The URL can be used to link to this page

LORING LIQUORS - ESTABLISHMENTS {.oc�nY f�gvo� s CoA Lor?►y otv+r�� ftNIVERSAL® UNV-12110 MADE IN USA SUSTAiDUlelE gEcyq.m PATIATWE CONIFNl10%� Corfisd Fmo,Somme PD$T �•i�� ' www.ffiDroprom.atp Ylrtt:Rr r Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo"etail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Loring Liquors File Number:BHF-2004-000015 70A Loring Avenue Salem MA 01970 LOCATED AT: 070A LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2011-0067 Jan 1, 2011 Dec 31,2011 $280.00 TOBACCO VENDOR BHP-2011-0066 Jan 1, 2011 Dec 31,2011 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31, 2011 Board of Health f4 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 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 HI1VIJ3E1U EY DRISCOLL PAZ(978) 745-0343 MAYOR DGREENBAUMQSAG?M.CONI DAVID GREENBAUM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT L o nr, L r-3TEL# �7d'"7�'�'l63 ADDRESS OF ESTABLISHMENT_70 (f} LU<<n!) P(V FAX# R 111- 7Y0- 63 S- 7 MAILING ADDRESS(if different) EMAIL- Business': Website: OWNER'S NAME F�l:1� UC t e5� TEL# ADDRESS191CC%Ar) �yl IQ �q P j STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) p EMERGENCY RESPONSE PERSON IC\ r hQ [� C�Y� HOME TEL# �DAYS'OF'OPERATION .i-, ::Monday ,.. .;Tuesday,! Ni.,"WednesdayThursday ' l� ,Friday !:.:Saturday Sunda_yr.'_: HOURS OF OPERATION Please write in time of day (, _, 11 l For example tlam-t1 m f ` VI ��(- -�� / �] — L� �/ TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE ES NO less than 1000sq.ft. -$70 1000-10,000sq.ft. C-52-8 more than 10,000sq.ft. =T420 RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YFa NO $25 TOBACCO VENDOR ES NO 13 ALL NON-PROFIT(such as church kitchens) YES NO V26— *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 state axes required under the law. IzI(tlko 04 3 31 g08'3 Si t Date Social Security or Federal Identification Number ------------------- ------ ------------------------'--------------- Revised 10/7/11 FOODAP201 Ladm Check#&Date /c2 6 91.5 Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT- Tel. (978) 741-1800 Fax(978) 745-0343 Name DateTvoe of Operation(s) T f Inspection A'Inv. LJ Service Routine Address �O j� �,} Risk Retail e-inspection ll v Level Residential Kitchen Previous Inspection Telephone n n. .U:�I -Y ❑ Mobile Date: Owner �) HACCP YM El Temporary O Pre-operation o k e-S ❑ Caterer ❑Suspect Illness Person in Charge(PIC) - Time ❑ Bed&Breakfast El General Complaint NA e, n In.r� �� ry�"v'v�� ❑ HACCP Inspector �� A Out. 1" Permit No. ❑Other Each violation checked requires7an 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 Antl-Choking1 Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E),/I 590.009(y❑ 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 - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded _ ___ ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE - ❑ 4. Food and Water from Approved Source ITimErrEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 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 ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control REOUIREMEHTS FOR HIGHLY-SUSCEPTIBLE POPULATIONS_(HSP El 9. Food Contact Surfaces Cleaning and Sanitizing ) 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing El ❑ 11. Good Hygienic Practices :CONSUMER ADVISORY E122. 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 24. Food and Food Protection (Fc-0)(590.0004))) 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: I PIC's Signature: Prints C(n ri 7(OPG C, �t , Page ofPages s ' Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) I Assig mentoFRes ttnsibilit " 3-302.1.1(A)(1.) Raw Animal Foods Separated from Coked.and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw ingredients 2-103.11 Person in charge--duties 3-302.1l(A)(2) Raw Animal Fails Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590,003(0 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 Contamination from the Consumer Charge* Returned Food and Reservice of Food* 590.003(G) Reporting b Person in Charlie* 31 590.003(1) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.00, E) Removal of Exclusion%and Restrictions 3-701.11 Food*ding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 4 Food and Water From Regulated Sources 9 Food Contact Surfaces - 590.004(A-B) Compliance with Food law* 4501.111 Manual Warewashing-Hot Water 3-201.12 Foci in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.73 Shell Eggs* Sanitization Temperatures* A-501.114 Chemical Sanitization-to H, 3-2(12.14 EMs and Milk Products.Pasteurized" �•,p 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101.11 Drinking Water fnxn 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 31.0 CMR 22.01, 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 Fail 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 Regulatory Authority Game and uMushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Disebargcs FromtheEyes,Nose and 3-202.1.5 Package Integrity* Mouth* � 3-101.11. Food Safe and Unadulterated* 3-301.'12 Preventing Contamination When Tasting* L e Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590k04(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(7) I Labeling of Ingredients* 5-204.11 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,O teration 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 Hardwishing Cleanser;Availability 8-103.12 Conformance with Approved Procedures* 6-301-12 Hand Drying Provision *Denot s critical item in the federal 1999 Farad Cade or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: _ r Date: 1(�—l0-1 D Pageof Z— Item Code C-Crmcal Item U' DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,. No. Reference R-Red Item - VerItied PLEASE PRINT CLEARLY p ,p Pos Watt fi P r _}-. d Nof /in n X31 10 A > @ r� Pn,M9Ui1 nd14, 1 n., �, a ,� 1 ( - o y � - U , Discussion With Person in Charge: Corrective Action Required: No ❑7yes 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 comply with all mandates of the Mass/Federal Food Code. I understand that ❑ Re-inspection Scheduled ❑ Emergency Suspension noncompliance may result in daily fines of twenty- ' e dollars or spypension/revocation of ❑ Embargo ❑ Emergency Closure r your food permit. /t/.ln ❑ Voluntary Disposal ❑ Other: 3-501,N4 C) PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(trams 1-22) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PRFs 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 0 ° ° # 3-302.14 Protection from Unapproved Additives" 590.004(F) 41 /45 F 15 Poisonous or Toxic Substances 3-50t.16(A) Hot PRFs Maintained at or above 140 7-101.11 Identifying Information-Original Roasts 3-501.16(A) Roasts Held at or above 130°F. 7-102.11 Containers* 20 Common Name-Workin Containers* Time as a Public Health Contra) 3-501.L9 Time as a Public Health Control 7-201.11 Separation-Stora * 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Lace* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPUUITIDNS HSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged luices and 7-204.14 Drying Agents.Criteria* .Bevem es with Warning Labels* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Parially Cooked Animal Food and 7-206.11 -Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served 7-206.!2 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY__ TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Pasted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or _PHFs Not Otherwise Processed to Eliminate 3-401.I1A(i)(2) Eggs- 155°F IS Sec. pathogens.*E" .1^ F Eggs-Immediate Service 145'FiSsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Came Eggs* Animals-155°F 15 sec. * 3401.11(B)(1)(2) Pork and Beef Roast- 130'F 121.nun* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed 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 Al(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145'F* 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 PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3.403,11(A)&(D) PHFs 165T 15 sec.* (Items 23-30) 3403.11(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 3-403.11(0) Commercial ly Processed RTE Food- found in the following sections of the Food Cade and 105 CMR 1400F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef i Item I Good Retail Practices .FC 590.000 Roasts* 2I 3. Management and Personnel FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25. Equipment and Utensils 1 FC-4 .00.5 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water.Plumbing and Waste I FC-5 .006 70`F Within 2 Hours and From 70°F - 27. -Physical Facility FC-6 007 to 4l'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41'F/45'F 30. Other Within 4 Hours* "Denotes critical item in the federal 1999 Food Cale a 105 CMR 590.000. Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor Kimberley Driscoll Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: Loring Liquors File Number:BHF-2004-000015 70A Loring Avenue Salem MA 01970 LOCATED AT: 070A LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0170 Dec 23,2008 Dec 31,2009 $280.00 TOBACCO VENDOR 13HP-2009-0171 Dec 23,2008 Dec 31,2009 $135.00 Total Fees: $415.00 PERMIT EXPIRES IDecember 31, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4`FLOOR TEL. (978)741-1800 KINIBERL.EY DRISCOLL FAX(978) 745-0343 MAYOR )DIONNE SALEM.COM -JANET DIONNE, ACTING HEALTH AGENT 2009APPLICATION " FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT / NAME OF ESTABLISHMENT 5-y /�� /J �-�'" S If �TEL# i ADDRESS OF ESTABLISHMENT 76 4 L-or," ALC- S vlifr-J FA�x# MAILING ADDRESS(if different) EMAIL- Business': (^ Website: OWNER'S NAME \4i ff . Ofk'<< S TEL# �6 9- �-t_-/3 6 G/ ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) p EMERGENCY RESPONSE PERSON (l(-teAn HOMETEL# 5-O �� J�� DAYS OF OPERATION !,:- Monday . nesda ;i,Thursda Fdda I Saturday. Sunda HOURS OF OPERATION 11 �+ q Please write in time M day. I( ; � — t� .—/ it � � ,t �( I (For example 11 am-11 pm fin" P� A"' n 91 P/1.! IP �r Alk P^ ' P TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE �LY S NO less than 1000sq.ft. - 1000-10,000sq.ft. 91 more than I0,000sq.ft. = 420 -------------------- -----------------------Tess-------than------25-----s-ea- t------------ $114040 _- RESTAURANT YES NO s L At (Outdoor Stationary Food Cart$210) 25-99 seats =$280 S more than 99 seats =$420 BEDIBREAKFAST/ YES NO $100 CHILDCARE SERVICES --------------------------------------....- 0-------------------0-----------------------------------------0------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO TOBACCO VENDORYE NO $13 ALL NON-PROFIT(such as church kitchens) YES NO "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Ceffpf2t 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 id all e t xes quired un r the law. a b11'(4 Signat Fe Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Checktl&Date 070A Loring Avenue Loring Liquors City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 7441630 Food and Food Protection FAIL Critical BLUE Owner: Comment:2 packages of sunflower seeds removed,outdated.Owner to closely monitor all expiration dates. Kirk Ofiesh Equipment and Utensils FAIL Non-Critical BLUE PIC: Comment:Wine fridge needs general cleaning in the door tracks. Brendan Mullins Physical Facility FAIL Non-Critical BLUE Inspector: Comment:Toilet tank is broken. Repair toilet tank;this must be conmpleted by next routine inspection. Elizabeth Salandrea Date Inspected:Correct By: '7118/200 Risk Level: Permit Number: BHP-2008-0062 Status: SIGNED OFF #of Critical Violations: 1 Time IN: 7Time OUT: Urgency Description(s): BLUE: Owner to fax last 3 months' extermination receipts to Board of Health within one week. Violations Related to Good Retail Practices (Critical No other health code violations noted at this time. 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®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 21,2008 ) Page 1 oft ti • 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®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 21,2008 ) Page 2 oft CITY OF SALEM, MASSACHUSETTS * BOARD OF HEALTH 120 WASHINGTON STREET,4:"FLOOR TEL. (978) 741-1800 KBIBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGREENBAUMa'SALEM.CONI DAVID GREENBAum, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTTEL# VA L) ADDRESS OF ESTABLISHMENT 7-n /�^n F c21-\VFAX# _ MAILING ADDRESS(if different) EMAIL-Business': 1 � Website: OWNER'S NAME VW'k, �� TEL# SOk I kis'- 0 C' [ r�\ ADDRESS (-a. S .Cah- +1 �Q1 4I IMS- C)19 I STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepare ) EMERGENCY RESPONSE PERSON 14l ff"A�5� HOME TEL# DAYS^OFOPERA710Nh�, Montlay,, ,; - .Tuestla Wednestlay tThursda"s ,',� Fnday, ; Saturday Sundays HOURS OF OPERATION Please write in time of day. ( �( S V f — (For example Ilam-11pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YE NO Tess than 1000sq.ft. $7 1000-10,000sq.ft. more than 10,000sq.ft. ------------------ :F-----------..------------- ------------.....-------------------------------------e-s"s,--------------at"------------------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------------ES Yff§------ ---------------------------------------------------- BED/BREAKFAST/ YNO $100 CHILDCARE SERVICES/NURSING HOME RM -----------ITS ------------------------------- -------------------------------------------------------------------------------------------- ADDITIONAL PE MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $2 TOBACCO VENDOR YE NO $135 ALL NON-PROFIT(such as church kitchens) S NO *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL r 62 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 id stat taxe equired derthelaw.� l 1�� L ( r._3 2-b:7 t ature Date Social Security or Federal Identification Number_ Revised 424/07 FOODAP2008.adm Check#&Date $�E�/dpi r/ $ 7 ~ 530 Loring Avnue Luba Levin Wellness Center City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 781-910-3381 PIC Assigned/Knowledgeable/Duties PASS ❑d RED Owner: Non-compliance with: Luba Levin Anti-Choking PASS PIC: Luba Levin Tobacco PASS Inspector: John Gehan EMPLOYEE HEALTH Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED 4/23/2007 Personnel with Infections Restricted/Excluded PASS RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2007-0112 Receiving/Condition PASS RED Status: SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS 0 RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 24,2007 ) Page 1 of Item Status Violation Critical Urgency RED; PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS 0 RED immediate corrective action) Proper Adequate Handwashing PASS 0 RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS 0 RED Handwash Facilities PASS 0 RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS 0 RED Toxic Chemicals PASS RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑d RED Reheating PASS ❑J RED Cooling PASS RED Hot and Cold Holding PASS 0 RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Posting of Consumer Advisories PASS 0 RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 24,2007 ) Page 2 of • Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: There are no violations at this time. Inspector to talk to health agent regarding permit. 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. Apr 24,2007 ) Page 3 of 14° T TF C1 �i -'�r�P✓Vt'^TM IIA�h. �.'1e4. 1M' .'G'Y^ k^.'+i^•�+ 1^' �P'w` "s[ -'de's` 'y'Y'}a.�y.V1'�Vrt9'+4+r�.+e9��IC'n LJ: YF -Wyk^�'�Y % Commonwealth of Mas as chus tt6¢. . r -mss v P{w t S A:Cityof Salem t r .:Board of Health IGmberley Driscoll ..120 Washington Street,4th Floor - Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Loring Liquors File Number:BHF-2004000015 70A Loring Avenue Salem MA 01970 LOCATED AT: 070A LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0062 Jan 3,2008 Dec 31,2008 $280.00 TOBACCO VENDOR BHP-2008-0102 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31,2008 Board of Health Gt,1t`if� This Permit is not transferable and must be reissued upon change of ownership or location.-The-permit must be posted in- n prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,an. plans for such must be submitted to and approved by the Salem Board of Health. page 3 of 46 4y 0 3 tl QTY OF SALEM, MASSACHUSETTS c BOARD OF HEALTH v' 120 WASHINGTON STREET,4'm FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR ISCOTTO SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL# q-)K-7uq"/(73 C> ADDRESS OF ESTABLISHMENT FAX# MAILING ADDRESS(if different) EMAIL-Business': '' // \\ Website: OWNER'S NAME kl r� 1 h TEL# S7)K-Frr/3-l�O /Y1 r — ADDRESS V`�eet[ �,- /n' J!� 7 -) ST ET CITY 'STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYS OF OPERATION ! Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION Q n Please write in time of day. 9- w — ) 1 — !{ For example 11am-11 m TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. C 280 more than 10,000sq.ft. =$420 -----------------------Y---ES NO.----------------------------------------less-'s'--,--than,--25seats -----=$1-J-40---- RESTAURANT (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 -�N -- LA --- --�--� ---------------------------- - -----------------------------------------------------... ----$' ...------ BEDIBREAKFASTI YES NO $100 CHII__DCARE SERVICES -------------------------------------------- -------------------------.-......__.---------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE Y NO $_ 5 TOBACCO VENDOR PS NO 13 ALL NON-PROFIT(such as church kitchens) 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 Chanter 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 retu an paiiga11 s eta es r uired u r the law. IZ U� Si ature Date Social Security or Federal Identification Number _ ---- ------- -- ------- -- -----—Tjjr-------_--------------------------- Revised 4/24/07 FOODAP2008.adm Checkg&Date /.ZT/b7 O I =11— 070A Loring Avenue Loring Liquors City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-1630 Physical Facility FAIL BLUE Owner: Comment:The front doors found open. All openings to the outside must be sealed. Kirk Ofiesh j PIC: The toilet tank cover cracked and broken. Replace cover. Brendan Mullins GENERAL COMMENTS: Inspector: Establishment sells a limited amount of pre packaged chips and snacks. No other health code violations cited at David Greenbaum this time. Date Inspected:Correct By: 6/18/2007 Risk Level: Permit Number: BHP-2007-0007 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 18,2007 ) Page I oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 18,2007 ) Page 2 oft CITY OF SALEM, MASSACHUSETTS r : BOARO OF HEALTH 120 WASHINGTON STREET,4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAx 978-745-0343 Kimberley Driscoll www.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �- UtlY1. fJUr) TEL ADDRESS OF ESTABLISHMENT 70h gyp _ 5 FAX# QV,-"7V'O MAILING ADDRESS (if different) E,vtAIL--business': N��}- . i Owner's: OWNER'S NAMnj�jI-C� 1A 2-Q TEL# ADDRESS /5- t ty'�—r STREET CITY STATE ZIP ' CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSONM1tf-K CC -sIn HOME TEL# IfFer YSOFOPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sit. URS Of OPERATION ease write in time of day. , Li ( 1 t/�j} example ilamltfpml �NA �P,,,,.. M 1Ar+ p°q �l'f+t �frn -CIM v.. li;;- TYPE OF ESTABLIT FEE {check only) RETAIL STORE ` YES/) NO less than 1000sq.ft. 1000-10,000sq.ft. =$100 more than 10,OOOsq.ft. ..----- ------ -------- --------- ------------------- ---- - --- --------- le- - -, ---- -- --"'----- -----"$--10- .-- RESTAURANT YES NO less than 25 seats = 100 25-99 seats =$150 more than 99 seats =$200 BED/BRE -AKFAST........YES- ---_N.._O.....-......_....... - .... ... .._...... .$_.100__ --------...._.----- - -- - ADDITIONA- - .L PERM..- - ......ITS. ... .._. -- ----- - - - ..._...._... ..._..._ - - ...--- - ......- .--- ----_ --...-----...- MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVEOUS NO $5 TOBACCO VENDOR NO $5 ALL NON-PROFIT(such as church kitchens) NO rr5 *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, have51 t st x r turns and paid all state I xes required under the law- Signature pate Social Security or Federal Identification Number - - - - - -- ----- --- ---- Re vi sed ---Revised 11113/06 POO DAP 2007.adm Check#&0ale t f a a �F (WO X20 �.�� rf�► �- Y� �y, t'2 ¢ M+ � b '�'.Mw x�y' s�p��y�v. "A= f eG ,� � �•r�� ,��,� ��Commonwealth of Massachusetts i� � ,� , � AyT §ba b <ti 7 zr , n� 4 ,, ` IGmberley Dnsooll'"' SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: Loring Liquors File Number:BHF-2004-000015 70A Loring Avenue Salem MA 01970 LOCATED AT: 070A LORING AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0007 Dec 19,2006 Dec 31,2007 $100.00 TOBACCO VENDOR BHP-2007-0032 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $150.00 PERMIT EXPIRES December 31, 2007 ZM Board of Health This Permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 17 of 29 Aug-03-06 01 : 16P P-01 ommercial Pest Control Agreement Company:- ' I!Contact .. _ . Address '' " 1Telephone — City Address State . ._ - —JJ Zip-- "-- I {City Telephone State zip - ❑ Multiple Locations Arrdcir Location Listing \N rWtaft WarmarNMhY l.tfQt.Mtq((e•��1Mr� L " MMMIII Terminix Will perform regularly scheduled service at the above ad vice address for the control of the-following pests, Service Frequency Roaches ❑ Mice Q Monthly U Semi-Monthly F1 Silverfish n Anti(excluding Carpenter,Pharaoh and First J n "mithly- weekly 0 Rata ❑ Other 1 ❑ Quarterly n Other A,d►tlonal Servile,Information ... .. _.. _ .... .. Ad$t *um Indicated Fwly areltme of d*,A gratrawast - U Customer Preparation Checklist Part I U Sighting Ij Equipment Saler U Clstollmf Preparation Checklist Part 2 U Customer p.Checklist for Apartments ❑ 11 Service Sehedule Checklist U Optional ' n Payment&hadak 7 . lnitinl Service Chargc E - IO Payment Amou Se umber Regular Scmce Charge E.. ..., � .. - - Arcual Total kcccived AI Completion AmounaifNumhec f.cxe 101 Year Advance Paymtent. E " _. ... _ ._: E Account Number Total Due You may recurnim a 3%discount for pre-paying one years w"ke charge I I'advance` 'Thin is if, certify that Tax Exemption Certif,I ate Number has been furnished with Mix Agreement it, Terminix. This agreement Is subject to The Terms and Nonditiuzrnothe-from an I track, _.. _.. ... including the Mandatory Arbitration provision. (AstomertAgent xlglmtare Tllis agreement is for an initial period-oflwrlvc months from the dateoftc first-wrvke and;unkm ca utled-by thelsurtbasrr,w,"a-lama ically. enatlnue on a monthly basis until canceled by either party upon thirty( )days notice.This ■grcement is not valid unlcs,accepted by rnatomcr within 30-days-of submission: In the evens u haus any gnrxtinnn or complains.,you may contact TenalahAuthorization- 1'1crminix rep entative by cal0ng 1.000-TFRMINtX(1-000-037-6464) , Termhdx Office .— Telephone , Iry -- -- - - Address .__ i' .- rifle ..... _ ..._ _ ... Date .. . .. ... ..--IbKMINix Rl- nh7n TAT IPmn m.) Tr FERIOINIX 911"AMIlrAYWrAlUNNFURE TERM/R/X: 'Not ereihab In CdNern• eala4l•Il Cmea 31 Hxlu T 1/06Pip4XIMA ] CUSTO COPY OM06 m,•TMnNU•nPe•L�en M L Y. 070A Loring Avenue Loring Liquors City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 744-1630 PIC Assigned/Knowledgeable/Duties PASS RED Owner: Non-compliance with: Klrk_Oflesh Anti=Choking PASS PIC: Kirk Ofiesh Tobacco PASS Inspector: John Gehan EMPLOYEE HEALTH Date Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑d RED l Od: _ Personnel with Infections Restricted/Excluded PASS ❑d RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS RED BHP-2006-0136 Receiving/Condition PASS RED Status: Open Tags/Records/Accuracy of Ingredient Statements PASS Q RED #k of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED 1 Time IN: Time OUT: 1 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. Jul 05,2006 ) Page I of 1 Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS RED Foodborne Illness Interventions and Risk Factors Food Contact Surfaces Cleaning and Sanitizing PASS RED (Require immediate corrective action) Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS 0 RED Prevention of Contamination from Hands PASS 0 RED Handwash Facilities FAIL RED Comments: Employee restroom had no paper towels. Provide paper towels in hung dispenser. PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS 0—RED Toxic Chemicals PASS 0 RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS 0 RED Cooling PASS 0 RED Hot and Cold Holding PASS 0 RED Time As a Public Health Control PASS F/7 RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS 0 RED CONSUMER ADVISORY Posting of Consumer Advisories PASS 0 RED 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. Jul 05,2006 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils FAIL BLUE Comments:Accumulation of dust on ceiling near fans in walk in. clean ceiling. Water, Plumbing and Waste PASS BLUE Physical Facility FAIL BLUE Comments:Water stained ceiling above middle isle around vent. Find source of leak and repair. Replace ceiling tile. Door by recycling area has aor gap on bottom. Provide weather stripping or door sweep to prevent entrance of rodents and or insects. Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: 687: Avxj///� 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. Jul 05,2006 ) Page 3 of # e,.Asn:�a.9araxc'M�eernfa?wc>`a',+i`os xa.��' �...c�'.,,� +c�st-*;^..*�c�aic� , ,rk«:=�e�xi�e�ia t,.of,'�- w.: s;tgr±�+�x�r.�+�:•I . Commonwealth of Massachusetts • e City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/27/2005 WHO'S PLACE OF BUSINESS IS: Loring Liquors File Number:BHF-2004-0015 70A Loring Avenue Salem MA 01970 LOCATED AT: 070A LORING AVENUE SALEM, MA 01970 - Permit Type Permit No. (Permit Issued Permit Expires Fee Restrictions!Notes RETAIL FOOD BHP-2006-0136 Jan 3,2006 Dec 31,2006 $50.00 TOBACCO VENDOR BHP-2006-0137 Ilan 3,2006 Dec 31,2006 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment l In accordance with the State Sanitary Code ,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 8 of 9 CITY OF SALEM, MASSACHUSETTS e ( ((� �. A. BOARD OF HEALTH D �` f s 120 WASHINGTON STREET, 4TH FLOOR jl/l�1 SALEM, MA 01970 DEC 0 8 2005 TEL. 978-741-1800 STANLEY J. USOVICZ, JR. FAX 978-745-0343 CIV OF SAL6M MAYOR WWW.SALEM.COM BOARD OR HEALTH JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT G 00(, TEL# ADDRESS OF ESTABLISHMENT 76 c MAILING ADDRESS (if different) SO'M12 OWNER'S NAME �1 f IU) t e-I `J TEL# OS�Z.N90 ADDRESS fr�e,I.C all -s4-- CITY 1' ire(l,-, I STATE w 0- ZIP 0 107 / S:j CERTIFIED FOOD MANA ER'S IAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardousfoodis prepared.) // /�/ / EMERGENCY RESPONSE PERSON l��t 1 , O 1 ' S HOME TEL# S�O�'P7 ?'!7� 7 HOURS OF OPERATION: Mon.�+'i 1( Tue.9-/(Wed. q-/(Thu. 9-// Fri. //Sat. !, // Sun. /Z^ /! TYPE OF ESTABLISHM FEE (check only) RETAIL STOREYES NO less 000 gq,ft. =$ 50 10,O more than 10,000sq.ft. =$250 ---------------------------------------l-ess-----tha------n------s- -0------------------ RESTAURANT 25-99 seats eat- s $10 =$150 more than 99 seats =$200 - ------------------------------------------------------------------- .....------------ BED/BREAKFAST YES O $100 ADDITIONAL PERM(..S MAKE (not just serve_) ICE CREAM, YOGURT, SOFT SERVE Y [T OBACCO VENDOR I _,O( YE 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 mustI be submitted to and approved by the Salem Board of Health. Pursuant to MGL Ch ter 62C Section 49A, I certify under the pains and penalties of perjury that I, to my best In d a beli ve fil d all to tax returns and aid all state taxes required under the law. gnature I Date I I Social Security or Federal Identification Number ------------------------------------ ------------------------------------------------------------------- Revised 11/03/05 FOODAP2.adm Check#&Date # L5"//A /�*m- Massachbsetts Department eof Public Health Salem Board of Health 120 Washington Street,4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPEC ZION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Da a T of 0 eration(s) Tvoe of Inspection Cn C y❑ Food Service ❑ Routine Address Risk /u�-� Retail ;qRe-inspection Level ❑ Residential Kitchen Previous Inspection. Telephone 16 > �� / / El Mobile Date: "I//G �) Owner HACCP Y/N ❑ Temporary ❑ Pre-operation 6 cc / ❑ Caterer ❑ Suspect Illness Person in Chargb(PIC) Time El Bed&Breakfast ❑ General Complaint El HACCP Inspector 1 Q out c7 J Permit No. ❑Other Each violation checked requires an e1(planation 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 immine hit health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. A FOOD PROTECTION MANOGEMENT.. .... ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS El2. Reporting of Diseases by Food Employee and PIC I ❑ 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 TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating *" E] 7. Conformance with Approved Procedures/HACCP Plans E3 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) i 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 bie 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 ofd earth. 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)(590.606) 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 FE129. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other �ed4r nN Fr n L � ` 1 DATE OF RE-INSPECTION: S,sMnsceMFormsia.e« Inspector's Signature Print: PIC's Signature: Print: =4Page of(Pages �N A A w A11Z r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F N Crass-contamination 1 -590,003(A) 5ossignment of Responubhty*_� 3-302.1 I(A)t1) Raw Animal hoods Separated from 590.003(B) Demonstration of Knowled e* Cooked and RTE Foods" 2 103 11 Person m churge -duriec Contamination from Raw Ingredients 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 Contaminacor.,from the Environment require reporting by food employees and 3-302.11(A) Food Protection* a dicants* 3-302.15 WashineFruits mid Vegetables 590.003(F) Responsibility Of AFood Employee Or An 3-3(}41.1 Fmxf Contact with Equipment and Applicant To Report To The Person In UtensilO Chasse" Contamination from the Consumer 590.003(G) Reporting b•Person in Char e* 3-306.14(A)(B) Returned Food and Reservice of FK)d- .3 590.0030)) 1 Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003 fl Removal of Exclusions and Restrictions Food 3-701..11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food` Food and Water From Regulated Sources L 9 Food Contact Surfaces 590.004(A B) Cum liap ncc with Food Law' 4-501.111 Manual Warewashi ng-Hot Water 3-20112Pond in a Hermetically Sealed Container* Sanitisation I em eratures` 3?01.i3_ Fluid Milk and Milk Products* 4-501-7.12 'Mechanical Warewashing Hot Water 3-202.13Shell Eggs* Sanitization Tem eramres* 3-202.14 F, Rs and Milk Product,,.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. * 3-202.16 ice Made From Potable Drinkina Water', 4-6()1.71(A} Equipment Food C:ontaciSud'acesand 5-101.11 Drinking Water from an A. roved Svstem* 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 Froman Approved Source 4-70211 Frequency of Sanitization of utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment;' Shellfish* c 4-70111 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 Re ulato Authorit 2-301.11 Clean Condition-Hands and Arms" 3-20318 Shellstock Identification Present* --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 g Receiving/Condition 2-401.11 Sating,Drinkin or Usin*Tabasco* 3-302.]i PI Received at Proper Temperatures 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Packaee lnte ity* Mouth* 3-101.1.1 Food Safe and unadulterated* 3-301.12 Preventing Contamination When Tastin=^` 6 TagslRecords:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstcx k Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3--402.1! Pmasite Destruction* Conveniently Located and Accessible 3-40'_12 Records.Creation and Retention" 5-20311 Notations and Ca asides' 590.0040) Labeling of Ingredients` 5-204.11 Location and Placement" 7 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance fHACCP Plans Supplied with Soap and Hand Drying 35021 L Specialized Processin�Methods* Devices 3-50212 Reduced ox eon ackaging,criteria"` 6-30111 Handwashiu*Cleanser.Availabilit 8-103.12 Conformance with A raced Procedures* =6301,12 (land Dr ing Pro sign '"Denotes critical item is rhe fedora 1999 food(lode or 105 Ch1R 590.000. ♦I - -..�R.. .Yr..b. ....,•,-..wy.•-. ....A�r ..iv..• a'rt .. ...-....'^�d'M1.'. ,�T. .l .n+ i ,..ji. .x . v '�y. • 1 .. Massachdsetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'" Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Dat Tvpe of 0 eration(s) Tvpe of Inspection < I (G for ❑ Food Service [�] Routine Address Rik Retail ❑ Re-inspection Telephone Q Level Residential Kitchen Previous I spection tl -2 " ❑ Mobile Date: s�a�1<)4- Owner p¢ Owner HACCP YM ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PICr Time ❑ Bed& Breakfast ❑ General Complaint InspectorIn. 1.'3D El HACCP vG t Out: S Permit No. ❑ Other Each violation the ed 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) [_1590.009(F) E]action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Dut s ❑ EMPLOYEE HEALTH 13. Handwash Facilities - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC k I ❑ 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 Sour e ` TIMEITEMPERATURECONTROLS(Potentially Hazardous Foods) ' ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION '"""" ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segreiation/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 Handwa�*ing 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 tie 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 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-6)(660.006) 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: / 30 0 `W,e S,5WInsp clFo m 141oc {�J J Inspector's Signature: Print: O G PIC's Signature: ` _ Print: Paged ofzages .r .7- Violations Related to Foodborne Illness interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT K Cross-contamination 1 I 590.003(A) 11 Asst lament of lies tonsibdity"` 3-301.11(Aid) Raw Animal Foods Separated from 590.003(B) Demonso-thou of Knowledge* Cooked and RIF.FooAs* 2 103 11 Pcrcon m ch use-duties Contamination from Raw Ingredients RuAnimal Foods Separated from Each EMPLOYEE HEALTH Other" 2 590.003(C) Responsibility of Che person in charge to Contamination from the Environment require reporting by frwd employees and 3-302.t 1(A) ,Food Protection" a ]kolas* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contnd with Equipment and Applicant To Report To The Person In Utensils" Chat*e* Contamination from the Consumer 590.003(G) Re o ins by Person in Charge* 3-306.,14(A)(B) Returned Food and Reservice of Food* 3 590.003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) I2zmoval of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources L 9 Food Contact Surfaces 590-004(A-$) Conteh mcg with Food Law'r 4-501,111 Yianual Warewashing-Hot Water Sanitization Icmeratures* 3-201.12 Food in a Hermetically Sealed Container* 3-20]13 Fluid Milk and Milk Products* 4-501_1.12 Mechanical Warewashhtg-Hot Water 3-202.13 She((Egas' Santhzttion Temperatures* 4-501114 Chemical Sanitization-temp.,pH, 3Fhs concentration and hardness. 3-202.16 Ice Made From Potable Drinking.Water* 4-(,01..1 RA) Equipment Food Contact Surfaces and 5-1.01.11 Drinking Water Prom an A roved Svstem* Utensils Ctean* 590-006(A) 'Bottled Drinking Water* 4-602.1 t Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Otensils* SheiMsh and Fish From an Approved Source- 1-702,11 Ficquency of Sanitization of Utensils and 3-201.14 Fish and Recte:ttionalfy Caught,hiolluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitizatut:<--Her Water and 3-201.15 Molluscan Shellfish from N'SSP Listed Chemicaii* _ - -- Sources" 10 Proper,Adequatr,4iandwashing Game and Wild Mushrooms Approved by 901.11 Clean Condition-Hands and Arms, Reculatort,Authorit 3-202.1.8 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3ll Good Hygighie Practices -201.17 Garne Animals* g Receiving/Condition 2401.11 F.atin ,J3rinlcin>orUsingTobacco* 3-202,11 PHFs Received at I ro ter Tem teratures* 2-401.12 Discharges From the Eyes..Nose and 3-202.15 Package Lttegrit " Reven 3-101.11 Food Safe and Unadulterated " 3-301.12 Prreventing Contamination When Tastin>" 6 Togs/Records;Shegstock 12 Prevention of Contamination from Hands 590.004(E) Preven[in,,Coruaninationfrom 3-202.18 Shellstock Identification* a 3-203.12Shellstock Identification Maintained* Employers* Tags/Records: Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-402.11 Parasite Destruction* 3-402.12 Records,Creation and Retention' 5-20111 Numbers and Ca azides* 590.0(1.4(J) Labeling of Ingredients' 5-204.11. Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenartce iHACCP Plans Supplied ivith Soap and Nand Drying Devices 3-50211 _Specialized Processin Method sa` 3-502.12 Reduced oxygen ackaRine,criterin* 6-301.11 H.andwashing Cleanser.Avaitabiiit 8-103.12 Conformance with Approved Procedures* 6-301-12 Haztd Drying Provision *Denote,critical item in the fulcra] 1999 Food(.ode or 105 C61R 590.000. CITY OF SALEM BOARD OF HEALTH { Establishment.Name: �i✓\ Date: ! O Page:__ of Item Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified t - I PLEASE PRINT LEA% Y ,t I �-v -, J_ s� J 'i r 'v i e, A t i L S Discussion With Person in Charge: ' Corrective Action Required: ❑ No Yes ❑ Voluntary Compliance ❑ Employee Restriction/ hhave read this report, have had the opportunity to ask que on agree to correct all , p Exclusion violations before the next inspection, to observe all conditio as described, and to `a� 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 5 Embargo ❑ Emergency Closure '. your food permit. r ❑ Voluntary Disposal ❑ . Other: ,K 3-501.14(C;)� PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to I-aw Cooled to Factors(items 1-22) (Cont.) 41".F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coalin"Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PFIFs Maintained at or below 3-202.12 Addaw,Vk590.004(F) 41°/450 F* 3-302.14 Protection from Una o Droved Additives* 3-501.16(.A) Hot PHFs Maintained at or above 15 ,Poisonous or Toxic Substances 140'6`. 7-101.11 ldentifpig information-Original 3-501.1.6(A) Roasts Held at or above 130°F. Containers* - 7-IO2.1 1 Common Name-Workintr Containers* 26 Timee aas s a Public Health Control 7-201.11 1 Separation Storage* 3-501.19 Time as a Public Health Conn'od* 7-202.77 Restriction-Presence and Use* 590.004( LVarmirceRe uirement 7-202.12 .Conditions of Use* 7-20311 Toxic Containers-Pohibitions* POPULLAA REQUIREMENTS HIGHLY SUSCEPTIBLE 7-204.11 Sanitnrers,Criteria-Chemicals` TIONS(HSP) HSP 7-204.12 C'henucalsforWashingProduc,Criteria" 21 3$Ol.l1(A) LnpasteurizedPce-packaged Juices and 7-204.14 Dr. iy ng Agents,C.oteda" Useet Pa with ed ELLg labels* 7-205-11 Incidental Food Contact Lubricants* 3-H01..11(B) Use,of Pasteuu�ed 11cgs* 7-206.]1 Restricted Use Pesticides.Criteria* 3-x01.11(9) Raw or Partially Cooked Animal Food and Raw Seed S proms Not Served.'k 7-206-12 Rodent Bait Stations* 3-80'L11(C) Uno ened Food Packa re Not Re-served 7-206.13 'tracking Powders,Pest Control and Monitoring' CONSUMER ADVISORY- TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Tempsretores for Aminal Foods'114 are Raw.Undercooked or PHFs Not Otherwise Processed to Bliminate 3-401.1.]A(1)(2) Eggs- 155'F 15 Sec. Patho ens Egtp;-Tmmednatc Service 145°F15sce- 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.1 I(A)(2) Comminuted Fish,Meats&Game Eggs* - Animals-155'F 15 sec k 3-401.11(11)(1)(2) Pork and Beo,i Roast- 1406 121 min* SPECIAL' REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meals 155°F 15 590.009(A)-(D) Violations of Seetion 590.009(A)-(D)in sec. ` catering, mobile food, temporary and 3-401.I1(A)(3) Poultry,Wild Game,Stuffed PFIFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited ander the appropriate sections Poultr,or Ratites-165°F 15 sec. a� above if related to foodborne illness 7401.11(07(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.7.2 Raw Animal Foods Cooked in a practices should be debited under ff29- Mierowave 165`F* Special Requirements. 3-401,1 I(A)(1)(b) All Other PHFs-145°F '15 see. * I7 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec. " (Itetns 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, '3403.11(C) Commercially Processed RTE Food- found in the fallowing sections of the Food Code and 305 CMR 140,71 590.0_.00. 3403-1.1(6) Remaining Unsliced Portions of Beef ItemGaod-Retai(Practices_ FC 590.000 Roasts* 23. -Management and Personnel PC -2 .003 Ig Proper Coaling 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 1,40°F to __----- __ --" 26. Water,Plumhirn and Waste FC � ;006__ 7016 Within 2 Hours and From 70'F 27. Ph sical Facilites__ FC-6 .007 to 4t°F/45°F Within 4 Hout_s. * 28. Poisonous or Toxic Materials FC-7 .008 L7:__[E HFsMadeFromAmbient 29_ S ecialRe uirementsre Ingredients to 41°F/45"F 30.___ Otherours* "'Denotes critical item in the feden) 1999 Food Code or 105 CMR 590900. co CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR �r a. SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO / MAYOR HEALTH AGENT June 17, 2005 9j U Loring Liquor 70A Loring Avenue Salem, MA 01970 Dear Owner: On Wednesday May 25,2005 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 16-year-old female purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Loring Liquor is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Protlucts. According to this section,the sale of cigarettes, chewing tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of (Two Hundred Dollar fine)for the SECOND offense. FOLLOWING THE THIRD (3RD) OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordere I to pay a fine of$200.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th floor,within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7) days of receipt of this Order). At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney.) Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or Investigation reports,orders,and other documentary information in the possession of this Board,and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, sL anne Scott Health Agent JS/mfp CERTIFIED MAIL: 7003 31110 0005 1992 1479 cc: North Shore Tobacco Control Program Christina Harrington, Board of Health Chairman and Members '^� � i+ > «rs, �C. �. F -.f rk F*n"4^ ..+. .+- 1 1. . 7✓..vy y.. .� * -.�yv. b+ �R .! ..•!. ✓th M"R. nil• R f.� 4n .. 1IY F: mm ..b e 2A ? GITY.-OF •SAL'EM9 MASSACHUSETTS -M ,.Aa.H %,0 BOARD OF HEALTH - ' *" 120 WASHINGTON STREET, 4TH FLOOR t r •' i3 n.,w :SALEM, MA 01970 - TEL. 978-741-1800 ' FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the lCity of Salem is hereby granted to: Type of Establishment: Liquor Store Name of Establish Ient: Loring Liquors Address of EstablisI hment: 70A Loring Avenue Owner's Name: Kirk Ofiesh Restrictions: Application Date: 12/16/2004 Permit for Food Establishment 240-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 52-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health... HEALTH AGENT o tr CITY OF SALEM, MASSACHIUS BOARD OF HEALTH 4� p M 120 WASHINGTON STREET, 4TH FLOOR �{ o TELL 978-741-1800EM, MA 970 DfC - 3 20 �gn„�aa D4 FAX 978-745-0343 C/�. STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO 804%O�SAL�M MAYOR HEALTH AGENT H 2005 APPLICATION FOR PERMIT TOf OPERATE A FOOD ESTABLISHMENT ATN NAME OF ESTABLISHMENT %Yx 1. TEL# ADDRESS OF ESTABLISHMENT 70iq ©t n,0. -k)5! SQQ9_W. MAILING ADDRESS (if different) cc.lyn e OWNER'S NAME KC A OCe.S ' n� TEL# g2y-(oV6-7J7d ADDRESS 1-1 W-A& WOOD 6 . CITYJ)0'h'r2.p-3 STATE Mt9-- ZIP 23 CERTIFIED FOOD MANAGER'S NAME(S) .Nln- CERTIFICA E#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON K\�k t'J�,eSh HOME TEL#G?Y'606-9TY0 HOURS OF OPERATION: Mon.9-11 Tue. 11_Wed. 4-11 Thu. 4 U Fri. -//Sat.q--if Sun. /2- // TYPE OF ESTABLISHME T FEE check only RETAIL STOREYE NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES !O less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE Y $5 TOBACCO VENDOR YE NO $50 ALL NO.M-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Si natur Date Social Securit or Federal Identification Number 9 �/�------------i 1 o_`>' , -- y(ly--3 r�4.-0 £�3--------- ------------- -- -- --- T ----- -- ---- Revised 11/03103 FOODAP2.adm Check#& Date +pp, CITY OF SALEM, MASSACHUSETTS < a]L BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR - a SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Liquor Store Name of Establishment: Loring Liquors Address of Establishment: 70A Loring Avenue Owner's Name: Kirk Ofiesh Restrictions: Application Date: 12/23/2003 Permit for Food Establishment 235-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 41-03 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. (dVLP�,O)� HEALTH AGENT r; u CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 pEC TEL. 978-741-1800 FAX 978-745-0343 spp-EM N STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO �PRp O : NEAT MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Lir%rte. L'9 tta-s TEL# q-)X-7LA/-/63 O ADDRESS OF ESTABLISHMENT Lora, �4 MAILING ADDRESS (if different) OWNER'S NAME �A;1w ny�2S h r6-9 O ADDF,ESS_/y fAhjC .yJ0d(9 CITY 4]c�r�•y-2.A-& STATE 01 ZIP /11 `L-3 CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentiallyhazardous food is prepared.) EMERGENCY RESPONSE PERSON K1Ak G3=teS1 l HOME TEL HOURS OF OPERATION: MoAl--U Tue. -I.I Wed. 9-[(Fhu. 9 '// Fri. Q-r/Sat._9-/ Sun. TYPE OF ESTABLISHMENT,—'\ FEE check only RETAIL STORE YES O /� v� less than 1000sq.ft. _ :2 1000-10,000sq.ft. =$100 more than I0,000sq. . RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my be knoI�cyge�ndelief, have filed all st to t x returns and paid all state taxes required under the law. u�id 1)'3 C) :ks O B 3 Signature ate' Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#6 Date L36-6-3p— e167 3J6-3p—y 1Od .. i Ir. t CITY OF SALEM, MASSACHUSETTS .j BOARD OF HEALTH Z 5j 120 WASHINGTON STREET, 4TH FLOOR r o' SALEM, MA 01 970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT August 23, 2004 Loring Liquors - 70A Loring Avenue Salem,MA 01970 Dear Owner, On August 11,2004 personnel from the Tobacco Control Program conducted a compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A 17-year-old male purchased cigarettes from a clerk in your store. Documentation is now on file at the Board of Health regarding that sale. Loring Liquors is in violation of Section III(A)of the Salem Board of Health Regulation Affecting the Purchasing of Tobacco Products. According to this section,the sale of cigarettes,chewing tobacco,snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be punished by a fine of ONE hundred dollars($100)for the FIRST offense. FOLLOWING THE THIRD(3")OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION OR SUSPENSION OF THE PERMIT. The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your employees to demonstrate methods to ensure compliance with this regulation. Therefore,you are ordered to pay a fine of$100.00 for the violation stated above. A check or money order payable to the City of Salem must be at the Board of Health office, 120 Washington Street,4th floor,within ten days of receipt of this notice. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in writing in this office of the Board of Health within seven (7)days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. If you have any questions regarding this notification please call me at 741-1800. Sincerely yours, /1 1r "J/oanne Scott Health Agent JS/bas Cc: Not Shore Tobacco Control Program Christina Harrington, Board of Health Chairman and Members '4 t Oil � N2 2183 City of Salem - Board of Health Violation Notice- Tobacco Sale to Minors This notice is to inform you that during a tobacco sales compliance check,your establishment violated the Salem Board of Health regulation#24 prohibiting the sale of tobacco products to persons under 18 years of age. ..or L� �;Od1S Name of establishment Address Date of sale Time of sale Minor's age ender Minor's ID# Adult supervisors Narrative report of incident and description of seller by adult supervisor who will testify at the Salem Board of Health meeting including a description of the seller: I affirm, under the pains and penalties of perjury, that the above report is true to the best of my knowledge hand beeliieef. Y�CA 0 ✓vim / > Adult supervisor(Signature) Adult supervisor (Print name) VBNDOI2 STAT: I acknowledge I received this Violation Notice on / // l� at Z' , u Id 1 am being given a carbon copy of this notice. [ also acknowledge that I have been told that a letter regarding Board of Health follow-up to this violation will be mailed to me at the above address. Owner/Manager/Clerk (Signature) Owner/Manager/Clerk (Print name) If vendor refuses this Notice or if Adult Supervisor feels unsafe in delivering it, an explanation must be written on a note attached hereto. Mailing of this Notice is thus required. For further information.contact the North Shore Tobacco Control Program at 978/741-5646. Board of Heahh-white/NSTCP-vellow/Establishnient-piilk I Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4'" Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date TVD2 of ion(s) Tvoe of Inspection O S'a -d� ❑ Food Service Woof Address 4a Ate Risk E Retail ❑ Re-inspection Tele hon Level El Residential Kitchen Previous InspectionP e A _ _ Ho30 ❑ Mobile Date: 6-/11?-03 :914 Owner 4. HACCP Y/N 13 Temporary [IPre-operation irk ❑ Caterer ❑ Suspect Illness Person in Charge PIC) ' Time ElBed&Breakfast ElGeneral Complaint C ri Inspector V. S 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_ ,. EI 12. Prevention of Contamination from Hands E] 1. PIC Assigned/Knowledgeable/Duties ,,/ EMPLOYEE HEALTH " " I_ '` ' ' "` - ICJ 13. Handwash Facilities - PROTECTION FROM CHEMICALS ' El 2. Reporting of Diseases by Food Employee and PIC El 14.Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE - El 15.Toxic Chemicals ❑, 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition [:116. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating, ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ' rt ". "` ❑ 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 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 C FN 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)(590.006) 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'5001Vs tForr 14,Coc n e t is Sin Lure• r,� Print P1V's rgnature: j Print: Pagel oP Pages iC in 1 Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1I 594.003(A) Assi*nmanf of Responsibility* 3-302,11(A)(]) Raw Animal Foods Separated from 590.003(13) Demonstration of Knowledge" Cooked and RTE Foods* 2-103.11 Person in charge-duties Contaminat/on from Raw ingredients 3-302,11(A)(2) Raw Annual FcxAs Separated from Each EMPLOYEE HEALTH Other* 03((5 Responsibility of the person in charge to Contamination from the Environment require reporting by fund employees and 3-302.1 kA) Food Protection* a )Iictuts* 3-302.15 Washin Fruits and Ve eta es 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 590.0O3(G} Reporting b Person in Cha �e* 3-306.14(A)(B) Returned Food and Reservice of Food- 003(G) 590.603(D) ExciusionsandRestrictions* Disposr'tionofAdulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCEFood" 4 Food and Water From Regulated SourcesF7)-- Food Contact Surfaces 590.004(.A-B) Conyatiance with Faxl Law* 4-501..11 1. Manual Warewashing-Hot Water Sanitization Tem eratures* 3-201.12 Foci in a Hermeticail Scaled Container* 4-501.1 t2 Mechanical Warewastting- Hot Water 3-201.13 Fluid Milk and Milk Products* a 3-202.13 Shell Eons* Sanitization Tcm eratures* 4-501.114 Chemical Sarutizaation-tern H, 3-202.1.4 Eo>s and Milk Products.Pasteurized' P concentration and hardness.,'K 3-202.16 Ice Made From Potable Drinking Water* 4-001.11(A) EquipmantFood Contact Surfaces and 5-101.11 Drinkin Water front an A roved System* Utensils Clean" 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(I3) Water Meets 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 3-2t}1.14 Fish and Recreationally Caught Molluscan - Food Contact Surfaces of Iul stent* Shellfish* 4703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical" Sources* 14 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arins* Reauiato Authority 3-20218 Shellstock Identification Proses(* 2-304.12 Cleaning*Procedure* 590.004{C) Wild Mnshr<wms` 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinkin or Using Tobacco* -202.11 PHFs Received at Yroger Tem eramtes* 2-401.12 Discharges From the Eyes. Nose and 3 3-2.0215 Packa re hue grit�* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.f2 Preventing Contamination�5'hen'F'asting* 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* EFlo ceO Tags/Records:Fish Products 13 mHandwash Facilities 3-402.1 I Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Ca acities," 590.004(1) Labeling of Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibi8t Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-50'2.12 - Reduced usvgen racka=ing;criteria" 6-301.11 Handwashnig Cleanser,Availability 8-103.12 Conformance with A. roved Procedures* 6-301.12 Hand D dug Provision 'Denotes critical item in the tedenal 1999 Forxl Code or 105 CMR 596.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: (0Date: 5 ' Page: of Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY i I F .rte , Y MC CIz(, s n !)(A 10 C — - s. Iris - 11 l jo o 1 /7 i -(- a i I i I: I I 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/ Exclusion i violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension c9mply 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 LIEmbargo ❑ Emergency closure j your food permit. ; ❑ Voluntary Disposal ❑ Other: i i 3-501.14(C) 'PHFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to 1,aw Cooled to Factors(items 1-22) (Cont.) 41°F/45"T Within 4 Hours. PROTECTION FROM CHEMICALS3-50115 Cowling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives''` 3-501.16(B) Cold PEtFs Maintained at or below 590.004(F) 41`!45°F* 3-302.14 Protection from Unapproved Additives* 3-SOL LG(A) Hat PHFs Maintained at or above 15 Poisonous or Toxic Substances 400P 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 3-501_19 Time as a Public Health Control* 7-202.1.1 Restriction-Presence.and Use'x 590.004(H) Variance Rz uirement 7-203.1.1 'Cork Containers.12 Conditions Containers f Use- 7-203 -ProhiMtioms* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP 7-204.12 Chemicals for Was'hine Produce,Criteria* 21 3-801 A NA) Unpasteurized Pre-packaged Juices and 7-204.14 Drying gents,Criteria* Beverages with Warning Labels-^ 3-801 II(B) Use ofPasteurized Eggs* 7-205.11 Incidental Food Contact.LuLncants* 3-801A 1(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed S>roats Not Served. 7-206,12 ,Rodent PStations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.1'3 Trackingg Poo wders,Pest Control and Monttrrrtng* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw,Undercooked or lfi Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate > _eeu1a+nnooi 3-40LLiA(1)(,2) Eggs- 155I 15 Sec. I - athogens.* Fr` Ergs-Lmmethate Service 145"F75sec' 3-302.13 Pasteurized Eggs Substitute for Raw Shell 1-40LII(A)(2) Corruninuted Fish,Meats&Game E s'" AmMak- 155°F 15 sec r SPECIAL REQUIREMENTS 3-401.11.(B)(1)(2) Pork and Brei Roast - 130'F 121 min* 3-401.11(A)(2) Ratites,Injected Meats 155'F 1.5 590.009(A) Violations of Section 590.009(A)-(D)in sec. x catering, mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PlIFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr or Ratites-165°F IS sec. s= above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beet 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- Micabwave 165'F* Special.Requirements. 3-401,1I(A)(1)(b) All Other PHFs-1,45'F15 sec. * I? 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 Standina Critical and non-critical violations, which do not relate to the Time" ,foodborne illness interventions and i i.sk factors lived above can he 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR '140°F* 590.000. ma e ___ 3-403.11(F.) - Remaining Unsliced Portions of Beef Item Good Retail Practices_ FC 69Q.m00 Roasts* 23. Mament and PersonnelFC-2 1_0-3 Ig Proper Cooling of PHFs _24 Food and Food Protection _ ______ FC_ 3___ 004 25. Equi ment and Utensils FC-4 .005 3-50'1.14(A) Cowling Cooked PHFs from 140°F to --H. _Water Plumbin and Waste FG_5-1_.006 - -- 70°F Within 2 Hours and Front 70'F 27 Ph sical Facility FC-6 .007 to 41'F145'F Within 4 Hones. * 28. Poisonous or Toxic_Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature ingredients to 41°F/45°F 30-_-...._.....Other -- _-_..__...------- Within 4 Hoursw a..=��ro,vtiaazmr Denotes Critical iVem in the ruderal 1999 Food Code or 105 CMR 590.000. 1.4Aassachusetts De artment of Public Health Salem Board Health S p 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 TvI2of O eratir>n s T e of Ins coon xC � &o 22113 5-Q_1 Food Service Routine Address Risk ❑ Retail I E Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: f ❑ Temporary [IIPre-operation Owner HACGP YtN o C a LGA ❑ Caterer ❑ Suspect Illness Persdn in Charge(PIC) Time ❑ Bed&Breakfast El General Complaint n ❑In: HACCP Inspector Permit No. ❑Other _ u . g fl - f t< Outr 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 590.099(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 PROTECTIONS 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 C] 4. Food and Water from Approved Source TIMEtTEMPERATURE y CONTROLS(Potentials Hazardous Foods) A. ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CgNTAMINATION ❑ 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) [121. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing _ ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑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 TN by a Board of Health member or its agent constitutes an 23. Management and Fersonnel (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: S:590JPV0 FnrmB-K d. '� •g Prink I 1 ,c t c: ignature: Print: r p� C ( Paged of!--Pages 1 J Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 _ Cross-contamination 1 n9 .003(A) A2signmentofResronstbil,ity" 3-302.11(A)(]) Raw Animal Foods Septn'atedfrom 590.003(B) Demonstration of Knowledge* Cooked and RIE Foods* 2-103 ]1 Pcrson m charge-dunes Contamination from Raw Ingredients 3-30-11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other"` 2 590.003(C) Responsibility of the person in change to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* atlicams* 3-302.15 Washing FrunsmidVegetables 590.003(1) Responsibility Of A Food Employee Or An 3-304.11 Food Coniact with Equipment and Applicant To Report To'rhe Person In Utensils* Charge* Contamination from the Consumer 590.003(G) - Re orcin,b Person in Char e* 3-306.14(A)(11) Returned Food and Reservice of Food* 3 590,003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 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 F9 Food Contact Surfaces 590D04(A B) Com Imp i ac'e with Food Law'" 4-501.17 L Manual Wv washing-Hot Water Sanitization Icm eratures" 3-201,12 Food in a Iicrmetieell Sealed Container* 3-201.13 Fluid Milk and Milk Products* 4-501,112 Mechanical TemperaWarcwatures"Hof Water Sanitization Ten? etdtllr'C5* 3-202.13 Shc(i E""s* 3-202.14 'Eggs and Milk Products.Pasteurized* 4-501.11,4 Chemical io nand I n d temp.,pH, concentration and ha,�dness. * 3-202.10 Ice Made From Potable Drinking,Water` 4-601_I I(A) Equipment Food Contact Sarfaces and 5-101.11 Drinking Water from an r1 .roved System* 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 22.0* Contact Surfaces and Utensils' ShetNish 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 Sarfaces Dill ui tnenf� Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201,15 Molluscan Shellfish from NSSP Listed Chemical' Sources* 1p Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.1 1. Clean Condition--Hands and Arms"` Regulatory Auhorit 3-202.18 Shellstock Identification Present* 2-301.12 01cannig Procedm'e* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash" 3-201.17 Game Animals" 11 Good Hygienic Practices 3 Receiving/Condition 2-401.11 Patin ,Dnnkin or Using Tobacco* 3-202.11. PHFs Received at proper Temperatures,* 2-401.12 Discharges From the Eyes.Nose and Mouth* 3-202.15 Package hinge itv* 3-101.1.1 Food Safe and Unadulterated* 3-301.I2 Preventing Contamination Whcn Tastin-* 6 FoodTagsSafe and:Unadulterated 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" Emsha ees' Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 'Parasite Destruction" Conveniently Located and Accessible- 3-402.12 ccessible3-402.12 Records-Creation and Retention* 5.203.11 Numbers and Ca aciiies* 590A04(J) Labeling of Ingredients' 3-204.11 Location and Placement" 7 Conformance with Approved Procedures 5-205.11 weessibility, Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying Devices 3-502.11 Specialized ProcessingMethods* 6-30 3-50212 Reduced oxvgen packaging,criteria" 1-1.1 Ffandwashing Cleanser,Availability 8-I03.I2 Conformance with Approved Procedures"` 6-307.12 Hand Drying Provision *Denotes Irak al item in the feral 1999 Food Code or 105 C NIR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: A it /. Date: Sd TO Page: of_ 4, Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION- Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY '. I i _ lI iL N/Y J O /Q A,,_^- / I , , IV • / 541 A/ � 8i u - 1 � lee.- X§�d 1r. Ae , I' u f2Y .L. {O h l71C Tnl7 fdl( �2ulx 2a!/! tJ�A _ ! 0 J r I c I, i piscussion 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 i 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/Fede I Food Code. I understand that I noncompliance may result in daily fines of.t enty-five dollars o sus_p sion/revocation of ❑ Embargo ❑ Emergency Closure youv food permit. ❑ Voluntary Disposal ❑ Other: I i I 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk Accordin,,to Law Cooled to Factors(Items 1-22) (Cont.) 41°1-145°.1-Within 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives I9 PHF Hot and Cold Holding 3-501.16B) Cold PHFs,Maintained at or below 3-202.12 Addmse`,° 590.004(F) 41145' F- 3-302.14 Protection from tina ,roved Additives* 3-501,16(A) Hot PHFs Maintained at or above I5 Poisonous or Toxic Substances 140'1-. 7-101.1,1 identifying Information-Original 3-501]6(A) Roasts Held at or above 130'F. Containers* 7-102.11 Common Name-Working Containers"` 20 Time as a Public Nealth Control 7-201.11 Se aradon-Stora e* 3-501.19 Time as a Public Healkh Control* 590.004(H) Variance Requirement 7-202.11 Restriction-Presence and Use's 7-202.12 Conditions of Use'" 7.203.11 Toxic Containers-Prohibitions" REQUIREMENTS FORHIQHLYSUSCEPTIBLE 7-204.11 Samtizers,Criteria-Chemical~* _ POPULATIONS HSPS 720 W4.12 Chemicals for ishi iv Produce,Crriteria" 2I_ 3-301.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying A rents,Criteria" Beverages with V� rwog Labels* 7-205.11 Incidental Food Contam Lnhricnnts* 3-801..11(B) Use of Pasteurized F ggs* 7-206.11 Restricted Use Pesticides.Criteria* 3-301.11(1)) Raw or Partially Cooked Anhual Food and Raw Seed Sprouts Not Served. 's 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME)TEMPERATURE CONTROLS 22 3-603.1 L Consumer Advisory Pasted for Consumption of 16 Animal Foods'fbat are Raw.Undercooked or Praper Cooking Temperatures for PHFs Not Otherwise Processed to Blitttinate Pathogens * rtecdva 111,'2001_3-401.11A(1)(2) Eggs- t55F7.5Sec. fi=[s-7inmedratc Sen-ice 145"F15sec, 3-303.13 pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats r&Game Eggs' Animals- 155°F 15 sec. ,' )( )( 3-40t.11(B t 2} pork and Beef Roast -130'1-121 into* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,injected Meats 155°F 1.5 590.009(A)-(D) Violations oP 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 wider 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 tisk 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`1- * Special Requirements. 3-40L11(A)(t)(b) All Other PHFs- 145°F15see. * I1 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165',P 75 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 Thee* foodborne illness iatervenliom and risk f a,tors listed above. can be ,403.11(C) Commercially Processed RTE Food- f tunri in the jalhavi tg sections of the Food Code raid 105 CMR 140'F* 590.000. 3-403.11(1-.) Remandng Unshced Portions of Beef item Good Retail Practices FC 59D.000 Roasts" 23. Management and Personnel FC-2 .003 Ig Proper Cooling of PHFs 24. Food and Food Protection _ FC_3 .004 -- 25 E ui ment and Utensils _ FC 4_ .005 3-SOL 14(A) Catling Cooked PHFs from 140°F to --26_._ Water,_P and W rite FC S A06 70°F Within 2 Hours and From 70°F 27. Physical Facility__._____ _ FC-6 .007 to 4I'T/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501,14(B) Cooling PHFs Made From Ambient 29 S eeial R ulrements ____ 009 Temperature Ingredients to 41°F/45°F 30 _ Other _ _ J------_ Within 4 Hours:x .e;5-moan'U.24 : Denotes el i lcel itrsn in the.(:'iteral 1999 Food Cade or 105 CMR 592000. Masshchusetts Department of Public Health Salem Board of Health 120 Washington Street,4'" Floor Division of Food and Drugs Salem, MA 01970.3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date T of Ooeration(s) Type orinspection ❑ d Service outine Add ss Fp'ORisk �tetail Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephoneq r) (1 ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) ^' Ti e / ❑ Bed&Breakfast ❑ General Complaint �J In � ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an expla on 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) 590.609(Fy 5� action as determined by the Board of Health. 4 FOOD PROTECTION MANAGEMENT, ,"u, r'1 ❑ 12. Prevention of Contamination from Hands ❑. 1. PIC Assigned/Knowledgeable/Duties ❑ 13. HandwaSh Facilities EMPLOYEE HEALTH - PROTECTION FROM CHEMICALS �' 1 ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded ❑ 14.Approved Food or Color Additives FOOD FROM-APPROVED SOURCE .� ,.j ❑ 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source T�METE7P �AURcONTROLS'(�� y Hazardous Foods) J ❑ 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 W- `-; ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection [120.Time As a Public Health Control -- - .�.-__ ._-_-_- - - ❑ 9. Food Contact Surfaces Cleaning and Sanitizing J REOUIREMENTS FOR HIGHLY SUSCEPTI@LE POPULATIONS(HSP), El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11.Good Hygienic PracticesCONSUMER ADVISORY;;,,e.�_�„� ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofCeaNh . 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 25. 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 ER29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other { '•- c DATE OF RE-INSPECTION: 1n n 4 Q C, � S:5HO1 u 'Fw 14.o , to r I (V lW\t VVI 4\a4 1 "'�„ �r\ Inspector's Signature: v Print: PIC's Signature• Print: A//f • 2 Page of`ages Violations Related to Foodborne illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION_ 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assig ment of Res nsibilit * Cooked and RTE Foods* 590.003(B) Demonstration of Knowled. ex: Contamination from Raw Ingredients - 2-103.11. Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590,003(,0) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.1.5 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Focal 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 by Person in Charge* 3 590.003(D) -Exclusionsand Restrictions* DisposdionofAdulteratedorContaminated Food 590.003(E) Removal of Exclusions and Restr ct ons 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 Hermetiejlly 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* 4-501.114 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[(A) Equipment Food,Contact Surfaces and Utensils Clean* 590A06(A) Bottled Drinking Water* 4602 590.006(B) Water Meets Standards in 310 CMR 22.0* .11 Cleaning Frequency of Equipment Food Contact Surfaces and Utensils* . . ShelBish and Fish From an Approved Source 4-702.1 t 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-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Gameand Wild Mushrooms Approved by M Re ato Authort 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellsnxk Identification Present* 2-301..1.2 Cleaning Procedure* 590.004(0) Wild Mush gams* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.1.1. PHFs:Received at Proper Temperatures* 2-401.12 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(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em 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* 590.004(J) Lataeling of Ingredients' 5-204.1.1 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Mand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced oxygen p packaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with.A loved Procedures* 6-301..1.2 Hand Drying Provision ''Denoleg critical item in the federal 1999 Food Caie or 105 00112 590.00. iF - CITY OF SALEM 1 BOARD OF HEALTH Establishment NameAn :147 . r �a o / Date: Page: "f _ Item Code C-Critical Item ( \ U DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date. No. Reference R-Red Item J verified PLEASE PRINT CLEARLY o U _A a k�zq- ok� Mo ,/.t. A' �l ✓J � n .e.e � 1 1, / 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 c� noncompliance may result in daily fines of twen -fie ollars r s spe sion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 1 r1 ❑ Voluntary Disposal ❑ Other: X � , 3-501,14(C) PHFs Received at Temperatures Viatations Related to Foodborne illness Interventions and Risk According to taw Cooled to Factors(Itens 1-22) (Cont.) d1'P/45°F Within 4 Hairs. PROTECTION FROM CHEMICALS 3-501,15 Coolin Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives*- 3-50L16(B) Cold PRFs Maintained at or below 3_302.14 approved Additives" 590.004(0 41°!450 F* oteckion from Ln 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140 , * 7-101,11 Identifying information-Original 3-501.16(A) Roasts Held at or above 13VE Containers* 7-102-I1. Common Name-WorkingContainers* 20 Time as a Public Health Control 7-201.11 Se aradon-Stora * 3-501:19 Time as a Public Health Control* 7-202.11 ,Restriction-Presence and-Use° 590.004{Hl 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* 21. 3-801.11(X) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for WashingProduce,Criteria* Beverages with Warni rr labels* 7-201.14 n Agents.Criteria* 3_SOI.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 Sproms Not Served- 7 erved 7-206.12 1 Rodent Bait Stations* 3-801.11(C) Uno ned Food Package Not Rc-served. 7-206.13 Tracking Powders,Pest Control and Monitoring- - CONSUMER ADVISORY TIMEtTEMPERATURE CONTROLS 22 3603.11 Consnmei Advisory Pasted for Consumpnan of 16 Proper Cooking Temperatures far Animal Foods That are Raw,Undercooked ar PHFs Not OtherwiseProcessedto Eliminate nate *ens.*o*`° fiver 3 401.11X(1)(2) Egan- 155F 15 Ste. Eggs-immediate Service 145°F15sec* 3-302.13Pasteurized Eggs Substitute for Raw Shell gW 31101.11(A)(2) Comminuted Fish.Meats&Game Animals-155°F l5 sec. * SPECIAL REQUIREMENTS 3401,11($)(1)(2) Pork and Beef Roast- 130'F 121 min* 3-401.11(X)(2) Ratites,Injected Meats-155°F 15 590.004(X)-(D) catering, of Section.temp racy and in sec.* catering,.mobile food temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-l650F 15 sec, * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and Tisk 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 165F 4 Special Requirements. 3-401.1l(A)(1)(b) All Other PIFs- 145°F 15 sec. i7 Reheating for Hot Holding WOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403AI(A)&(D) PHFs 165-F 15 sec. * (Items 23-30) 3-403.11($) Microwave- 16S F 2 Minute Standing CMicat,and non-critical violations,which do not relate to the Time« foodborne illness intervendans and ris&factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the fallowing sections of the Food Grine and 105 CMR 140°l:* 590.000. 34011.11(E) Remaining Unsiiced Portions of Beef #ern ! Good Retail Practices FC 690.0X7) Roasts* 23_ 1 Management and Personnel { FC-2 .003 18 Proper Cooling of PHFs i 24. 1 Food and Food Protection 25. 1 Equipment and Utensils _( FC-4 .005 1 3-50L M(A) Cooling Cooked PHFs from 140`F to 26, 1 Water.Plumbing and Waste - FC-5 .006 70°F Within 2 Hours and From 70'F 27. Physical Facitity FC-6 007 to 41`F145°F Within d Hours. * i 28. Pdson"us a Toxic Materials i FC-7 .008 3-501.74f.Q) Cooling PHFs Made From Ambient 29. Special R uiremoms 009 Temperature ingredients to 4PF/45°F 30� 1 Other Within 4 Hours'" 3 Llemtes critical hem in the federal 1999 Facd Code or 105 CMR 590.000. A Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Datgg Tvoe of Operation(s) T e fin Ins ection J�rf l l0 U (� ( ❑ Food Service Routine Address J tl Risk d Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone a'�$1 �, ❑ Mobile Date: Owner '' '/`` HACCP Y/N ❑ Temporary ❑ Pre-operation to I e S ❑ Caterer El suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint Sam 9-, In: X0,30 ❑ HACCP Inspector SCk(cxht4-rcc� I 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 Antl-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_ '®'�"• .f"7� ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El_ _ 13. Handwash Facilities [EMPLOYEE HEALTH s. -.�.,, PROTECTIONFROMCHEMICALS' " El2. Reporting of Diseases by Food Employee and PIC E] 3. Personnel with Infections Restricted/Excluded [114.Approved Food or Color Additives ❑ 15.Toxic Chemicals LFOOD FROM-APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMEIfEMPERATURE CONTROLS(Potentially.Hazardous Foods) ❑ 5. Receiving/Condition El 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 ❑ 8.Separation/Segregation/Protection [120.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS_(HSPJ El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices .CONSUMER ADVISORY„t,, F ❑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-z)(ss0.0 4order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3)(Sso.00a) 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:seonspecr-oma-a.dx Inspector's Signature• Print: lIZq '-)a 1QnjCX- PIC's's Signature: Print: Ir _6 2S �1 Page I of-a Pages v� Violations Related to Foodborne Illness Interventions and Risk Factors(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) Assignment 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 Aininal 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 Washin Fruits and Vegetables applicants* 3-304.11 - Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003 (3) ReportinE by Person in Charge* 3 590.003(D) Exclusions and Restrictions* Food dsiflortoiAdutteratedorContaminetetl 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food"' 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 Warewasbing-Hot Water 3-201'.12 Food in a Hermetically Seated 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 Fns and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. * 3-202.16 Ice Made From Potable Drinking Water* 5-101.'11 DrinkingWater from an Approved System.tem* 4-60111(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 590.006(B) Water Meets Standards in 310 CMR 22.0* 11 Cleaning Frequency of Equipment F d Shefffish 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 lasted Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authord 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstoek Identification Present* 2-301.12 Cleaning Procedure* 590.004(0) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* - 1-401,12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.'12 PreventingContamination When Tasting* 6 Tags/Records;Shellstock 12 Prevention of.Contamination from Hands 3-202.18 Shellstock Identification" 591).0(M(E) Preventing Contamination from 3-203.12 Shelistock Identification Maintained* Employees* - TagsfRecords: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.1.2 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(1) labeling of Ingredients' 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Pians Supplied with Soap and Hand Drying 3-502.11. essin Methods* Devices 3-502.12 ceQen acka 'ng,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301..12 Hand Drying Provision *Denotes critical item in the federal 1999 rood Code or 105 CMR 590.000. i CITY OF SALEM 4` BOARD OF HEALTH Establishment Name: 101 t '{t �tc"UCAS Date: lou /it Page: o� of Item Code C-Critical Item ✓ DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- 140. Reference R-Red Item Verified PLEASE PRINT CLEARLY - N3Ure cel\ Cc01 erg Vic-py.e vJ to uCcvrcfte �r� rer l `I� C41 .� ._ I xr-cya,-3n c s , n ( vi <- < — CX 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 C3 Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food CodfLundersrand that noncompliance may result in daily fineive ollars or su pension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. (/ i ❑ Voluntary Disposal ❑ Other: Q c r .t 3-501,14(C) FHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to factors(Hema 1-22) (Cont.) 41'FAFF Within 4 Hours. PROTECTION FROM CHEMICALS3-501..15 Cooling Methods for PHFS 14 Food or Color Additives - 19 PHF Not and Cold Holding 3-501A(5(13) Cold P13Fs Maintained at or below 3-202.12 Additives* 590.004(F) 41'!45'F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 1400F * 7-101.11 identifying Information-Original 3-501.16(A) Roasts Held at or above 1300F.* Containers* - 20 Time as a Public Health Control 7-102.11. Compton Name-Working Containers* - 3-501:19 Tim as a Public Health Control* 7_2111.11 I Separation-Stora * 7-202.11 .Restriction-Presence and Use* 596.064(H) VarianceRequirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanidzers.Criteria-Chemicals* 7-204.12 Chemicals fir WashingProduce,Criteria" 21 3-$01.11(4) Unpasteurized Pre-packaged raises and Beverages with Warning Labels* 7-204.14 eats.Criteria* 3-801.11(B Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-9 1.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 - Rodent Bait Stations* 3-801.11(C) Unopened Food Pack Not Re=served. 7-206.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY TIMEIPEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or Not Otherwise.Processed to Eliminate 3-401.IIA(1)(2) Eggs- 155"F 15 Sec. enmon o PHPathO s.* rnrmer Eggs-Immediate.Service 145'F15sec* 3-302.13. E Pasteurized* Eggs Substitute for Raw Shell. 3-401.11(A)(2) Comminuted Fish.Meats&Game Animals-155OF 15 sec.* SPECIAL REQUIREMENTS 3401.11(8)(1)(2) Pork and Beef Roast-13TF 121 min* 3401.1 I(A)(2) Ratites,Injected Meats-155°F 15 590.004(4)-(D) Violations of Section 590.009{A}-(D)in sec.* catering,.mobile ford,temporary,and 3-401.1I(A)(3) Poultry,Wild Game,Stuffed PRFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-I65'F 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 Foods Cooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3441:1I(A)(1)(b) All Other PHFS- 145*F 15 sec. 17 Reheating for Not Holding VIOLATTONS RELATED TO GOOD RETAIL PRACTICES 3403.41(A)&(D) PHFS 165°F 15 sec.* (Items 23-30) 3403.11(B) Microwave-165`F 2 Minute Standing Critical.and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, cern be 3-403.t l(C) Comast is ly Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 1400F* 590.000. 3463.11(E) Remaining Unsliced Portions of Beef item i Gaod RetaFt Ptactless PC 540.000 Roasts* ; 23_ i Management and Personnel FC-2 .003 18 Proper Cociing of PHFs 1 24. !. Food and Foci Protection FC-3 .004 125. Equipment and Utensils FC-4 405 3-50L14(A) Cooling Cooked PRFs from I40`Fto 126. J Water,Plumbing and Waste 1 FC-5 006 70"F Within 2 Hours and From 70`F 27. Physical Facifty FC--6 007 to 41`F/45'F Within 4 Hours.* i 28. ' Poisonous or ToxEc Materials FC-7 .008 3-501.14(B) Cooling PHFS Made From Ambient �29�_S�ecial R uiremants .009 Temperature Ingredients to 41°F/45°F 30' i Other j- Within 4 Hours" "Denotes critical min it,,the L-deril 1999 Fuad Cale or 105 CMR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"'Floor DYv'ision of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT IN ECTION REPORT Tel.G(()? Nt Name DatL Type ofCiperation(s) Type_gf Inspection lt)` F d Service outme -Addres Risk ❑ eteil Re-inspection Telephone , l Level El Residential Kitchen Previous Inspection ❑ Mobile . Date: Owner HACCP YIN7 ❑ Temporary [I Pre-operation N& ❑ Caterer ❑Suspect Illness Person-in-Charge(PIC) ,! Timg El Bed&Breakfast L]General Complaint In.<l El HACCP Inspector Ou : Permit No. ❑.Other Each violation checked requires an exa 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_(Red Anti-Choking 590.009(E) ❑ Items) Violations marked may pose an imminent health hazard and require immediate Tobacco a 590.009 IF) ❑, corrective action as determined by the Board of Health. Allergen Awareness 590.009(G F-1 FOOD PROTECTION MANAGEMENT ,� _ _ __._ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties t -' -+ ❑ 13. Handwash Facilities EMPLOYEE HEALTH ;PROTECTION FROM'CHEMICACs;_ ❑ 2. Reporting of Diseases by Food Employee and PIC El 3, Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives -- _____ ❑ 15. Toxic Chemicals „FOOD FROM APPROVED SOURCE - TIMEITEMPERATURE.CONTROLS.(Potentlal ❑ 4. Food and Water from Approved Source _ ty Haxeidous Foods) ❑ S. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling r - - . - ---- -., ----,-- 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 bREOUIREMENTS FOR_:HIGHLYSUSCEPTIBLE=POPULATIONS':(HSP).' ❑21.Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing El 11. Good Hygienic Practices El 22. Posting of .Consumer A-_ Rdviso_ ries_ - _ ❑22. P 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-3)(590.004) 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 26.Water, Plumbing and Waste (FcsX5s0.005) the food establishment permit and cessation of food 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-7x590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.00s) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: - U L d vv),g Inspector's Signate Prin PICS Signature: Print: r,S� i,4 Pagel 0f GYages 3 Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION g Cross-contamination FOOD PROTECTION MANAGEMENT 3-302AA(A)(1) Raw Animal Foods Separated from 1 I 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(6) Demonstration of'Knowledge* ._ Contamination from Raw Ingredients 2-1.03.11. Person in charge-duties 3-302.1.1(A)(2) Raw Anima Foods Separated from Each Other* EMPLOYEE HEALTH i Contamination from the Environment 2 -5-90-003(C) Responsibility of the person in charge n> 3-302A I(A) Food Protection* require reporting by food employees and 1 3-302.15 Washin Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Foot Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Char * 3-306.14(A)(B) Returned Food and Reservice of Food'* 590.0C03 Reporting b Py erson in C name* Disposition of Adulterated or Contaminated 31,590.003(D) Exclusions and Restrictions* Food 590.003(,E) Removal of Exclusions and Restrictions 3-70LI1 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 4 Food and Water From Regulated SOU(C&S Food Contact Surfaces 590.004(A-B) Com Ilimce with Fcxxl law'" 4-501.111 Manual Warewashing-Hot Water Sun3-201.12 Food in a Heruteticall•Seated Container" Mechanical Temperatures* 3 201.13 Fluid Milk and Milk.Products* 4-5GI.1 l2 Meehanical Temperaturesng-Hat Water _ Sanitization Tem Temperatures* 3-202.13 Shell E-mss* 4-501.11.4 Chemical Sanitization-to H, 3-202.14 Ea s and i Silk Products.Pttsteurizzsi* ��'p concentration and hardness. 3-202.16 ice Made From Potable Drinking Water* 4-601_il(A) Equipment Food Contact Surfaces and nkip tr,'aterfrom an A rove ' 5-101.11 Drid System-tem" Utensils Clean* 590.006(Al Bottled Drinkinj Water* 4-602.1.1 Cleaning Frequency of Equipment Food 590.006(13) Water Meets Standards in 31.0 CMR 22.0* Contact Surfaces and Utensils* Shagsh 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" 4-70"3.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSF Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.1 I - Clean Condition-Hands and Arms* Re ulata Autitorfi 3P 2021& sheilsto k identification Present„ 2301.12 Clearing Procedure* re* Wd rootns* 2-301.14 WhentaW`ash*als* . Good fiygisnie Praotieas Condkion2-401..31. Eatin ,Drinkin or Usin Tobacco* ived at Pt er Tem raittre.s* 2'101.12 Ltischarges:From the Eyes,Nose andMouth* te it'* I . 3-301.12 . . Preventin Contamination When Tasting* and.Unadulterated* 12 Prevention of Contamination from Hands rds:Shelistock 3-20218 Shellstuck Identification irm* 590,004'(E) Preventing Contamination from Ha to es* 3-203.12 SheUstock identification 1?aintained'� _-YI 13 Handwash Facilities TagslRecoMs Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction" 5-203.11. . Numbers and Capacities* 3-402.12 Records,Creation and Retention" 5-20111 Location and Placement* 590.004(7) tabeiing of ingr¢di¢nts3 ? Conformenc¢with Approved Procedures 5-205.11 -Accessibilit , ration and Maintenance tHACCP Plans Supplied with Soap and Hand Drytrtg Devices 3-502.11. S ecxalizRdPracessin �rlethals* .,6-30LII Handwashing Cleanser,Availability 3-502.12 Reduced oxygen acka'no,.criterm* --6-301.12 Hand Drying'Provision 8-103.12 Conformance with Approved Procedures` +llenote-w cdGad,•tem In nle feral 19991^a)d(:ode or 105 CMR 590.000. BOARD OF HEALTH Establishment Name. Date: b— q_t3 Page: '� of Item Code C Critical Item '> - ". .DESCRIPTION'S OF VIOLATION / PLAN OF CORRECTION Cate No. Reference R'—Red Item , <, = � zA Verified PLEASE PRINT CLEARLY Q U Iv t _ Discussion With Person in Charge: Corrective Action Required: ❑No s ,. Voluntary Compliance ❑ Employee Restriction/ Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure t ❑ Voluntary Disposal ❑ Other FORM 7348 (REV. 7/2000) HOBBS & WARREN, - BOSTON This Form Approved by the Department of Public Health Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1.22) (Cont.) According to Law Cooled to 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 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°F.* Containers* 3-501.16(A) Roasts Held at or above 130°E* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11. Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce.Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22. 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw, Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Eeecnre...1200' 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145*F 15 Sec.* 3-401.11(A)(2) Comminuted Fish, Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(B)(1)(2) Pork and Beef Roast- 130*F 121 Min.* catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats- 155*F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and not-critical violations, which do not relate to the 3-403.11(B) Microwave- 165*F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Eq ui ment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70*F 27. Physical Facility FC-6 .007 to 41°F/45*F Within 4 Hours.* 28, Poisonous or Toxic Materials FC-7 .008 3-501.14(8) Cooling PHFs Made From Ambient 29. S ecial Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.