEMPERATURE CONTROLS 22 3-603-11 ConsumesAdvisory Posted for Consumption of Animal Foods That are Raw.Undercooked or Proper Cooking Temperatures for Not Otherwise Processed to Eliminate PRFs Patbo*ens.+tea`11` ' 3401.11A(1)(2) Eggs- 155'F 15 Sec Eggs-immediate.Service 145'Ft5seca 3-302.13. Pasteurized Eggs Substitute for Raw Sheri { E >.. 3-401.11(A)(2) Comminuted Fish.Meats&Came . Animals-155'F 15 sec.* SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* 590.009(0)-(D) Violations of Section.590.009(0)-(D)in 3-401A I(A)(2) Ratites,Injected Meats-155`F 15 sec. * catering,mobile food,temporary and 3-401.1 1(A){3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites4650F t5 sec. * above if related to foodborne illness 1 3 40I.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145T* 590.009 violations relating to gold retail i 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- y Microwave 165°F* Special Requirements. i 3-40'LI I(A)(t)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs 165T 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 l Time* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Contnt orally Processed RTE Food- jound in the following sections.of the Food Code and 105 CMR 140T* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef m Goad Retail Practices FC 590000 Roams* 23. Mona ment and Personnel -FC-2 .003 tg Proper Cooling of PHFs 124." Food and Foal Protection FC-3 .004 ; 25. Equipment and Utensils _ FG-4 .005 i i 3-501.14(A) Cooling Cooked PHFs from 140'F to 26. 1 Nater.Plumbing and Waste FC-5 .006 1 70°F Within 2 Hours and From 70°F 27. 1 Physical Faci l + FC-6 .007 to 41`F145°F Within 4 Hours.* 1 28. 1 Poisonous or Toxic Materials 1 FC-7 .008 ' .3-501.14(.6) Cooling PHFs Made From Ambient 29. Special R uiremems I .009 1 r Temperature Ingredients to 41'F/456F ' 30 1 Other Within 4 Hours* '4 'Dmores critical hzra in the federrl 1999 Fecd Cale a'M CMR 590.000. i ' w Massachusetts Department of Public Health Salem Board of Health Dwision of Food and Drugs 120 Washington Street,0 Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name I Dat Type of Operation(s) Type of Inspection �J 0 Food Service -V=1 Routine Address Rik R Retail ❑ Re-inspection Telephone Level El Residential Kitchen Previous Inspection 114 ❑ Mobile Date: OwnerHACCP YM El Temporary [IPre-operation 1*I �jt ❑ Caterer ❑Suspect Illness Person-in harge(PIC) TI ❑ Bed&Breakfast ❑ General Complaint In ❑ HACCP Inspector Out: Permit No. ❑.Other Each violation check6d requires an explanation on the narrative page(s)and a citation of specific provis(on(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Anti-Choking 590.009(E) ❑ Items) Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑ Allergen Awareness 590.009(G) ❑ corrective action as determined-by the Board of Health. [FQOD_PROTECTION MANAGEMENT' ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties F]-� 13. Handwash Facilities i EMPLOYEE HEALTH ❑ IPROTECTION FI10WCHEMICALS. 2. Reporting of Diseases by Food Employee and PIC .[114.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals EF,000'FROM-APPROVED SOURCE TIMEREMPERATUt2E.CONTROLS -_ ❑ 4 Food and Water from Approved Source „___ ____ (Potantlally 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 El 20.Time as a Public Health Control J�2Q,/9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLXSUSCEPTIBCE=POPULAT ONS(N$P)__ ❑21.Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMERADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): F T] of Health. Non-critical (N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. C N 590.000Ifederal Food Code.This report,when signed below 23. Management and Personnel (FC-2X590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (Fc-3Xsso.00a) order of the Board of Health. Failure to correct violations 25. E ui and and Utensils cited in this report may result in suspension or revocation of q p (FC-4X590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC5X590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6X590.007) have a right to a hearing. Your request must be in writing 8. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. j 30. Other DATE OF RE-INSPECTION: MOMOMa,.. C �1� Inspector's Signature: Print. PICsSignature: Print a/L,�� Pageao Pages � .1�...�r•-.•.,,\.- �.� .... ,-.-.... ,.._+`.....rte w.,-a 4 tT 4�....� a•: ... /� -..qtr'^ uc, x Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 11 Cross-contamination 1 590.003(A) Asci ment of Res ❑sibili[ * 3-302.1.1(A)(1) Raw Animal Foods Separated from Conked and RTE 590.W3(B) Demonstration of Knowledge* Raw I Contamination from Raw ngredrents 2-103.11. Person in charge--duties 3-302.11(A)(2) Raw Amund 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) I 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* 590.003E Reporting tin b Person inCharee* Disposition ofAdufteratedor Contaminated 31 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3--7013 1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fora* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004A-B) Compliance with Food law* 4-501..1.11 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* - Sanitization Temperatures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501-11.4 Chemical Sanitization-temp.,pH, 3-202.16 Iee Made From Potable Drinking Water* concentration and hardness.* 5-101..11 Donkin Water firm:m 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 31.0 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 Rea ealionaily CauQJ t Molluscan Food Contact Surfaces of Equipment* Shellfish* Food Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSF Listed Chemical* Sources* 10 Proper,Adequate Handwashing Regulatory Autltcrlt Game and Wild AuthoMusrity .Approved by 2-301.1.1 Clean Condition-Hands and Arms* 3-202.18 Sheilstoch identification Present* 2-301.12 Cleaning Procedure* 590,004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* - Il Good Hygienic Practices 5 Receiving/Condition 2401.11. Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper TernLxiaturesli 2401.12. Discharges:From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-i0i.l l _ Foal Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shel!stock 12 Prevention of Contamination from Hands 3-202.18 -Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to es* Tags/Records:-Fish Products - 13 Handwash Facilities - 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(.f) Labeling of Ingredients' 5-204.11location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance ±ACCP Plans Supplied with Soap and Hand Drying 3-502.11 S' cialized P- essing Methods* Devices 3-502:1.2 Reduced Os en acka"ng,triter a* 6-301-11 Handwashing Cleanser,Availability 8-103.!2 Conformance with Approved Procedures" 6-301..12 HandDr ' Provision *Denotes cdtjctl item 41 the Weral 1999 Ford Cale or 105 CMR 590.0W. %ate/ • R . I MAE©=_ W A Z.cr_ 3.501.14(C) PHFs Received at Temperatures Violations Related to foodborne 11tress Interventions and Risk According to Law Cooled to Factors Mems 1-22) {Cont.) 41'F/45°F Within 4 Hoists. PROTECTION FROM CHEMICALS3-501..15 CoolingMethods for PHFs 14 - - Food or Gator Additives - 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3=202.12 Additives*--i-- 590.004(F) 41*1450 F* 3-302.14 Protection from Unapproved roved.Additives* 3-50L16(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 Held at of above 130'F. Containers* 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* 3-501:t9 Time as a Public Health Control* 7-201.1 l Separation-Storage4 590.004 H! Variance Requirement 7-202.11 .Restriction-Presenceand Use* 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizets.Criteria-Chemicals* 7-204.12 Chemicals for WashingProduce,Criteria" 21 3-801.11(A} Unpasteurised Pre-packaged iuices and :Beveraees with Warning Labels* 7-204.14 Drying Agents.Criteria* ^;-901.11M Use of Pasteurized Eggs* 7-205.11 Incidental Food Contac,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Foci and 7-206.11''' -Restricted Use Pesticides;Criteria* Raw Seed Sprouts Not Served- 7 erved. 7-306.12, Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-2€16.13 Tracking,Powders,Pest Control and Monitorme' CONSUMER ADVISORY IIMEti EMPERATi1RE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or ib Proper Cooking Temperatures for Not Otherwise-Processed to Eliminate PHFs Patho*ens.*F4eonvs Vlv r . 3-401.11A(l)(2) Eggs- 155F 15 See Eggs-Immediate Service 145'Fl5sec* 33FP Pasteurized Eggs Substitute for Raw Shell t 3-401.11(A)(2) Comminuted Fish.Meats&Game Animals-155'F 15 sec. 3.401.11(11)(1)(2) Pork and Beef Roast- 130`F 121 min* SPECIAL REQUIREMENTS 3 401.1 i(A)(2) Ratites,injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(I))in sec. * Catering,.mobile food,temporary and 341.1.1(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 3-101-11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145`F* 590.009 violations relating to gaol retail { 3-401.12 Raw Animal FcxAq Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3-401:11(A)(1)(b) All Other PHFs- 145'F 15 sec. t. 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES A 3403.11(A)&(D) PHFs 16ST 15 sec.* (Items 23-30) }� 3-403.11(B) Microwave- 1650 F 2 Minute Standing Critical mid non-critical violations,which do not relnu to the Time* foodborne illness interventions and risk factors listed above,can be 3-403.11(C) Commercially Processed RTE Food- }bund in the following sections of the Food Code and 105 CA6R { 1400F* 590.000. 3403.11(E) Remaining Unsticed Portions of Beef item Good Retail Practices FC 590 Wo Roasts* 23. 1 Management and Personnel -FC-2 .003 1 18 Proper Cooling of PHFs 24----T Food and Food Protection FC-3 .004 1 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PRFs front 140`F to ? I Water.Plumbing and Waste FC-5 .006 70'F Within 2 Hours and From 70'F 27 Physical Faci' FC-6 007 to 41`F/45'F Within 4 Hours. * i 28. Poisonous or Tunic Materials ! FC-7 .008 009 3-501.14(1) Cooling PHFs Made From Ambient ~29. Special R uiremarns .--- Temperature Ingredients to 410F/45°17 30 1 Omer Within 4 Hours* ssarma-..y:xm: Detoxes critical itzm in the f-doral 1999 Food Cate o'105 CMR 590.000. l t rte _ A7 IMMON MR .11J !�►�. t'i�11�A� IMMMI1 J ►ill!' Ar, - .I. A_Owl-m. MN M ���� .._ S•. 1ANyl rim , I'm IN MOMENUIRPM1 At 09 09 0 N�lp WOR MIMM low� 01=MMEA.. dF._�.,�1;_' �:.. r �I \ �� 1■ � .� ►� u / � _ ►I- __—\�• i■� '� %!� � / �a/---/LLiliGifi�Y C 1 3-501.14(0) PRFs Received at Temperatures itioleflons Related to Foodborne fitness Interventions and Risk According to Law Cooled to Factors fftems 1-22) (Cont.) 41'7/45°F Within 4 Horns. PROTECTION FROM CHEMICALS3-501..15 Coolie Methods for PHFs 14 Food or Color Additives 19 PHF Not and Cold Holding 3,202.12 Additives' 3-501.16(B) Cold PHFs Maintained at or below 3-302-14 Protection from Un coved Additives* 590.004(/•1 4101450 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) RoasmHeld atorabove 130'F. * Containers* 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* * 3-501:19 Time as a equie Health Cnntrnl° 7-201.11 Separation-Storage590.004(H) Variance 7-202.11 Restriction-Presence and Use* e Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11. - Sanitizers.Criteria-Chemicals* - 21 3$01.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for WashingProduce,Criteria° Beverages with Warning Labels* 7-204.14 Drying Agents.Criteria* 3$Oi.11(B Use of Pastemize<1 E¢ * - t 7.208.11 Incidental Food Contact,Lubricants* 3-801A I( ) Raw or Partially Cooked Animal Food and L 7-206.11 -Restricted Use Pesticides,Criteria* - Raw Seed Sprouts Not Served * 7-20&12 - Rodent Bait Stations* 3-801AI C Unopened FoW Package Not Re=served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 ConsumerAdvismy Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for Not Otherwise-Processed to Eliminate PHFS Padro+zns.*�+-•°ere mrta!r 3-401.11A(i)(2) Eggs- 155`F 15 See. Eggs-Immediate Service 145°FlSsec* 3-30113. Pasteurized Eggs Substitute for Raw Shell y 3.401.11(A)(2) Comminuted Fish.Meats&Game E ggO 'a Animals-155°F 15 sec. SPECIAL REflU1REMENT5 3.401.11(13)(1)(2) Pork and Beef Roast-130-F 121 min* 1 3 401.11(A){2) Ratites,Ltjec[ed Meats- 155°F 15 see. 590.00WA)-(D) Violations of Section .590.009(A)-(D)in s * catering,.mobile food,temporary and • 3-40El I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'1715 sec, ' above if related to foodborne illness ' 3401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail C 3-401,12 Raw Animal Foxxki Cooked in a practices should be debited under#29- r' Microwave 165OF Special Requirements. t( - 441:11(A)(I){b) All Other PHFs-145°F 15 sec. IT . Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(1)) 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 Time* foodborne diners interventions and risk factors listed above, cars be 3403.t 1(C) Commercially Processed RTE Food- found in the following sections-of the Food Cade and 105 CB,'R 140°F* 590.000. 3403AI(E) Remaining Unsliced Portions of Beef - Item j Good Retail Practices FC 59oDW i Roasts* 23. i Mana4ement and Personnel FC-2 .003 IE Proper Coating of PHFs 24.. i Food and Food EL012 ion _ FC-3 .004 ' 125. E ui ment and Utensils I FC-4 .005 1• 3-501.14(A) Cooling Cooked PHFs from 140°F to 2g. Water.Plumbing and Waste FC-5 .006 70°F Within 2 Hours and From 70°F 27. Ph sical Facility FC-6 .007 to 4 VF/45°F Within 4 Hours. * i 28. Poisonous or Tonic Materials FC 7 .008 i j 3-501.14(6) Cooling PHFs Made From Ambient ~29. Special R uirements .003 Temperature Ingredients to 41°F/45°F 30 l Other Within 4 Hours* s_vncm�aoz c: _ t 'Denotes critical 1wrn in the federal 1499 Fawd Cade w 105 C'.MR 590.000. B , 1 4 OF WAWA W231 A-MIN Moll � .T m _-�_ 1G.. '�� \ 5��'L�Ltl1�;'�.IIL• ��•i.�_I _6•��LL� ! JN�� rAjmtM I OWN W 41— ��—� i / `� .�. _` a i►c � w,�►�� —�_®_ '. �_ _�:�.rr'!�/ii�L_ �►I _ � � / •.eC�71'fi!!�I[e9�►�1_���r IN 3-501.14(C) PHR Received at Temperatures Vlotations Related to Foodborne Illness lnteryentlons and Risk According to law Cooled to Factors(Mms 1-22) (Cont.) 41'F145°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs PHF Hot and Cold Holding 14 Food or Calor Additives 19 3-501.16(13) Cold PIIFa Niainmined at or below 3-202.12 Additives* 590.0 4(F) 410145 F 3-302.14 Protection from Una 3-501. roved.Addidves* g5 Poisonous or Toxic Substances 3-501.16{A} Hot PHFs Maintained of or above 140'F. 7-101,11 Identifying Information-Original 3.501.16(A) Roasts Held at or above 1300F. " Containers* - Time as a Public Health Control 7-10211. Cmmuon Name-Working Containers* 20 3-501:14 Time as a Public mentG Control, 7-201.11 Separation-Storage.. 7-202..11 .Restriction-Presenceand Use* - 5`�• 4(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULA71OHS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.1](A) BevUnperages with Pre-packaged Juices and 7-204.14 . encs.Criteria' Beverages with Warning labels" a 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B Use of Pasteurized Ea 3-801.11(0) Raw or Partially Cooked Animal Food and 7-20611 Restricted Use Pesticides;Criteria* Raw Seed S ns Not Served.* 7-206.22 Rodent Bair Stations* 3-801.11(C) I Unopened Food Package Na Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring'* CONSUMER ADVISORY - T[MEREMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of Animal Foods That are Raw.Undercooked or 16 Proper Cooking Temperatures for Na Otherwise Processed to Eliminate PHFs 3-40i.I1A(1)(2) Eggs- i55'F 15 Sec. Pathogens.' an neo Eos-Immediate Service 145'Ft5sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell 3-401.g1(A)(2) Comminuted Fish.Meats&Game E Animals-155'P 15 sec.* SPECIAL REQUIREMENTS �c 3.401.11(B)(1)(2) Port:and Beef Roast=130'F 121 mio* 3-40111(4)(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 3-4011.t(.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 3-40g.i1(C)(3) Whole-mmscle,Intact Beef Steals interventions and risk factors. tither 1456F* 590.009 violations relating to good retail { 3.401.12 Raw Annual Foos Cooked in a practices should be debited under#29- t Microwave 165°F* Special Requirements. 3-401 A I(A)(1)(b) All Other PHFs-145'F 15 sec. 17 Reheating for Hot Holding VIOLAT/ONS RELATED TO GOOD RETAIL PRAC77CES 340311(A)&(D) PRFs 165-F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-'165°F 2 Minute Standing Critical.mrd non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 373.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 140°f* 590.000. _+ Item Good Antall Practices FC 590.000 3 4U3.I I(E) Remaining Unsliced Portions of Beef - Roasts* 23. 1 Mana amen and Personnel FC-2 .003 gg Proper Cooling of PRFs 24.. Food and Food Protection FC-3 .004 125. Equipment and Utensils i FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140`F to 1 26. Water.Plumbing and W ante 1 FC-5 .006 70°F Within 2 Hours and From 70°F 27. Physical Facility FC-6 007 to 41°F/45'F Within 4 Hours.* 1 26. Poisonous or Toric Materials FC 7 .00 3-501.14(8) Cooling PER Made From Ambient 1 29. S ectal Requirements j .009 Temperature Ingredients to 41°F/45°F 30 Within 4 Hours* ssvor„aas.r a: ' 'Denotes uitical i>em in the federal 1499 Feral Cede or 105 CMR 590.000. r r! - l • it CM` OF SALEM, MASSACHUSETTS Ll'tJ"f, BOARD OF HEALTH 120 WASHINGTON STREET 4:"FLOOR P11�)j{CHCA�111 , Prevent.Promote.Protect - TEL, (978)741-1800 FAX(978)745-0343 KIMBERLEY DRISCOLL lramdinna salemxom MAYOR _ LrvtRY Rr�Mll1N IZSjREHs,ctio,('.P-PS HF.ALlli AGENT This Fonn will be collected during your next Board of Health inspection. QUESTIONAIRE -GREASE TRAPS 2012 Il Kees -R<trch t- Ste; 1. NAME OF ESTABLISHMENT: (2 5 j I Lcz-gc"t t?F2L)4 f ti 2. ADDRESS OF ESTABLISHMENT: (? ' )A G'M /0 11- 3. 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? �t1 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? »� §e I Iry > "Commonwealth of Massachusetts _ € ' ; f = , s e City of Salem , Board of Health KifnbetleY DFIS r p toll C e: k „`1120 Washin ton Street 4th Floor; M2YOf g s � �- » aw SALEM,MA01970 Y Food/Retail Establishment Permit z l 5 g DATE PRINTED: :r 11/29/2012 3 ; ' ` $ V6, ' ., z 4_ ESTABLISHMENT NAMEc u. Leslies Retreat Grtib & Pubg , �a `-°- - '-" File Number BHF 2004-000008 "- y :' x.96 NorthStieet --'`„ ' e4s`k� ' f s E r WK, `F I I A , � ; vw _ �F{ Salem" "` MA 01970. �. LOCATEDeAT 0096 NORTH STREET '' SALEMMA 01970 - P. Permit Type i" Permit No!`® Permit Issued;.Permit Expires : .Fee Restrictions/Notes FOOD SERVICE BHP-2013=0004 Jan1, 2013 -Dec 31, 2013: $280.00 ESTABLISHMENT • ' u� <., e A' . ' - Total Fees $280.00 F S aC" f�q•v' g ? ? "rY' } ' M ."r Xa rte`" H: 11 4 4- 4 1 14 s � � d�.�k.�—� a- •_� .i.. .n.r. fi ..�` �s`� .� " �� X.: v�✓ S'f't' � � sem`' ti 19` '.a a. »f- - '* xIt' PERMIT EXPIRES December 31;2013 ; r ` Board of Health ' V ; r P B ,p Thts Permit is not transferable and must be reissued u on change of ownerstu or location:The permit must be postedt�, in a prominent locationin 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. Pagel q� Tk ter,_ CITY OF SALEM, r X ° MASSACHUSETTS t 111 h tm !I 120 WAS}QNG'CON SIRE HT,4'°'FLOOR ' KIMBERLEYDRISCOLL (978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/RENIS,CNO,CP-FS MAYOR ,ln GpA Iranadin0a salem.com HEAIIPH AGENT �Of od Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) / 1) Establishment Name: V-r R-S {�I N r r I t &-5L i5iS Rerec+L I 0-1-a 2) Establishment Address: (4rsl',Re6 3) Establishment Mailing Address(if different):i ti 4) Establishment Telephone No: � - z 4+ 0iJ- 5) Applicant Name&Title: 6) Applicant Address: I�BIZ Y 7 7) Applicant Telephone No: J-7F 74ij�j� T-24 Hour Emergency No: 77P Uv(, 2Email: 8) Owner Name&Title(if different from applicant): 9) Owner Address(if different from applicant): 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address A corporation f An individual 1 IPJ' UL P12 e5' A partnership �QL UZ 1 Other legal entity # (i 12 Person Directly Res onsibleFor Daily Operations Owner, Person in Charge, Supervisor,Manager,etc. Name&Title: C'1nn'`AI-I i2 e L- Q l0-t- � E Address: Vpi 1 A— Telephone No: 57 V 7M5" 7 Y rFax: c(I,, M) 6 1 Yj'�Email: Emergency Telephone No: i- ( (U Z_ 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#: ��ti Date: Amount: 6;?90 Food Establishment Information 14) Water Source: 15) Sewage Disposal: { DEP Public Water Supply No: ( if applicable) CD l (I I -7."M I WM- 16) Days and Hours of Operation: - - --) v /{jN 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures( if 25 seats or more): V es No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑ Caterer t,Permanent Structure 2Tood Service-( Seats) ❑ Frozen Dessert Manufacturer Mobile EFood Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: - ------ ----- ----------------------------------------------- - --------Breakfast Establishments - (check one) RETAIL STORE RESTAURANT Snnual ❑ Less than 1000sq.ft. $70 ❑ Less than 25 seats $140 easonal/ Dates: ❑ 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 EK25-99 seats $280 n ❑ Bed 8 BreakfasUChildcare Services/Nursing Ho _R More than 9--- ---s- . _$420 TemporarylDateslTime: ----- -- - ------ - - - .... - ^ me $100 ------------------------------------------------------------------------------------------------------------------------------------------ ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare 8 private clubs 23) Food Operations: Definitions: PHF—potentially hazardous food(timeltemperature controls required) Non-PHFs—non-potentially hazardous food(no time/temperature controls required) check all that apply): RTE—ready-to-eat foods(Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only. Preparation of Non=PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered f Retail Sale. Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: Pursuant to MGL Ch.62C, sec. 49A,I.certify under the penalties of perjury that I,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26) Signature of Individual or Corporate Name: I _ _ Commonwealth of Massachusetts ` r City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/13/2011 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-2012-0004 Jan 1,2012 Dec 31,2012 $280.00 ESTABLISHMENT Total Fees: $280.00 a . PERMIT EXPIRES lbeceniber 31, 2012 Board of Health A This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in.a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page t • CITY OF SALEM, MASSACHUSETTS �` 11 BOARD OF HEALTH 120 WASHINGTON STREET,4...FLOUR TEL. (978) 741-1800 KMI13ERLEY DRISCOU FAx (978) 745-0343 NiAYOR 4amdingsatem.com LARRY RA1fDIN,ItS/RI?ITS,CI10,CP-I;S Hl;.%i x t A(i FNf 201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT hRi4 j �i`l.tt'S �e'ri?cnf-/�r¢t �iMt�Ul TEL# q '1(�- I�Y 70 � ADDRESS OF ESTABLISHMENT 1`I'pi2T� ST S p ct >t /I 1 f! FAX# 7 Y NO 0 F5 MAILING ADDRESS(if different) EMAIL- Business': Website: OWNER'S NAME POP-Z TEL# Agg7f 7ys�'7VS ADDRESS Ia (�iZ (4—TT— �it- I e M M x9 O 6-7 L STREET JCITY STATE i ' ZIP CERTIFIED FOOD MANAGER'S NAME(S) C/ tJ2"Gl l r �1/ 01 S CERTIFICATE#(S �1 1 G ,1Ll 3 1 (Required in an establishment where potentially in dous food is repared)/n� t01 cL7 bat 1 V 4 ZZ Z. EMERGENCY RESPONSE PERSON A LQ E �i,A-� t I"��� HOME TEL# (7V 745--5-7af [HU OF.OPERATION . ' "Mond - J,'-,Tuesda ° Wednesda - Thursda .,.Frida Saturday Sunday S OF OPERATION ! write in time of day.ample Ilam-11pm) 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 ----- - - - - less than 2 RESTAURANT YES NO 5 seats 140 (Outdoor Stationary Food Cart$210) 25-99 seats = 280 more than 99 seats -$420 --- ----- ----- - ---------------- ----- ----- ------------------------------------------------------------------------------------------ BED/BREAKFAST! YES O $100 CHILDCARE SERVICES/NURSING HOME--------------------------------------- ----------- - - -- ----------------------- ------------- - --------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES Nl � $25 TOBACCO VENDOR YES It $135 ALL NON-PROFIT(such as church kitchens) YES N $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. 0 7 � J Signat Dale Social Security or Federal Identification Number - - ------------------------ Updated 523/11 1700DAP2011.a CheckN&Date / S I 04. CITY O SALEM, NIASSACHUSE I"I:S BO.ARD OF IIBII.,I'H 120 WASHINGTON STRR81' 4"'FL0xxi CLI- (978)741-1800 I<IhlBlilt]:.EY Di2ISCOLi' FAX (978)745-0343 MAYOR 1raindin sem.com LMMYR,AiMDINRti/RHPIS,CHS),CP-FS HI;U:Cii AC,71.N'I' This Furin will be coliected during your next Board of Health inspection. i QUESTIONAIRE -GREASE TRAPS 2009 v14cr5 l31Z1q.hr Por" F I b.ca les l I l f' G 2 r 1� 7. NAME OF ESTABLISHMENT: �IJ� 2. ADDRESS OF ESTABLISHMENT: `l I�(>IZ l ✓/ �� d l" MA D 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? l `i 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR j BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OP. PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? c)19Ue s 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? ai7ll e,-