Loading...
LOS AMIGOS SUPERMARKET - ESTABLISHMENTS Los gmi90s SuftfMOfk4t 122 Lufpyefff Wetf ftNIVERSAL® UNV-12110 ALINE IN USA SUSTAINABLE A�! ,yp� FORESTRYCONIQJf 10%® INITIATIVE Cenuieg ni er Sourcing POST w ,fipregmmorg M u1TU �� � � y�^ Board of Health � '<��" IGmbefley .riscAll � x �, a € �� � � SALEMAO1A70 F . 'ATOBAGCO S �� DATEPRINTED �€ 01/072014 <�f r, � �,�h my 3 - - �e.{ l& . k ESTABLISHMENT;IVAME F � F s �� LosAuugos Superntarkef�� € File Number BHF 2004-000016� � X122 Lafayette`St[cetr `� �x ° '*..+ ,' �;. �. .qs' v �. w ,. ^'. .'^e F'- .`°' tzi..H1`._„ '{:.Salem g.,� � 2 f'r� �� �«m r � '&.»� � w ;a•� : �. .�"�''. ` " b'4'�Fr '.•,���� kA*'�s k� s }LOCATED#ATxi �,(�+�,( �( s'/ COf / SAL41Y1� 0. �" "¢c hyJ •e*' T 4 : - v. '3- a". ro' :. .a, s'J ^ 'ga.3w�. •r'k. t f` x �" '-° - Permlt a Perrot No , Permit Issued Permlt Eaplres p ,Fee Restnchons/Notes;FAs ; 's a fm ,Y�s �w- ,r .g as*, m Ta, ss.ys �, v yr sx_.gma Ts TOBACCO VENDOR BHP 2014-0339 Jan 1;2014 �I)ec 31,2014$135 00&,/ W-ATER SOURCE CITY f _ � � � ` x WAnk SEWERSDISP CITY S"",{"; ,s.- "` WATER 'N�`'z`�"" =„3 " 3lz � TofalFeessz * 4n, �^ `` a �n, w_ f A� 5,e..: 1 ``s vi.,x*'kAl �s � `' }'.sy'•vr a - z° .. 'L '°es"q,�E •y . Cl�. 4 �* .£. % n `+ my' " `T f * tz `�' '''lg�.. �. ?ss�.ay+,ara �a l' .e»ti H-.'�-t^ *�q;, '� Ti"Y� � � XCy�ev "' t ^'9 z xa. T"c4"4cx '%"� f 'U, A 9 q �*s .. . t '-s � e �� ,�` .tea ya -'7 F4'a'=� `*zR`x � n '��-es .s9.. �„ .33^ 's',. s+ IS '�x'� .?�+o,� r" z�' r. � v ,� ws p�F " R .` ,x '¢` '+.` PERMIT E, xPHtES ecember 31;2014 � � "W IS .�.z`�`ar ha'3'`5 n",. s" d ., x"z� -`.,.''s xS � a.� i t,j°t` „ r"•.4 "ex sx'a + a 'fi se t "''�,� '�x _ P�e 1 Nmkl � r � s, c r�'x §'' e�..v ,&sed ✓,§ z+ va s as( �- ,¢ #'^ ".+.£ r� T am n JAN76-2014 01:21P FROM: TO:9787409138 P.1 i,�,'0/202032 05:21 #2238 P. 0031003 CI'T'Y OF SALEM, MASSACHUSET'T'S BOARD OF T417A:11I 120 WASfUNGTON Sl'R=,e'FLCM)R TEL,(978)741-1$00 rAX(978)745-0343 KTAtAL RLL YL)R1SCC)LSd O 'al -iii? 1.,lRRY RA2ff?In R9/kF tf t:t1t} CP P$ MAYOR 11I Al'll l A(:IGUT 201 APPLICATION FOR PERMIT FOR SALES OF TOBACCO A NICOTINE DELIVERY PRODUCT PERMTT FEE 5135 NAME OF ESTABLISHMENTA S Am,hoj S u 1.'P N`6.Y `%6 TEL# 1I L - �Q * WL ADDRESS OF ESTABLISIi1Mi i� �' �-04 0. kk P,t FAX# DEPARTMENT OF REVENUE AF PLICATION NUMBER A 4 2 0't'� MAILING ADDRESS(if diaf rant) EMAIL.Susiness.- webeft OWNER'S NAME L rL S err C-\U.f.r r PVC 1) TEL# - 14k) - �\ ADDRESS I s t� S 0 a^v^2rc 01 V- S STREET CITY STATE Zip EMERGENCY RESPONSE PERSON _HOME TEL# Type of Products Sold:Cigarettes 1! Qpm ChvMng TbbA= PlpdQprsts Tobatxa N(odw Dallvwy Dsvh=s Oiler Tabacco Prod (list ort aditwiat$heal) .•10.Y59Fp69tATifkr �• trisiliday i• "Tufx�ay :. I : Th'tisttay :Ffilgy. $tduNay tIfUR;Ot OPERATtOT71tob&VA- ! i .bJ Gtrt1: Db 0.w\- 1'•00 rwr7YI Rmwi lukredthy. ' � .to OL tio:oo� %ID*! V,ii lo'.ovQvA� lO'. Q� 'tNesse pay total with one shack pi pble to the City of Salam. This Permit in not trarwferable am must be reissued upon champs of ownmhlp.The Permit must be pouted In a prominent location intho Estat#shmar#. in accordance with the State SanN my Code,betors any renovations.Improvements,or equipment changes are matte,all plans for such must be submitted to and app roved by the Salem Board of Meaw Ptreuant to MGL Ctuaptor 61C,Section QA,I certify tinder the pains and penalties of pe4ury that 1.to my frost K wwMge and belld,have Red ell®bee tax realms&id paid Ml at**tam requked w der the low. Signahrn: Date Social sectuity or fodo al woadfiaetim Nu abox trpdoW741112TOMM.aoo aDec Al �� S Commonwealth of Massachusetts s i City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 1212812011 ESTABLISHMENT NAME: Los Amigos Supermarket File N=bm BHF-2004-006016 122 Lafayette Street : Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires FeeRestrictions 1 Notes RETAIL FOOD BHP-2012-0152 Jan 1,.20i I Dec 31,2011 $70:00 ( WATER SOURCE: CITY WATER SEWER DISP:CITY WATER TOBACCO VENDOR BHP-2012-0166 Jan 1,2011 Dec 31,2011 $135.00 f WATER SOURCE: CITY WATER SEWER DISP: CITY WATER Total Fees: $205.00 PERMIT EXPIRES December 31, 2011 ---� 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 ace ordance with the State Sanitary Code,beofre any revonations,improvements;or equipment changes are made, all plans forsuch must be submitted to and approved by the Salem Board of Health. Page 1 �J •` CIT ' OF SALEM, MASSACHUSETTS 1 BOARD OF HEDLTH 120 WASHINGTON STRF_FT,4"' FLOOR TLL. (978) 741-1800 KINIBERLEY DRISCOLL F:11 (978) 745-0343 D' -WOR lramdin@salem.com LARRY RA:IIDIN,RS/RIJ IS,to 1O,CP-I;S HI'd IXII A(;FM, 201_ APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT q NAME OF ESTABLISHMENT_ L-a S / U .1'>iw.Jx4K� #- 9T) k- X 540 /'l G y ADDRESS OF ESTABLISHMENT FAX# (9 Fr) '>0 3- 0 30 0 MAILING ADDRESS(if different) EMAIL- Business': / Website: OWNER'S NAME C S l' U Y�i—O TEL# nl ?8" 2Y( ADDRESS e�- G1 STREET n Ur CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) C'e .Sar GU-P-� CERTI FI CATE#(S) (Required in an establishment where potentially/hazardous food is prepared) EMERGENCY RESPONSE PERSON L e SG.r-- HOME TEL# DAYS OFAPERATION 1 Monday Juesday + Wednesda " 1 :-Thursda -, - Frida Saturda i Sunda HOURS OF OPERATION q 7? 7 . Please write in time of day. - (For example llam-11 pm h1. .0 10 `lJ TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YAC NO less than 1000sq.ft. 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 --- --------------------------------------------------------------------------- ----------------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Car, $210) 25-99 seats =$230 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 (Yvg NO TOBACCO VENDOR S NO 13 ALL NON-PROFIT(such as church kitchens) YES NO 5 '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 retums and paid all s e taxes required under the law. ry St )afore Date --��— Social Security or Federal Identification Number -------------------- - - ---- -- - ---- - -----------'------- Updated 523/11 FOODAP201 Ladm Chmk#&Date $ 1 Commonwealth of Massachusetts .. City of Salem Board of Health l(imberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo"etail Establishment Permit DATE PRINTED: 01/11/2010 ESTABLISHMENT NAME: Los Amigos Supermarket File Number:BHF-2004-000016 Penas Accounting 17 Canal Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0240 Jan 4,2010 Dec 31,2010 $70.00 / WATER SOURCE:CITY WATER SEWER DISP: CITY WATER TOBACCO VENDOR BHP-2010-0241 Jan 4,2010 Dec 31,2010 $135.00 / WATER SOURCE:CITY WATER SEWER DISP:CITY WATER Total Fees: $205.00 PERMIT EXPIRES December 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS y + BOARD OF HEALTH .120 WASHINGTON STREET,4`FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978)745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GREENBAum, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT---LOS-AMIGOS MARKET` TEL A978-740-911 4 ADDRESS OF ESTABLISHMENT—1 T.afa*-et.te Rt _ ga;Iem ,_ fes_ FAX# N/A MAI LING ADDRESS(if different) SAME AS ABOVE EMAIL-Business': N/A:, Website: OWNER'S NAME CeRar r_.,o o TEL# ADDRESS 122 Lafayette Street Salem MA 01970 STREET - CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) N/A CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON Jose A. Rodriguez HOMETEL# 978-825-0760 DAY$©F OPERATION £ "r•_,r Monday, xTuesday<, WeBnesdayThurstlay, F.n l'ay rSaturda - Sundaj HOURS OF OPERATION Please write in time of day. Forexam ellam-ttpm 17am-1 0 m 17am-±0pm j 7am-1 Opm, 7am-1 0pmham-1 0pm lam-1 0pm Sam-9pm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 - 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -------------------------------------------------------------- ----- ---------------------------------------------------------------------------------------- RESTAURANT 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 YES NO $25 TOBACCO VENDOR NO $135 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 1,to my best knowledge and belief,have filed all state lax returns and paid a ate taxes required under the law. 12122/09 043-45-18A7 uSiggnature ' Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date J / $ VL Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency ;.Telephone: PROTECTION FROM CONTAMINATION 745-9114 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: Comment: Bleach sanitizer of proper concentration was available, however test strips were not.Provide test strips for sanitizer. Cesar Guerrero PIC: Cesar Guerrero Inspector: Elizabeth Salandrea Date Inspected:Correct By: 8/20/2009 Risk Level: Permit Number: BHP-2009-0095 Status: SIGNED OFF i#of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: All other violations noted in the 8/11/09 inspection report have been corrected. Violations Related to Good Retail Practices (Critical . , violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeOTMSO 2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 14,2009 ) Page 1 of 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®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 14,2009 ) Paget oft Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-9114 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: Comment: Bleach sanitizer of proper concentration was available, however test strips were not.Provide test strips for sanitizer. Cesar Guerrero PIC: Cesar Guerrero Inspector: Elizabeth Salandrea Date Inspected:Correct By: 8/11/2009 Risk Level: Permit Number: BHP-2009-0095 Status: VIOLATION #of Critical Violations: 2 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical y 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®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 20,2009 ) Page l of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions /Comment: Personal food items observed stored in front counter refrigerator.Employee items may not be stored with product for and Risk Factors (Require sale to customers;store all employee items separately. -Qj immediate corrective action) l/ /At time of inspection establishment was selling cut,wrapped pieces of melon and cheese.Establishment is not properly equipped or permitted to conduct these activities and must cease doing so immediately.Items currently for sale were discarded. A/There was food being stored on the floor of the walk-in cooler and on the basement stairs.All food must be stored at least 6-8"off the floor. The following outdated items were removed: 5 veryfine OJ 2 veryfine grapefruit juicwe Approx.8 cans Goya passionfruit juice 3 flavorsmart pringles 5 cans pam 4 bottles aunt jemima syrup 4 packages quaker frescavena 1 bottle wishbone dressing 2 goya mayonaise 1 jar fluff 2 cans river queen peanuts 2 jars goya salsa 6 jars sanka instant coffee Owner to closely monitor all expiration dates. Equipment and Utensils FAIL Non-Critical BLUE 6001,omment:Shelves in the walk-in cooler need thorough cleaning. door of the walk-in cooler needs thorough cleaning. g/eezer in back room is in disrepair along the bottom edge of door.Repair door. . /Floor of back room needs thorough cleaning. NNN Shelves of front counter fridge need general cleaning. ✓ontainers in vegetable aisle need general cleaning. mall fridge next to meat freezer needs new internal thermometer. Physical Facility FAIL Non-Critical BLUE ,./omment:There are several stained ceiling tiles above the vegetable aisle.Investigate for leaks and replace stained tiles. /here is water leaking down the side of the basement wall in the drink storage area.Investigate for leaks and repair to be leak-free. Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 20,2009 ) Page 2 of Item Status Violation Critical Urgency Please have last 3 months' extermination invoices available at reinspection. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2009 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 20,2009 ) Page 3 of CITY OF SALEM BOARD OF HEALTH Z Establishment Name: I C(�1\C✓�� U Q.XV'(1CfDate: , I141/ CR Page: Of I Item Code C-Critical Item, DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date No. Reference sR—Red Item . �,.. r.. �." ,:";._. Verified � a w j PLEASE PRINT CLEARLY vvonc a e4 m4& s iv s : cxin _ ca otWr at fit ' -mat 3n _ \Ub-P (s . Uk(�_saes PM Q� 'AV CRU CIL) �r \cR _ lig c� call -tit Cil t1 t1rt vh ��� 'liv incl -( or(lte ) 2L- I Gc(t A e (.Vies i vrk_). i Hecl s ��o_Vj cxchon nen cfi s untie . A A� Ac..4 . �` �ic�Lhi �rICQ.fI - r 1 Discussion With Person in Charge: Corrective Action Required: ❑ Noy ❑^ ,Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension 'comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five-dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. -� ❑ Voluntary Disposal ❑ Other: _-_ii)1,1 4C(7 PHF,Recived at Temparatures Violations Related to Foodborne Ifiness interventions and Risk According In Lac Cooled to Factors(floras 1-22) (Cont) 4I`F/45 F Widlin 4 Hears, "1-561.15 Conlin" Method�for PHIRS PROTECTION FROM CHEMICALS —F-ricm-oFor Additives 1 19 PHF Hot and Gold Holding 1=4 so C Ks Maintained ator below Cold P 3-202,12 Additi va�,v I I i �llli'� ) 41�/45"�F8 3-302,14 pmtwical Ina Una) rover bVes Poisonous or Substances 150 1,1(v A) Hot f1Hf­q tamed at Of above 11 I or oxic Substan ­L1146"I. -l' 7_10, 11 iltnnlal 3-5ol,16(A) RAlasts field at or above 1_sO'F CtaaaLiers j) Time as a Public Health Control 7-102,11 CknIftolOn Name - 1_'—,"' 3-5U_19 _lTimie as a Public Health coraroV 7-201.11 [tun-.socia I ft _ e'—__ 90,00411) Vari _11CRIS-11t 7-202.12 Corsfinrxls of ljso* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE Prollibl,wal* 7-204.11 sanni7ers,cateria-Che I lT I"ick� POPIJLATION�_ -—_I w')04.12 Ciunlucals fra wrls 21 3.801ABn,nfrc A) Ulmearized -pada,, d Juices and [_2 _t,�,ccwgS, ,fill Wain, 14 Crin-ria� 3-801 11(P,) of !_205,11 haideral Foixi Conta(�t,heal wanis' Pa tcunr<d E ns - S01 I I D) Raw or Paxtirdl,,Cook�-d Animal Foorl and L7-206.11 Rell loed tll,�Pe'rici&s,Crin-1 1) Rodent Bit St�t(nlnS' �3 ��j—I 7-206.12 11�):: T n `T�06—,-, and 1_112—erled llnq_P�U ldk_P�21 fit—servol CONSUMER ADVISORY __iT 7,,0_31 F for Conguniption of TIMEfTEMPERATURE CONTROLS Almnal}+K ds That are Raw, Urrdorcrark,<d 1=1 Proper Cooking Temperatures tW_1 Nrot Ohl, erwise Prrlressed to Ifliganaze h PHFS —,N�j el, j �7F7 5 -102.13 Pawurmd Eggz:Sablrtnule for Raw ShOl ; 7 ..�_LLL_hylneiLl 11�, Sc r_111 G,IL5_1�1—5-IM :l-10 LT I_(A)(2Conrl'imoW rich,Mellis&Gaurk Animals 155T 15 Sec. _T461_jj(Bjcj_j(2) SPECIAL REQUIREMENTS 0 1—1 -- 1 2"(Wil_21 n—ii-n 5qf),00r(A)-(J)) WIIULJOB,�04'SeCtWn 590.(X)9(A)-(D) in -174 l(A)(2) flatilre,, [_'5:F 1.5 me E crltcringarobiV fkxxt,leinporai v and 3-401.11(A)13) 1-cmderwal kilchell operations sbould be sleffineCowainlre, FishMeat, dehoed under the appropriatc,;ectbals alvVe if relitled to fixidborne Bhlcsa Rados 169`1 15 sec. h1wo Bf Steaks intei venflons and risk factors Other 145'T 4 590.009 violatioll's relating to good retail I _FoZ Calked ler a practices ,bcadd be debited under #29 - Microwaw ]6i'Fkajuiremonts. 1 A l 1 (b) All(Xhei PUC, ­ 145'F 15 sec's ----- Reheating ,),fill H01W109 v VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-,103JJ(A)&,(D) (Items 23-30) 3-403.1 UB) I'dicrowavc- 165"6 2 Minnie Standing Ciincaland nen-rr7u,:al viola60n,, which do rion relate io the Filyar, foodborne illness nuervenliow nod n4jactarr Uvted alwi;e, can lye, 403.11 (C) Coannei,fady Procaiiod R'1'1-'F,,xxi- found in the wallowing rerrions of,he Food Crete and.105 0448 9(f,(Xio, 3-40'3.11(E) Remaining Unslwed Portiores(if Beef TWai 23, Maompmeni and_Personnel_ r T Cooling of�HFS Forld end Food Pronactio'n, FG 3 i '004 ng 25 E paaol t�sas_ G05 oil a Coo P"a C op ro P: g�(7ilkrtgdoPf 147 boni 14017 i ------- �-501A,VA) C kx),I it, Water.tumbirig mte 006 and i 7W,F Within 2 1 lours aid From 70�1 FC-6 i 007 to 41-F 1-F/45�F Within 4 Hunni� 008 '4,501,F C'orlhu,PHFs Made FromAmbi 4(B) S ecrat_5o i nffjL�, r .009 �R_ lf�L_mL Tinriperature Widii a=4 flour, Dewltc,S Intwal eon ill Ill"r",k, 'ral 1949 Fo,,dC,Kte,,r 165('M. R5W0s3 } CITY OF SALEM 3 BOARD OF HEALTH G� Establishment Name: All J(h, Date: I At Id / Page: / Of Item Code C—Critical Itemn - DESCRIPTION OF VIOLATION/PLAN OF CORRECTION'S"; 4. Date No. Reference R—Red Item .,¢ = 1 Verified, PLEASE.PRINT CLEARLY 1) 4YL 2 M//h ' k ' D/ lick /mea ,L oD , /ke4llIY4 lZt d 1 /i . re-161114' d L'-7 '-Y/ /)e-)Y hi' 0n) 0gle laheks a / /��l A Lo-/B AJXY A14 h,1V G21 n 72a,( ) 2C /) > /C a /,l / Q e9 1/i .LCl /J -A /J/ /O l 0W iJ/1 Q l P_ 1!4//' r Ci /720 . I/ 4 /JV I /7Y/ /� rl C DD ' Discussion With Person in Charge: Corrective t' n Require c�r o Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ =Voluntary Compli nce ❑ Employe Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo « ❑ Emergency Closure your food permit. C _` ❑ Voluntary Disposal 0 Other: -5;11.T�(CT PIfFs Received at]`el Violations Related to Foodborne Illness-Interventions and Risk According to Lao, Coxoiedrt`u Factors(hours 1-22) (Cont,) 21'F(45 F Wrfbinl Hours, PROTECTION FROM CHEMICALS 1=4 Additives Cooloo,Nloaio&for PHN � Fund or Color Addes PHF H�and ;�tng soy!.wft) Cold PHES Maintained at or blow 3-202 12 Aduave, c90 004(f3 4 1 /45"F� -=T1-30=)-271 4 fIrtitex,ti on t root Ij!% 3 1,1 WA) Hot PfWs tolairtained at or above P, orsorwoursor Toxta 6 9 14017. -- 'r<,oaf Roaists Held at or above 13(r"F, Concainzrs" -=:- -7142.11 Coumcni N4aRle-----'-------j E20 Time as a Public Health Control 3 501 19 Tiaw as a F�bfic f lealth Corio`�T' 7-20 L I I S�vamuon-storaec� 1 9-711--, ---- I — owM�{ c P 1-202,11 Re'"riecon - 'w7Le- ------ 0- 7-2 '.12 Condibom of Uso* I - - REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-10111 Toxic Conlainevs Proltibvionsi: POPULATIONS(HIS PS 7-204.1 i Sannizers,Corer tt,-checncaW Prc-pacl%agcd ano 7-2U4.l 3-8011NA) Ch"'Inicais fou Cgitezial Bevsranes with 7-204,1 Criteria'f _Jj -- -1-801.11011 1�Ke, of 7 20,5�1 Inciclzrital FkAxl cksqact�I'vin icanWl 3Z 01.1](1)) Raw or PaWafly Cook-d Agurnal Fo(al and 'Uo� pe�vicides,Critei to Rae,Sc.,,�LLSJMLUB Not Sea 7-206.12 Rodent B��o Statl"Tt�, I,11!{i rl—,-- Z—:1:1,11 --- Re sin—vc," 206 13 t Tracking P,evder� f',-m Cowrol and cam —mofli!, CONSUMER ADVISORY 22 3-60" 11 Covaunor Anvinoty floscvd forConsoinption of TIME/TEMPERATURE CONTROLS Aoincd FKxl� fbat I are Raw. Undercooked or 16 Proper Cooking Temperatures Gr PHFS Not Othcru ise Proceswd to Flintmare 401.1] A(3 i(2) J-. I Palta) fr 1,55'F 15 S��c- -------I---- 5ervicc tA,fy,15.gec- 1 3.36° 13 Fosteunzcd Egg-Subsunite fo Raw SlW1 401.1 I(A)(2) Coolminkned Piste,c Nfcats&Gana: Animals 15 � ` ' I "5I F I I stc, SPECIAL REQUIREMENTS 3-4FL1l(13)(l)( polf And flcf Roast 130,F, 121 mi0 Vial otjnns of Section 590.009W (DI in ,. 40 1.11(A)(2) J Rtaife�, filleo'exi Wins --155 F I IF sec. remdcu I I mobile hx�d tompt,rars and W Kitchen operations should IV 3-40l.1VA)3j poultry,��,IdTiaroc, nfedPifis, Solfling Coflliiwn't FlshMein, debited under flic ipproprmtcse>fiows III frsultry or Mores-165'T' i 5sc,- alkwe if related to ftx)dhorric.illness thole-mu le Iniaci Beef Steaks itaciventionsand risk factors. (Mrcr 145 1; 590,009 violations relating to good roful 3-401 [2 Raw Auin�l Foott,Cooked in a practices should tv debited udder #29 - lliiorwave 165 F Special Requirements. 1-3-.401 11(Al(l)(b) All Othei Plll--�-- 145'1 '15sec.1 Fi7 eating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-4(�3 11(,�T&(fo PIIF� 1b5'T l wG. (Hems 23-30) 3.403,11(H)-Microwave t(i�'F 2 Minute Standing Cmirafand rem-cruiral violahona, whirit do goi relart,jo thc m" foodhome ilhwss iwei wntiorry and ri,�kfo(iors listed above, tan be 403.11(0} Comm rrially Pro e_sed—RTo( FT0- the toad Cade and.105CMR 140-F I I -3-403.31(1:}— —Remainin" Unsifired ftcrtions of f3cei 1"Were Good Retail Practices fiC 590,00 ltoast,. FC -21 00 24, Food and Food Proledion FC 3 j 004 (g _ Proper Coaling at PNFs I--25-- -E t arlqY ,------ cl!�;f2eTnt 3-501.14(!") Cwhi)g Cook,,d PHFs from 140'I'to < 26, i Watts,Plumbin _qmd Waste C 70'F Within 2 Hours and From 701' X27 Phrs,ry Fa FC-6 007 -—----------- to 41�1-1445'F W'ithin 4 How monous or Tow Materials 1 FC -7 008 501,141 PFIFs M -------- ado Front Ambient S .009 Temperature lqrvdieras to 4VF/45'F -Wvthm41louW tk:noesanical rEea,m lhr(,,Aend F)')4 FoNI(Axle or 105(AIR 599 W, f CITY OF SALEM BOARD OF HEALTH Los Amigos Market Address: 122 Lafayette Street Owner(s): Cesar Guerrero Phone: 978-740-9114 December 16, 2008 Based upon a routine inspection conducted by Elizabeth Salandrea, Sanitarian for the Salem Board of Health the Owner of this establishment was asked to appear in front of the Health Agents due to concerns with their labeling machine. The labeling machine is not printing dates due to a malfunction of the machine. Proper information must be included on all labels. The owner of this establishment discussed information regarding the handling of raw meat products. A review of this procedure was reviewed in accordance with the State Food Code. Pre-cut meats are purchased from C & G Tropical Dist. These products are delivered and re- packaged at the time of delivery. The new packages are frozen. A scale, certified by the Sealer of Weights& Measures must be used to weigh the meat. The owner is not cutting any meat. A bleach sanitizer, checked with test strips, is being used. The packages for sale to the public must have a label with the following information: type of meat, weight, price per pound, sell by date, name and address of the store. There must also be a Safe Food Handling label. L Janet Mancini Date Acting-H Ith Agent — r Cesar G rrer6 Date Owner Richard Jimenez Date Translator _ \161 CITY OF SALEM BOARD OF HEALTH Los Amigos Market Address: 122 Lafayette Street Owner(s): Cesar Guerrero Phone: 978-740-9114 December 16, 2008 Based upon a routine inspection conducted by Elizabeth Salandrea, Sanitarian for the Salem Board of Health the Owner of this establishment was asked to appear in front of the Health Agents due to concerns with their labeling machine. The labeling machine is not printing dates due to a malfunction of the machine. Proper information must be included on all labels. The owner of this establishment discussed information regarding the handling of raw meat products. A review of this procedure was reviewed in accordance with the State Food Code. Pre-cut meats are purchased from C &G Tropical Dist. These products are delivered and re- packaged at the time of delivery. The new packages are frozen. A scale, certified by the Sealer of Weights &Measures must be used to weigh the meat. The owner is not cutting any meat. A bleach sanitizer, checked with test strips, is being used. The packages for sale to the public must have a label with the following information: type of meat, weight, price per pound, sell by date, name and address of the store. There must also be a Safe Food Handling label. rd/i& f Jariet Mancini Date t ( Aciing H,e/alth Agent Ces r Gue'rrerd Date Owner (` s7 C Richard Jimenez Date f C Translator CITY OF SALEM LostBOARD OF HEALTH / f I Establishment Name: WJ 7�fiY11�5 �Y1PY(Y1Rn 1 i Date: ! `l l 1001 Page: f of / i nem ;Code „y ., C—Critical Item � DESCRIPTION OF VIOLATION I PLAN OF CORRECTION m Date No.='"` Reference R-Red Item / a �"- t„ %'` a z„ �. %xa at PLEASE PRINT—CfLE�ARLY w +- a - i wcc5 czndk�ded -r IU 4-o HotAin�: (Aus Y17�,• # , f I Many pm-LoAck>, c,-P perf44 Taff C_-I-if/ dor),--)f haty oraou (cu�P(;� E CknA �� n 0- CV13 hOf k(_W-Q _ Ia,I ,IC r CQ (l, Prtl vYlQc21 - �< . fc° im tL=f �10 c in at ct rt .iv It"v>G- 1_�1-) c---h( --b d i, t s ( a )ft-h ffe a ( f h c ,n� r s� rerir Ic { o M0ctt- ' a-, dr4icim ;-Erni .=-1 +o oce)nLr- a" F cai-inr v hP l� v�cj Y Qan itl t$ I � alp Ccn t.1t � elY � i t �cl rzncA hA (C-_(nD CfAlnc, tip tr; lsz, 0T re : - �r ��cP k:� trn 0-i4- hv' -ncYcr r/ - lrn t l S fDiscussion With Person in Charge: / Corrective Action Required: ❑ No ❑ Yes I1 ❑ Voluntary Compliance ❑ Employee Restriction/ t I have read this report, have had the opportunity to ask questions and agree to Correct all Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that "r noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. `i ❑ Voluntary Disposal ❑ Other: i i Violations Related to Foodborne illness Interventiarts and Risk According to LaNa Cooled to Factors(items 1 1 1 -22) front.) 4 ff/45"'F Within,! flours. - - �o ��ooliug Mcth(x� 3-� 1,71 r PHIFs PROTECTION FROM CHEMICALS —4 19 PHF Not and Cold Rokling 1=4Food or Color Adtfitwee 15o1�16 B) old N PHlidaint at or below 3-20" 12 rkdditiv�s` 4V/45"F- 3-302,14 lon'teroan —1 P""-" 3-�01 WWI Ito PFIFv Maintained at or alx)w 1= P""- of-sonous w-Toxic Substancert— 14WE 101.11 Idenlikanir Infonnalion --Oat real 3-501.,16-�A) Roasts Held at or above 00'i,7* Time as a Public Health Control 7 1 Cootillon'Narn, - Work;, Coneli 10111 cer's* LL0— -- 3-3011(� Time.as a Public Health Control `265—1 590,i)p4(Hj variance 7-262.12 CoiidWom ofLha FOR HIGHLY SUSCEPTIBLE 7 3 t I Toxic Containei, -Prohihi!iovs5z POPULA IONS HSP 1 2 o,' 7- 04.11 not-e Chemiuki-' 12 21 1-S01,11(A) I'llilmicurized Pre-palt,alt d Jurccqaad -204.12 T204,14 Drvile.Ave.w.Critei ia- f 3-80 t N(T3) T.srof Pa�teuriz�,d Eop* T -1—milmoi 11-(Nxj Cono)oI Ali))I Carl S" 1-80 1.;1(1)) Row or Parljall� Gok-,�d Anneal Food and7-206.f-I Rcso icoyd Use Pent ids Catena -Raw Sc t d 9 create Not Seised. 7-20&1 R(Acu! Boil station.' -�-,ot ?06.13 'I'mckim,Po�Wem Pest Control and , 'Mouitot CONSUMER ADVISORY TIME(TEMPERATURE CONTROLS -22 360 11 Corisurocr oatyi goi y femed for Consomption of Proper Cooking Temper Animill Folds-11witarc Raw, Uredercwked er (as r PHFSNot Otherwise rlmwemwd to iqhiiinaic P rho 3 40 1.11 A(l)(2i 15i'F 15 S%. 145Flfisec1 a.-307' 13 Paqieurized FggA SuT)'wrl'to, Cw she11 I(A)(-) carnininwed Fish,Meet,A.(1,13111 mintaLs- 15,5"F 15.SeC- � SPECIAL REOUIREMENTSA and —W1915 T --- ----I 7 40 1 1 i(Ifa,J)f'2) li�ef pu;,, 121 rian N—)9(— —F7 — 'v)71� I i1a Flw)"Ot s'Clio', io0.009(A)-(D) III A0 J.11(A)(2) 11-5T' 15 catering, inobdofood,temporary and 3-401.11(A)01 resident al-kitchen Opel afltitlAioold be sileffula,('Oraajnin�Fish. Meat, debited under the appropriate sections Poultry oi karts 1651E 15 we. above if relived to foodborne illness E(Q(1,i Nhole-nalsAc,Intacl Beef SICUS intaitientionsandriskfacforr Other 14'i'Jz 590.0A09 violationv relating to (xxi retail 3-40IA2 Anitual F(N Kki Cooked its It practices should loc debited under#29 Microwrov 165'1'* Special Requirciriante- 3-401,11(A}(103) Al Other PIIFy -- 145"IF 15 It 17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403J1(A)&i0) PilF, 165'T- 15 sec. (Iteltv;23-30) 463.11{;$) v mowaw- 165"r 2 kfinwe standint", Critical und non-critwal vwfolwa, ohich do nw relate,io dw ,foodborne illness inierventiowand ri.kfactors hvtedabove um be 403 1 J,C, found III the 1�.Wowwg.wtionv of the Food Code errol 10-7(71IR 140'F 59WXV, cef Ftwm visit practices FC 59aaw 403 H(F) ( Kon tieing.Fe;1i,,TPoCino A 23, 1 Management and personnel Wd"72 7-moti — Protect ion 4, )4a4Tojd-­' -3 1 M4 Proper ---------- 25 FC -4 Ayt -TiOl 14(A) Cool 11oz cookId pfli-Is ft oni 1.WF to Water,Plurnoing anh Waste I FC-5 1 0013 M'P withill 2 1 four:: and From 7WF7 Phi!cal Fac lihL 007 FC-7 3-501.34{B) hng PHFS Made Front Ambient 1 29 Temperawre Inurdicnis to411145"F wiflo a 4 fikrjrs 1 Commonwealth of Massachusetts F City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit" DATE PRINTED: 12119/2008 ESTABLISHMENT NAME: Los Amigos Supermarket File Number:BHF-2004-000016 Penas Accounting 17 Canal Street Salem MA 01970 LOCATED AT: SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions 1 Notes RETAIL FOOD BHP-2009-0095 Dec 19,2008 Dec 31,2009 $70.00 / WATER SOURCE:CITY WATER SEWER DISP: CITY WATER TOBACCO VENDOR BHP-2009-0096 Dec 19,2008 Dec 31,2009 $135.00 / WATER,SOURCE:CITY WATER SEWER DISP: CITY WATER Total Fees: $205.00 PERMIT EXPIRES December 31, 2009 —. Board of Health v _ This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 KRABERLEY DRISCOLL FAX(978)745-0343 MAYOR 7DIONNe a SAF,F.M.COM JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT LOS AMIGOS MARKET TEL# 97R-74O-9114 ADDRESS OF ESTABLISHMENT 122 LafaAretta Street; FAX# MAILING ADDRESS(if different) Same As Ahoyp EMAIL-Business': N/A Website: OWNER'S NAME_ rp�ar Gnerrexo TEL# 978-740-9114 ADDRESS 122 Lafayette Street Salem MA 01g70 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) N/A CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON Jnse A ReclxiTuea HOMETEL# Apg Ag0 DAYS OF OPERATION' Monday Saturday Sunday, HOURS OF OPERATION j Please write in the of day. (For example I1am-11pm) Ilam-1 Olpm 1.7am- TYPE OF ESTABLISHMENT FEE , check only) v) RETAIL STORE YES O less than 1000sq.ft. =$ 70 1000-10 OOOsq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANT YES less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ---------------------E ----------------------------------------•----------------------------$---10-------- BED/BREAKFAST/ Y �_ � 0 CHILDCARE SERVICES ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE Y � $25 TOBACCO VENDOR Y NO $135 ALL NON-PROFIT(such as church kitchens) YES (LqUD- $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, 1 candy under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns anndApaid all state taxes required under the law. T T ..- Signature Date' 6' Cj� �J Social Security or Federal Idenh ft7it,Num ----------------------------- ---------------------------- Revised 424/07 FOODAP2008.adm Check#&Date //7�r7.5 �oZ//d�0$( $ 6 394 )A/te/ot 7d IMPORTANT MESSAGE FOR /,1... ... a S S A.M. DATE �7� TIME �_i�bt. M /��e //Lci�.�im� OF I PHONE AREA CUCE NUMBER EXTENSION U FAX U MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU 'WILL CALL AGAIN WANTS TO S E YOU. .BUSH.. .... RETURNED YOUR CALL WILL FAX TO YOU. MESSAGE .'--� O+ e2t nlrOl 2-2,2. Or -SIIGGNpED �\ FORM 4009 / CC��// MARE IN LLS. _____ �,_�.os,�m�`avos l n���,o�._._ _._._.. _ ._,�_. .._ _ _, �..__._ ._ � __ - 4 _ _ .... , _ � -- - - ._._...._ „.r. t �� . ...� l.,J t%. Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: - Violations Related.to Good Retail Practices (Blue Items) 749114 ��C• R114 Food and Food Protection FAIL Critical BLUE Owner: - - t/omment:At time of reinspection,there was a damaged cardboard box of whole chickens in ice in the back room and an employee Cesar Guerrero was preparing to package them for sale.Establishment does not have proper permit to conduct these activities and does not have proper equipment or certification.Chickens must be discarded andownerwill need to meet with Health Agent to discuss changes l FIC: to permit. G K-& C"3 O-F /aILI Cesar Guerrero J Inspector: The following were removed,outdated: Elizabeth Salandrea trbb`/utdated Parke preads'n back frioge still on the shelf.Owner to remove these and closely monitor all expiration dates. Date Inspected:Correct By: O Tri Ot M Jhm —Some packages of meat in back freezer do no have labels or correct dates on them.All meat packaged by establishment must 12/3/2008 have correct labelling and dates. Risk Level: ° —There are some unlabelled items wrapped with paper&string in the back freezer. Food may not be wrapped in paper and string, and must have correct labelling at all times. Permit Number: BHP-2008-0087 —Individual slices of cake for sale at front counter do not have sell-by dates.All items must have sell-by dates. Status: Equipment and Utensils FAIL Non-Critical BLUE PARTIAL COMPLY Comment:There is a meat saw in the basement of this establishment which,acc to the aer is not in use.All unused equipment must be removed from establishment; meat saw must be remove next routine inspection. Of Critical VIOIatIOfiS: Physical Facility FAIL on- ri ica BLUE Time IN: Time OUT: _Comment: Lights in walk-in cooler missing covers.Provide protective covers for all lights in the cooler. —There are several stained ceiling tiles throughout the store.Investigate for leaks and replace all stained tiles. Urgency Description(s): I Mens/ BLUE: I Final reinspection will take place F Way et SHt, all remaining violations must be corrected. Violations Related to Good Retail Practices (Critical violations must be corrected i All other violations noted in the 11/25/08 inspection report have been corrected. : 1 immediately or within 10 Please have September and October extermination receipts faxed to the Board of Health within one week. 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. Dec 08,2008 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) C� City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 08,2008 ) Page 2 oft /� ��� :. `�/„�' � �� � � //,�Oth / �l x �� . � , ; I UNITED STATES POM�S k EX-ESSE oF'I MA 018 4 C' m ag ees m I • Sender: Please print your name, address, and ZIP+q in this box-*, I � M M- i+ I n C/1 ' n w M BOARD OF HEALTH = D ,, — SALEM, MA 01970 �' m o co M II MA N ' " SENDER:,. .T COMPLETE SECTION - n 0.. ■ Complete items 1,2,and 3.Also complete A. Sign , item 4 if Restricted Delivery Is desired. r ❑Agent 0. Print your name and address on the reverse ^y ❑Addressee so that we can return the card to you. B. Rece ed by(Prf .Name) C. Date of Delivery III Attach this card to the back of the mailpIce, or on the front if space permits. D. Is delivery address different from Item 17 ❑Yes 11. Article Addressed to: If YES,enter deliveryaddress below: C3No cl� (ear ('Lie � � UWvv4 C.03A1jOS Jnw'� 1,)L-7- LC' ii4ti a5�tr1 Z'G��P'hti✓v' O `r L� 3. Service Type ❑Certified Mall C3 Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mall 0 C.O.D. 4. Restricted Delivery?(Extra Fee) 0 Yes 2. Article Number 7005 3110 0000 7160 3347 (transfer from service Iabso PS Form 3811,Fory_my.�2fiQ ,^-s.W%?. 40gT0 FHetumRecolpr,urt1ftr1nlrn«lnIIIIII rlfdp"krfhlk ni��IE III Mi l�Dornesfic Mail I . insurance coverage Provided)— M •- - TIAL USE a r- Pie 0 Certified Fee 0 Postmedc O Ream Receipt Fee Here O (Emiomement Required) 0 (EOOO meat Required) V-9 M Total Postage&Fees $ Ln O em ro orPOeoxNa. 'uYeAF ztP+4 Certified Mail Provides: (asemhf)amGunr'ooeE uaad ed ■ Amailing receipt ■ A unique Identifier for your mallplece _ ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Carolled Mail may ONLY be combined with First-Class Nlail®or Piiority Mails. ■ Certified Mali Is notavailable for any Gass of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ Foran additional fee,a Return Receiptmay be requested to rovide proof of delivery.To obtain Return Receipt service,grease complete antl attach a Retum Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailplece with the endorsement"Restricted Defiveiy. ■ If apostmark on the Certified Mail receipt Is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt andpresent it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TEL. (978) 741-1800 ICIMBERLEY DRISCOLL FAX(978) 745-0343 MAYORJSCO'rrna SAI,rM.COM JOANNE SCOTT, HEALTH AGENT August 25, 2008 Cesar Guerrero, Owner Los Amigos Market 122 Lafayette Street Salem, MA 01970 Dear Mr. Guerrero: On August 20, 2008, during a routine inspection of the basement of the lodging house at 116 Lafayette Street it was determined that you have a meat cutting saw and a storage room that has unfinished floors, walls and ceilings. A review of our records has shown that you are not authorized to conduct food processes such as meat cutting at your establishment. Therefore, in accordance with Board of Health Regulation#26, and Chapter 111, section 31 of the Massachusetts General Laws, you are hereby ordered to cease all preparation of potentially hazardous foods, including but not limited to the cutting of raw meat or poultry, immediately. Equipment to cut such food products must be removed from your establishment. In addition,the basement storage room must have finished floors,walls and ceilings so that they are impervious and easily cleanable. A re-inspection will be conducted 30 days from receipt of this order to insure compliance. Failure to comply with this order may result in revocation of your food establishment-permit and/or a complaint being sought against you in Salem District Court. 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. Sin erely yopq I (Se for Sanitarian CERTIFIED MAIL 7005 3110 0000 7160 3347 REGULAR MAIL it 'v Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: ��,\ -91(l� Violations Related to Good Retail Practices (Blue Items) 74&9114 V Food and Food Protection FAIL Critical BLUE 'Owner: /comment:The following were removed,outdated: Cesar Guerrero All Parkey spreads in back fridge. PIC: _ 1 oscar meyer bologna Cesar Guerrero 12 starbucks frappucinos y Inspector: 12 cans diet pepsi 5 barq's root beer i Elizabeth Salandrea 31L diet coke Date Inspected:Correct By: 1 1L canada dry gingerale 11/25/2008 1 2L diet coke 1 2L orange fanta Risk Level 2 pkgs bar s hotdogs 1 tropical queso blanco 5 peanut butter ritz bitz IPermit Number: 31gal sunny d t BHP-2008-0087 3 stove top stuffing - - 7 lipton soup mix ]Status: 8 jars mole verde I PARTIAL COMPLY 20 sazon completo I#of Critical Violations: ( 4 miracle whip 4 kraft ranch dip 1 - - 7 wishbone french dressing }Time IN: Time OUT: 1 duncan hines cake mix 5 ducal black refried beans `- - 14 cafe bustelo cappuccino mix Urgency Description(s): 2 jars sanka instant coffee BLUE: 12 lemon juice Violations Related to Good Retail Practices (Critical Owner to closely monitor all expiration dates. . violations must be corrected immediately or within 10 V40me items had price labels obscuring expiration dates.Do not cover expiration dates with labels. days)(Non-critical violations Some packages of meat in back freezer do not have labels or correct dates on them.All meat packaged by establishment must "must be corrected immediately have correct labelling and dates. or within 90 days) There are some unlabelled items wrapped with paper&string in the back freezer.Food may not be wrapped in paper and string, 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. Dec 03,2008 ) Page I oft r • Item Status Violation Critical Urgency RED: �� d and must have correct labelling at all times. Violations Related to o Foodborne Illness Interventions I me of the bags of bread do not have sell-by dates.All bread must have sell-by dates. and Risk Factors (Require — Individual slices of cake for sale at front counter do not have sell-by dates.All items must have sell-by dates. immediate corrective action) Equipment and Utensils FAIL Non-Critical BLUE —Comment:There is a meat saw in the basement of this establishment which,according to the owner,is not in use.All unused equiant must be removed from establishment;meat saw must be removed by time of reinspection. , f the walk-in cooler needs general cleaning/sweeping. 4Soda racks at far end of the walk-in cooler need general cleaning. bCL 4wat freezer needs general cleaning. �,G g Li ft side of ice freezer needs general cleaning. y�ont counter refrigerator missing internal thermometer. Provide visible,accurate internal thermometer for this fridge. � 6� hermometer provided at time of inspection. tp l4Fruit and vegetable shelves and containers need general cleaning. � 5 ontainers in ice cream freezer need general cleaning. x�,� Physical Facility FAIL Non-Critical BLUE "c " n —Comment: Lights in walk-in cooler missing covers.Provide protective covers for all lights in the cooler. . There are several stained ceiling tiles throughout the store.Investigate for leaks and replace all stained tiles. Reinspection in one week, all violations to be corrected. A� Please have September and October extermination receipts available at reinspection.~1077W vk\t` IMM 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. Dec 03,2008 ) Page 2 oft C&G TROPICAL DIST* A LOWELL, MASS 01851 Tel,: (978) 912.1790 NAME SOLD' BYr5©� — ADDRESS �" a DATEj,) QTY. LBS. DESCRIPTION UNIT TOTAL PRICE r ! o P 1 �' /° s� l e f' C. d .D Y.D 1 � vJ0 9 T WIM(6 6�2- 101, rc7A �• Nr 1 � / CC ° � v yr 9 r. M: ' Opa Prin6n912121561-0394 _ nva C a±t' E 'N � .rt.+. H+vn✓= MfTs '-N I Nrt Nnl- 4 �qY� "Y3 r ... Ysr> u�.^ '+T lY yq er•Y tT� ,yeiAEi' . .m %'^€"'�','.. x .xs,. -:Commonwealth of MassachusettsW4 Clty of Salem , Board of Health lU 120 Washington Street,4th Floortllbbetley DriSooll _ Mayor SALEM,MA '01970 Food/Retail Establishment Permit = DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Los Amigos Supermarket File Number:BHF-2004-000016 Penas Accounting 17 Canal Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes- RETAIL FOOD BHP-2008-0087 Jan 3,2008 Dec 31,2008 $70.00 / WATER SOURCE:CITY WATER SEWER DISP:CITY WATER TOBACCO VENDOR BHP-2008-0116 Jan 3,2008 Dec 31,2008 $135.00 / WATER SOURCE:CITY WATER SEWER DISP: CITY WATER Total Fees: $205.00 PERMIT EXPIRES IDecember3l,2008 Board of Health 49 it d This Permit is not transferable and must be-reissued upon change of ownership or location The permit'niust-6e posted& 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 4 of 46 ♦ 1 r ♦ e 3 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4'm FLOOR TSL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR ISCOTFaISAUKCOM RECEIVED JoANNE SCOTr, DEC 17 2007 HEALTH AGENT CITY OF SALEM BOARD OF HEALTH 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT LOS AMIGOS MARKET TEL# 978-740-9114 ADDRESS OF ESTABLISHMENT 122 Lafayette Street FAX# MAILING ADDRESS (if different) Same as Above EMAIL-Business': N/A Website: OWNER'S NAME recar R71errarn TEL# 978-740-9114 ADDRESS 122 Lafayette Street Salem MA 01070 STREET CITY STATE - -ZIP CERTIFIED FOOD MANAGER'S NAME(S) N/A CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON Jose A. Rodriguez HOME TEL# 825-0760 DAYS OF OPERATION Monday Tuesday I Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION Please write in lime of day. For example 11 am-11 m 7a -1 TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 -------------'-------'---------------------------- S------- O--------------------------------------------"---------'----'--"--------------'---------- 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 CHILDCARESERVICES. ........................................--------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YE NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. ' Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax retums and aid all state taxes required under the law. 12it07 043-45-1827 Signature Date Social Security or Federal Identification Number ------------------- ---------------------------------------------- - - - -- - ------$------------------- --- �,� ------------------------------ Revised 4/24/07 FOODAP2008.adm Checkd&Date ' S Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: 745-9114 ,Owner. I Cesar Guerrero . ;PIC: Maribell Guerrero Inspector: Elizabeth Salandrea Date Inspected:Correct By: 5/27/2008 Risk Level: Permit Number: BHP-2008-0087 Status: }_SIGNED OFF #of Critical Violations: 0 )Time IN: Time OUT: Urgency Description(s): BLUE: All violations noted in the 5120108 inspection report have been corrected. Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days) Non-critical violations must be corrected immediately g or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 27,2008 ) Page 1 of .4 y 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 GeoTMSO 2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 27,2008 ) Page 2 oft Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency )Telephone:, PROTECTION F M CONTAMINATION (.745-9114 Food Con Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: omment: Knives in back room have some food debris on them. Knives must be properly washed,rinsed and sanitized before .Cesar Guerrero being stored. - #i PIC: Violations Related to Good Retail Practices (Blue Items) 9 Cesar Guerrero Food and od Protection FAIL Critical BLUE _i Inspector: omment:The following items were removed,outdated: Elizabeth Salandrea 9 veryline orange juice Date Inspected:Correct By: s coke zero 5/2012008 10 diet cokes !;-liter Pepsi ft Risk Level: b4u packages sliced cheese from front display case unit. 1 fruit punch sunny D Kermit Number: 2 oscar mayer ham 17 goodstart baby formula r BHP-2008-0087 t Status:-: _ Ov�Nfer to closely monitor all expiration dates. x PARTIAL COMPLY M/any packages of frozen meat for sale had dates of more than a month ago on them.Closely monitor these items and ensure they 1#of Critical Violations: only stay out for sale for 1.2 weeks-remove all outdated packages. 11 22 Equipment d Utensils FAIL Non Critical BLUE i Time IN. `d•` " Time.OUT: .i om ant: Floor in back room needs general cleaning. Urgency Description(s): g any frigerationlfreezer units throughout establishment missing internal thermometers. Provide visible,accurate internal i BLUE: the ometers for all units. 'Violations Related to Good oth freezers along back wall need general cleaning. Retail Practices (Critical .violations must be corrected 1 Reinspection in one week, all violations to be corrected. immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) v City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 27,2008 ) Page 1 oft Item Status Violation Critical Urgency RED: i ;Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) � z City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. May 27,2008 ) Page 2 oft ,Pe Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 745-9114 Physical Facility FAIL Non-Critical BLUE. Owner: Comment:The bathroom ceiling is in disrepair. Repair the bathroom ceiling. Cesar Guerrero PIC: There is a missing electric plate cover in the back room. Provide a cover on this outlet. Angel Guerrero GENERAL COMMENTS: Inspector: All other violations cited in the 10/15/07 inspection report have been corrected. David Greenbaum Date Inspected:Correct By: 10/22/2007 Risk Level: Permit Number: BHP-2007-0262 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. Oct 22,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 22,2007 ) Page 2 oft Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: - PROTECTION FROM CONTAMINATION 745-9114 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑J RED Owner: i Comment: There are knives stored between a pipe and the wall in the back rrom. Properly clean and sanitize the knives and store Cesar Guerrero in an appropriate knife rack. PIC: j Violations Related to Good Retail Practices (Blue Items) Angel Guerrero Food and Food Protection FAIL Critical BLUE Inspector: Comment:The following items removed from the shelves outdated: David Greenbaum 4-Wheaties Date Inspected:Correct By: 1 -Grape nuts 10/15/2007 1 -Baby cereal 5-Gerber carrots Risk Level: 5-Gerber Garden vegetables 27-Good start formula 4-Hood sour cream Permit Number: 2-Mozzarella cheese BHP-2007-0262 2-8oz.Miracle whip 1 -16oz.Miracle whip Status: 1 -pop tarts PARTIAL COMPLY 2-Old EI Paso taco shells # of Critical Violations: Closely monitor all expiration dates. 2 Equipment and Utensils FAIL Non-Critical BLUE Time IN: Time OUT: Comment:The back Beverage air reach in needs a general cleaning. Urgency Description(s): The wall walk in/reach in needs a thorough cleaning, including under the racks. BLUE: Provide a sign stating"Employees Must Wash Hands Before Returning to Work"at the bathroom hand wash sink. Violations Related to Good Retail Practices (Critical Physical Facility FAIL Non-Critical BLUE violations must be corrected Comment:The bathroom ceiling is in disrepair. Repair the bathroom ceiling. immediately or within 10 days)(Non-critical violations There is a missing electric plate cover in the back room. Provide a cover on this outlet. 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. Oct 15,2007 ) Page / of Item Status Violation Critical Urgency RED: GENERAL COMMENTS: Violations Related to Reinspection in one week, all violations to be corrected. Foodborne Illness Interventions and Risk Factors (Require This establishment had a minor electrical fire on Sunday, October 14, 2007. This fire was contained to the front immediate corrective action) deli case only. No food or food product was affected by this fire. The deli unit is not working and must be repaired to good working order prior to being used. The counter flooring was cut open to access the fire and for precautionary reasons and must be repaired after the insurance company has inspected the damage. Establishment is granted permission to reopen immediately. 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. Oct 15,2007 ) Page 2 oft Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 745-9114 Physical Facility FAIL Non-Critical BLUE Owner: Comment:The light in the back storage room needs a protective cover. Cesar Guerrero PIC: The ceiling in the employee bathroom is in disrepair. Repair ceiling. Angel Guerrero GENERAL COMMENTS: Inspector: All other violations cited in the 4/3/07 inspection report have been corrected. David Greenbaum Date Inspected:Correct By: 4/11/2007 Risk Level: Permit Number: BHP-2007-0262 Status: SIGNED OFF # of Critical Violations: 0 Time IN: Time OUL I Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 11,2007 ) 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. Apr 11,2007 ) Page 2 oft Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-9114 Handwash Facilities FAIL Critical RED Owner: Comment:Thr front hand wash sink found obstructed. Keep hand wash sinks clear and accessible at all times and use for hand Cesar Guerrero washing only. PIC: Angel Guerrero I The back hand wash sink missing soap. Provide soap at this hand wash sink at all times. _ j Inspector: David Greenbaum Date Inspected:Correct By: 4/3/2007 Risk Level Permit Number: BHP-2007-0262 Status: VIOLATION #of Critical Violations: 2 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 03,2007 ) Page / of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comment:There are many price labels obscuring ezpirationlsell by dates. Do not obscure any expiration/sell by dates with price immediate corrective action) labels. The following items removed from the shelves at the time of inspection: 6-Trix 2-Rice Chex 1 -Whipped cream 3-Dragone Ricotta cheese 2-quaker Avena Molina 4- Lunchables 2-Ritz 2-Lemonade 2-Caribik Sun 11 -yogurt Personal items stored on the meat slicer.Store personal items in an appropriate storage area to prevent cross contamination. Knife stored betwwn wall and electric piping. Store knives an appropriate knife rack. A bucket of Pailcas Salada in the reach found outdated and had hairs in the packages. This product discarded at the time of inspection. There is food stored directly on the floor of the back storage area. Store all food at least 6-8 inches off the floor. Equipment and Utensils FAIL Non-Critical BLUE Comment:The walk in flooring needs a general cleaning. The ice cream freezer needs a general cleaning. Physical Facility FAIL Non-Critical BLUE Comment:The light in the back storage room needs a protective cover. The ceiling in the employee bathroom is in disrepair. Repair ceiling. GENERAL COMMENTS: Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Apr 03,2007 ) Page 2 of J :Y Item Status Violation Critical Urgency 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 03,2007 ) Page 3 of 1'y. 6Q, "" r :{#,� §w.rh�u`.edw*F.�r. k t }a•1iTy 4 �¢ ..i'r.• 'rt W 3'.i"rJe •L ° S• " iA'-fin ' k R 4'Y w atm-' . +h 'F `s„7R°*k'" � i Commonw alth.ofMass achusetts s hc�"4E • ' • �"c- '* '��' s .: yes rt�i'a(�,- y'�*r`-� '�„�' + x+L '�' Ind , � x IUM dilly Dnscoll v, "a k f =- 120 Washington Street,4thFloor , Y "� Mayor Y s SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/02/2007 ESTABLISHMENT NAME: Los Amigos Supermarket File Number:BHF-2004-000016 Penas Accounting 17 Canal Street Salem MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0262 Jan 2,2007 Dec 31,2007 $50.00 / WATER SOURCE: CITY WATER SEWER DIST:CITY WATER TOBACCO VENDOR BHP-2007-0267 Jan 2,2007 Dec 31,2007 $50.00 / WATER SOURCE:CITY WATER SEWER DISP: CITY WATER Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 Board of Health Of This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 2 of 7 Dec 14 08 02. 33p Joanne Scott Salem BOH 878 745 0343 p. i CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH I _ r 120 WASHINGTON STREET, 4TH FLOOR 7 11 -C E I V E D SALEM, MA 01970 TEL. 978-741-1800 DEC 18 2006 FAX 978.745-0343 KimberleyDriscoll sA en•coM CIT Y OF SALEN/I BOARD OF HEALTH JOANNE SCorr, MPH, RS,CHd Mayor HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 10::—fir 1wle"C3J�C,- '3 �� aif&4''�Of` TEL Ili 79 - _ ADDRESS OF ESTABLISHMENT _ �p e .2L FAX# — 2��— MNLING ADOrRGSG(it different).-._. Cr_� mo'`'d EMAIL—Bu&ness':— Qwflers:_. OWNER'S NAME (fz,4K �/ U /112 'e,�,a pp TEL a 4 7 ")L(/o - 91/V ADDRESS I a °� 4 -t�� LA, c.. RC1 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S)_ CERTIFICATE#(S) (Kegwred in on establishment where potenllally hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL F Fd SQF0P6ATI0N Monday TtlesdaV wedaesAaV. Thursday Fn�lay I0 Satin AaV _ suntlaV _._ N0U8SOF0PFRATfON 1� � 4 � .� / � 7 �/D 11� Please write mumrt at der _ ! J�� 6y�7 .tFgt example alum-fttnni- .. . �. .�_1 _ TYPE OF ESTABLISH M T FEE (check only) RETAIL STORE NU coo than I000sq.ft. =$SO 1000-10,000sq ft. =5900 more than 10,000sq,ft. =$250 RESTAURANT YES N6 less than 25 seats =$100 25-99 seats =$15/'�0 rrini'e 111,31-1 99 seats -$20Q 8E0/BREAKFAST YES NO $100 ADDITIONALPERMITS MAKE (riot just serve) ICE CREAM, YOGURT SOFT SrRVE YES NO $5 T0BACC0 VENDOR ES NO $50 ALL NON-PROFIT(such as church kitchens) S NO $25 'Ptaose pay total with one nheck payable to the City of Salem_ This Permit is not transferable and must be reissued upon change of ownership. 'f he Permit must be posted m a prominent location in the Establishment In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are (11ade, all plans for such must be submitted to and approved by the Salem board of Health. Pursuant to MGL Chai;tw 62C, Secitort 40A,I cettfy under Iho pains and penallics of perjury that 4 to ray best knowledge nrtd bebel, tIavo filed A s?11C lox I'yturm and pa.d NII;,late tnAo6 re,7tiirUd under tho law s�gnao.._e - -� bato Socit;i Security or Fodet>ai Identif,cali6n Number -- ..'-------.-.. ._---..-..___...- .................... .......... ............. .---...... ....-------'-----------..---._._....................... ------..... R,',twd,tnalcirt000AP:au:r.ad1„ ✓cf,eck#&oole q'g.25, 1m//8�06 b ,Lat2:_{rt) IMPORTANT MESSAGE FOR ind (�Z. A.M. DATE TIME J i30 P.M. ill M rN/'i(1111.1 ' �� Q�ll'Lt.V1G, OF PHONE AREA CODE NUMBER EXTENSION U FAX U MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL ' WILL FAX TO YOU MES AGE ,y v . v s Nv�rn s. SIGNED FORM 4009 MADE IN U.S.A. � NOTES Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-9114 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED Owner: Comment: Knives stored between the sink and wall. Knives to be cleaned and sanitized and stored in an appropriate knife rack. Cesar Guerrero Violations Related to Good Retail Practices (Blue Items) PIC. Food and Food Protection FAIL Critical BLUE Angel Guerrero Inspector: Comment:There are price labels obscuring many expiration/sell by dates. Do not obscure any expiration/sell by dates with price David Greenbaum i labels. Date Inspected:Correct By: There are product labels that do not state a clear expiration date. The labels must contain the words"Sell by"or"Best if used by" 10/4/2006 clearly shown on the label. Information regarding this requirement was given to the owner on 9/27/06. Risk Level: Equipment and Utensils FAIL Non-Critical BLUE Permit Number: Comment:The mop bucket found in the 3 bay sink. Store mop bucket in an appropriate storage area. BHP-2006-0138 Label the hand wash sink"Hand Washing Only" Status: GENERAL COMMENTS: PARTIAL COMPLY 867:AII other violations cited in the 9/26/06 inspection report have been corrected. #of Critical Violations: 2 Time IN: Time OUT: I Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 05,2006 ) Page I oft t Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Oct 05,2006 ) Page 2 oft Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 745-9114 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑r' RED Owner: Comment: Knives stored between the sink and wall. Knives to be cleaned and sanitized and stored in an appropriate knife rack. Cesar Guerrero `T ' PROTECTION FROM CH ICALS PIC: Toxic Chemicals FAIL Critical ❑d RED Angel Guerrero Inspector: C menta There is fly paper laying on top of produce. Fly paper must be placed in an area not near any food product. David Greenbaum Date Inspected:Correct By: 9/26/2006 Risk Level: Permit Number: BHP-2006-0138 Status: VIOLATION #of Critical Violations: 4 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 27,2006 ) Page I of T Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (Requirel�Comment:There are price labels obscuring many expiration/sell by dates. Do not obscure any expiration/sell by dates with price immediate corrective action) �/ Labels. The following items removed from the shelves outdated: 9-baby apple sauce 2-sour cream 1 -bacon 1 -salt bacon 1 -tropical crem exicana 17-frescav 2-pa Ke 1 op tart -salad dressing 4-miracle whip 1 -media creme 2-hotdogs 2-lunchables Owner must closely monitor all expiration and sell by dates to insure no expired product is out for sale. Th is food stored directly on the storage room floor. Store all food at least 6-8 inches off the floor. .There are product labels that do not state a clear expiration date. The labels must contain the words"Sell by"or"Best if used by" clearly shown on the label. Information regarding this requirement was given to the owner on 9127106. Equipment and nsils FAIL Non-Critical BLUE omme he produce shelves have an accumulation of food debris. Thoroughly clean the shelves. T ack Beverage air freezer has an accumulation of spills and splatter. Thoroughly clean this freezer. The mop bucket found in the 3 bay sink. Store mop bucket in an appropriate storage area. Th alk in floor needs a thorough cleaning. Hbel the hand wash sink"Hand Washing Only" Special Requireme s- FAIL Critical BLUE Co ment:There is an infestation of small flies throughout the establishment. Owner to contact the licensed pest control operator nd treat for these flies. E�I,cge corn mt was received by the Board of Health regarding pantry flies found in a box of Cream of Wheat. Owner must contact the ed pest control operator nad have the establishment treated for pantry flies. Owner must forward all extermination invoices e Board of Health. 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. Sep 27,2006 ) Paget of r Item Status Violation Critical Urgency GENERAL COMMENTS: 851:Reinspection in one week. All violations to be corrected. C / / 175�- City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 27,2006 ) Page 3 of FROM FAX NO. Sep, 28 2006 07:52M P1 7Mh4AtUnr Rd 67BBD2+933DNorth Shore Pe,st M-SW2710 Control ftx Ta daye8teeflbdtatr- First Fm 978.7454M ftPw 3 Pirs�w OSSM W250 an LOS XroposMm de cc: [3 U#fpW . D Far/b•Irw O rbMa cemom! tubow ftply Ea F1s�ss A�agdr MY W►mp dm Las k"m Me", GWyAoftA I l FROM : FAX N0. : Sep. 28 2006 07:52PM P2 tNorth Shore- t Control CQMMERWAL-RESIDEWIAL-iNouSTMAL 7 IAWAutMx Road.Peabody,MA 01990 (978)532-3330• (781)698.2710 September 27, 2006 I Mr. David Greenbaum Health Department City of Salem 93 Washington Street Salem,MA 04970 Re:- Los Amigos Market Dear Dave, in response to your call on September 27, 2006, I-inspected Los Amigos Market on 122 Lafayette Sura,Salem,MA. Upon inspection of the shelving-containing-grain products(flour,cornmeal,Cram of Wheat, etc.)I found no sign of infestation. None of the packages had any sign of insects or the webbing they ereate. Idid find some fiver spillage around theshelfcorm6ning the flour bags: Idirected store employees to clean up all spillage and sanitize the shelf I also addressed the fsuitfly problem around-the produce counter by instructing the owner (through his sister-in-law who served as interpreter)to thoroughly clear the entire fruit taunter and discard any over-ripe or rotting fruit. I also eonveyed to him the-importance of keeping the door to the street closed. I set out several"Natural Catch"fruitfly traps to help control further infestation(see attached.informabon). I am confident that these problems will be corrected promptly. I have been servicing Los Amigos Market for more than tenryeass and I have never-had any problem widrtheir cooperation in doing what is necessary to maintain proper pest control. If you have any further questions or concerns please do not hesitate to contact me. �Sincerely, 't/24 Gary 3. Ami ult Owner/operator dma Fax 0 978.745-0343 NATURAL CATC14® ri FRU ITFLY TRAP CL M N m Natural Cattfcontrols frmt dies (Drosophila) with an N innovative trap wfiidt is safe, _ nontoxic and easy-to-use. ul The convenient container is safe for use anywhere fruit flies amaproblem kitchens, countertop, display cafes, and dining areas. Natural Catch®comes enrnplete and ready-to-use: Qz Directions: 1. Write the date you activate Natural CatchP on the bottom of the trap.Natural LL Catch®is effective for 30 days or longer. 2. Gently pierce the openings of the Natural Catch*with theslick provided. The stick opens the trap just the right amount for maximum effectiveness. 3. Place the Natural Catch®wherever fruit flies are a problem:Countertops, kitchens,display cases and dining areas. 4. Occasionally inspect the trap entrance and keep it flee of debris.The trap is safe to use around food and the an ractant is nontoxic and pesticide-free. a 8ioOlwogInc.P,Oamn SIS Mlhw W^Oregon 972"15 Fw more information,dual our website at PW Pw 5®J5a.967 wVvw.bugtryp/.c*m T Email:~bug6"&M r&LL 010V/-rOD68io-loYk i,cllf ripMbrwrvai Penas Accounting Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 745-9114 Hot and Cold Holding FAIL Critical ❑d RED Owner: Comment:The Beverage air freezer had a temperature of 60°F. Repair unit to maintain a temperature of 0°F or below. Cesar Guerrero Violations Related to Good Retail Practices (Blue Items) PIC. Food and Food Protection FAIL Critical BLUE _Angel Guerrero Inspector: Comment:There are price labels covering expiration and sell by dates. Do not cover any expiration or sell by dates with price labels. David Greenbaum The fillowing items found outdated: Date Inspected:Correct By: 2-salad dressing 4-miracle whip 6/6/2006 2-mayo Risk Level: Closely monitor all expiration dates. Equipment and Utensils FAIL Non-Critical BLUE Permit Number: Comment:The Ice cream freezer needs a visible,accurate thermometer. BHP-2006-0138 Status: The walkin floor has an accumulation of food debris. Thoroughly clean the floor. SIGNED OFF The refrigerator on the back wall needs a visible,accurate thermometer. #of Critical Violations: 2 Physical Facility FAIL Non-Critical BLUE Time IN: Time OUT: Comment:The stairs going into the back room need to be painted. Urgency Description(s): There are broken floor tiles in this establishment. Replace all broken floor tiles. BLUE: GENERAL COMMENTS: Violations Related to Good Retail Practices (Critical 646: violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 07,2006 ) Page 1 oft f Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) / City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 07,2006 ) Page 2 of } A&1r,y' r x "3f• a 4.ro- Y4 bg wa,satF Yn s '+ ` iX 5 z¢' w,.."C"§'rn.Y k,; +'ia'ae #'� x *M [ M4 r"w -d .R v en"•"if:°g." k*iW''>n'nw`m.-+snY+rx.f!s*� .7!!'reN✓F£ k-e"°"'fin"'vL--d++-rr^ak ..+.nY- re+.i •P,..:h ♦ .ar.nr.. a,..,�...pz m�.a�p 7en ,� Commonwealth of Massachusetts s s City of Salem Board of Health ,gam 120 Washington Street,4th Floor ^� SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/27/2005 WHO'S PLACE OF BUSINESS IS: Los Amigos Supermarket File Number:BHF-2004-0016 Penas Accounting 17 Canal Street Salem MA 01970 LOCATED AT: SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FROZEN DESSERTS BHP-2006-0139 Jan 3,2006 Dec 31,2006 $5.00 RETAIL FOOD BHP-2006-0138 Jan 3,2006 Dec 31,2006 $50.00 TOBACCO VENDOR BHP-2006-0140 Jan 3,2006 Dec 31,2006 $50.00 Total Fees: $105.00 PERMIT EXPIRES December 31, 2006 Board of Health i; This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 9 of 9 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH c 120 WASHINGTON STREET, 4TH FLOOR 10 T SALEM, MA 01970 ]� TEL. 978-741-1800 U STANLEY J. USOVICZ JR. FAX 978-745-0343 DEC 0 5 MAYOR WW ' W .SALEM.COM 2905 JOANNE SCOTT, MPH, RS, CHO CITY OF SALEM HEALTH AGENT BOARD OR HEALTH 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT L.0,—S j%ryi US /I/I aYkft TEL# / V6 ADDRESS OF ESTABLISHMENT tk MAILING ADDRESS (if different) 4- 14 OWNER'S NAME C'2Sq'r CU TEL 1 zJT TEL# /Iwx ADDRES d-v1- ZGT'� �✓ CITY_ STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) 2 qu-A y •CERTIFICATE#(s) 3a 0J (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSOf} _ o C` HOME TEL# HOURS OF OPERATION: Mon. , Tue. ed. ThuFri. Sat. L-� Sun. L,- ?-rU -�yJPw. 7-i0 -?-i0 k-� TYPE OF ESTABLISHU05 FEE check onl RETAIL STORE 'YES NO less than 1000sq.ft. _ 1000-10,000s .ft. =$100 S q more than 10,000sq.ft. =$250 ........................... ..................................... ........ - --- ----.........-- ........ RESTAURANT YES NO less than 25 seats $100 25-99 seats =$150 more than 99 seats...... =$200 J ........ BED/BREAKFAST YES NO $100 j/ o_ ADDITIONAL PERMITScp �� j �iV%KE (nGtji:St 3CrVe) ivE QRE^.I'.v1 YOGUPT�SOFT CGo E YES �) G5 TOBACCO_VEND.OR� ��Q NO ALL NON-PROFIT(such as church kitch sh ) 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 orequipment chan 9es 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 retur s and paid all state taxes required under the law. Czs c1.i G vs,-r� '1115y/u y l i n -� O'Y,3 YLT/ kq- Signature Date Social Security or Federal Identification Number --- --------------------------------------------------------------- - ---------- --- r ------------------ Revised 11/03/05 FOODAP2.adm Check#&Date "2t9 U � 07--- iila j6 S /o b 122 Lafayette Street Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: "" PROTECTION FROM CONTAMINATION 745-9114 Handwash Facilities FAIL Critical ❑Q RED Owner: Comment: Counter handwash sink missing paper towels. Provide disposable paper at handwash sink at all times. Cesar Guerrero . Violations Related to Good Retail Practices (Blue Items) PIC , Food and Food Protection FAIL Critical BLUE Angel Guerrero inspector: "°r°r Comment: 11 items removed outdated. Closely monitor all expiration dates. - David GreenbaumEquipment and Utensils FAIL Non-Critical BLUE Date Inspected: COrreCt By: - Comment:The ice freezer,Kelvinator freezer,and Beverage Air cooling unit need a thorough cleaning. 11/30/2005 " ` The Kelvinator freezer nad the freezedr in the back room need visible accurate thermometers. The freezer near the back stairs noods a thorough clowning. Risk Level;. Physical Faalit FAIL Non-Critical BLUE Y Y Comment:The backroom stairs are unfinished. Finish stairs to be impervious and easily cleanable. Permit Number: � P v BHP-2005-0192 GENERAL COMMENTS: Status. 3 v 389: -SIGNED OFF- #of Critical Violations = 2 m 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®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 01,2005 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 01,2005 ) Page 2 of .y • 1 122 Lafayette Street Los Amigos Supermarket City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ ,Telephone: { r Item Status Violation Critical Urgency Nature of problem or correction s 745-91141 +- ��` � Non-compliance with: Not Done Owner I F x Anti-Choking N/A ❑ Cesar Guerrero - Tobacco PASS ❑ 'PIC FOOD PROTECTION MANAGEMENT Not Done ;Angel GUeITerO - PIC Assigned/Knowledgeable/Duties PASS RED Inspector. David Greenbaum EMPLOYEE HEALTH Not Done Date Inspected: COrreCt By d ( Reporting of Diseases by Food Employee and PIC PASSJ❑ RED 5/18/2005 'r `- Personnel with Infections Restricted/Excluded PASS ❑Q RED Risk Level s- FOOD FROM APPROVED SOURCE Not Done Permit Number Food and Water from Approved Source PASS ❑d RED ❑ - BHP-2005-0192 u _ Receiving/Condition PASS ❑d RED ,Status: ., Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNED YOFF 5 i w #Of Critical VIOIffiIOnS ,_„_, t Conformance with Approved Procedures/HACCP PASS kRED Plans �; i" A PROTECTION FROM CONTAMINATION Not Done ,Time IN -" IT;me OUT " Separation/Segregation/Protection PASS ❑d RED Notes !& 54 77m Food Contact Surfaces Cleaning and Sanitizing PASS RED 149 ; Proper Adequate Handwashing PASSd❑ RED � .. = -s ; Urgency,Description(s) ?' Good Hygienic Practices PASS ❑d RED BLUEX f - prevention of Contamination from Hands PASS ❑d RED Violations Related to Good f Retail Practices (Criticalr � ' Handwash Facilities PASS ❑d RED violations must be corrected ; immediately Or within 10 days)(Non-critical violations GeOTMSO 2005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 18,2005 ) Page I of • 1 122 Lafayette Street Los Amigos Supermarket must be corrected Immediately PROTECTION FROM CHEMICALS Not Done or mWlthln 90 days) Approved Food or Color Additives PASSd❑ RED RED: Toxic Chemicals PASS d❑ RED Violations Related to Foodborne Illness Interventions TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done and Risk Factors (Require Cooking Temperatures PASS ❑d RED immediate corrective action) Reheating PASS RED Cooling PASS ❑d RED Hot and Cold Holding PASS ❑d RED Time As a Public Health Control PASS ❑d RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP PASSd❑ RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A ❑Q RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Critical ❑ BLUE 22 outdated items were removed from the shelves at time of inspection. Owner must closely monitor all expiration dates. There is food stored directly on the walkin floor. All food must be stored atleast 6-8 inches off the floor. Equipment and Utensils FAIL Non-Critical ❑ BLUE The beverage air freezer and the Kelvinator cooling unit need thorough cleaning. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility PASS ❑ BLUE Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 18,2005 ) Page 2 of 122 Lafayette Street Los Amigos Supermarket GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. May 18,2005 ) Page 3 o1f3 *q•..,ak++rM ..s:..+,.....w�vwr.:r-z*+ ..+f ,;«;.a .s ;'"Y' p' L Y ,l �' 'a y.r NEI r d pd. c * k y4.l y"+3eait 4i'Fi•2'ft',a" 1 ' Pe CITY OF SALEM,MASSACHUSETTS j .� / BOARD OF HEALTH " 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Los Amigos Supermarket Address of Establishment: 122 Lafayette Street Owner's Name: Cesar Guerrero Restrictions: Application Date: 12/2/2004 Permit for Food Establishment 132-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 31-05 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. qM E4NT HEALTH AGENT CITY OF SALEMr MASSACHU / BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLO p q 20041 �J SALEM, MA 01970 ;"a 6 l� TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALEM STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT LOS V•hrt IC of Sp.1tAGH l<t,-f TEL CW 7e) 7- 0 - t l V ADDRESS OF ESTABLISHMENT (ZZ' t^0.�G y e � s�. MAILING ADDRESS (if different) OWNER'S NAME cr,spa CU�R2e�eQ TEL 9�� �5��-5a 19 ADDRESS o? ,,C 6 CJa / 5�. CITY ��cc�f iN STATE /K ZIP 6 /97-+0 CERTIFIED FOOD MANAGER'S NAME(S) `5j4oe CyUC7eRC-/zJ CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON�-00vl 67066-i &kO HOME TEL# 78qO q/1�4 fjari ?aa1 17 A 17a.. ?&� �?>.-t &'ar HOURS OF OPERATION: Mon t�� Tue.f M Wed. ( Thu. A�Fri.�Sat.lD�Sun. 9.o M TYPE OF ESTABLISHM J'f' FEE check onnI RETAIL STORE ES NO less than Q00so.ft. =$ 50 I 1000-10,000sq.ft. =$100 / more than 10,000sq.ft. =$250 RESTAURANT YES NO y less than 25 seats =$100 � 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR ES NO $50 ALL NON-PROFIT(such as church ,kitchens) 3/J 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 stat tax eturns and paid all state taxes required under the law. 3 Y-5 1 9 F 7- Signature —Date —Social Security or Federal Identification Number --------------- ------ ------- -- Revised 11/03/03 FOODAP .adm Check#&Date as )/x� % CITY OF SALEM9 MASSACHUSETTS • BOARD OF HEALTH s 1 120 WASHINGTON STREET, 4TH FLOOR 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: RETAIL FOOD Name of Establishment: Los Amigos Supermarket Address of Establishment: 122 Lafayette Street Owner's Name: Cesar Guerrero Restrictions: Application Date: 12/18/2003 Permit for Food Establishment 230-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 50-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT " u CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH • • 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTo­'O`j A/y/i�1 OS �6a TEL#g C 7( ` �z V ADDRESS OF ESTABLISHMENT � {� 7 MAILING ADDRESS (if different) PI OWNER'S NAMECeC, 2 PL E T IZ 0 TEL# ADDRESS CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON AW6 (S COU ]4i,"OME TEL�-7�7Y � Y/1y HOURS OF OPERATION: Mon. V/ Tue. Wed. Thu. Fri. Sat. `-�' Sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. 54 1000-10,000sq.ft. =$100 j0 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR :"? d),4 <IEV NO ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check able to the Cit of Salem a y payable 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 t knowledge belief, have filed all state t�r�urns and paid all state,j es{ef{uired finder the law. l/ / P � Sign ure Dae Social Security or Federal Identification Number ---- -------------- Re ,sed 11/03/03 FOODAP2.adm Check#&Date 20 YV- /rZ A l--3 Of Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4th Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name . Date �Q � Type of ODeration(s) T oof inspection Q Las t y' LJ Food Service utine Address 2 ` r, r` Risk P-getail ❑ Re-inspection Telephone Level El Residential Kitchen Previous Inspection ja/O ❑ Mobile Date: OwnerHACCP Y/N [I Temporary ❑ Pre-operation CICFAIL- 09 �'U 1r(Z0 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) 5.AkAj- Time ❑ Bed& Breakfast ❑ General Complaint In: El HACCP Inspector 0044? ffit6641144W 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. i FOOD PROTECTION MANAGEMENT - _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 3. Handwash Facilities a 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 :. El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source 'TIMElTEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling 'PROTECTION FROM CONTAMINATION'-` "":' ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection . ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ,_ ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ..CONSUMER ADVISORYi ❑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 Boardof today, the items checked indicate violations of 105 CMR F-V- -,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 cited in this report may result in suspension or revocation of (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: 5:5901nsp Farm 14m Inspector's Signature: Print: /J PIC's Signature: Print: �� SJ`�- Page of`Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination _ I 590.003(A) Assignment of R,esponstbilit "' 3-302.11(A)(1) Raw Animal Foals Separated fiam 790.003(B) Demonstration of Knowledge* Cooked and RPh FWds' 2103.11 Person in charge--duties Contamination from Raw ltgredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other= 2 590.003((') Resprimibdity of the person in ch nge to Contamination from the Environment require reporting by food emplotiees and 3-302.1.1.(A) Fwd Protection* applicants" 3-302.15 Wastnne PnIns and Veggetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* - Contamination from the Consumer 590.003(G) Re urtica by Person in Charge* 3 ,00J I(A)(B) Returned Food and Reset vice of Food` 31 590.003(1)) 1 Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) _Removal of Exclusions and Restrictions Food 3-701_11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE food" q 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(,0 R) Compli nce with Food La"" 4-501.11 1. Manual Warew tshing-Hot Water 3-201..12 Foal inaHermetically Sealed Coctainer* Samtizationlem.etatures* 3-201.1.3 Fluid Milk and Milk Products* 4-501.112 'Mechanical Warewashing-loot Water 3-202.13 Shell Ecgs* - Sanitization Temperlutes* . > 3-202.14 Egp,*s and Milk, 4-507114 Chemical Sanitization-tem Products.Pasteurized- p"11l, 3-202.16 Ice Made From Potablc Drinking Water* concenhation and hardness 4-601.11(,A) Equipment Food Contact Surfaces and 5-107.11 Drinking Water from an A nosed System* Utensils Clean* 590.006(,0) Bottled Drinking Water'' 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surf=aces and Utensils* Shellfish and Fish Froman Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish k 4-703.11 Methods of Samuzation Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical`" Sources* Ip Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Regulatory AuthorityClean Concli Eton-Hands and Arens" 3-202.18 StwINtock Identification Present* 2-301.12 Cleanim>Procedure` 590 004(C) Wild Mushrooms* 2-301.14 When to Wash` 3-201.17 Game Animals: 11 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating, Drinking or Using Tobacco* 3-202.11. PF1Fs Received at 2-401-12 Discharges From the Eyes-Noseand 3-202.15 Package integrity* Moath* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* (; Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-2402.18 Shellstock identification* _ 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records: Fish Products - 13 Handwash Facilities 3-002.11 Parasite Destruction* Conveniently Located and Accessible 3-403.12 Records.Creation and Retention 5-203.11 Numbers and Ca acities* 590.0040) Labeling of Ingredients' 5-204.11 Lavation and Placement" 7 Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance IHACCP Plans- Supplied with Soap and Hand Drying 3-502,11 specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 fiandwashing Cleanser,Availability 8-,103.12 Conformance with A p coved Procednrest` 6-301.12 f:land Drying Provision Denotes entice(item in the federal 1999 Food Code or 105 CNIR 590,000. CITY OF SALEM BOARD OF HEALTH Establishment Name: L g Sr 0664 re s S7J/c-R Nt vl. leyf— Date: fp[ 0�/ Page: of Rem Code c-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 2,)5 tj e ti 5- u L U"I f- 2 ¢r1tt3 ef- rAO? Plesv 2 cre io a ar RS A4- - I�tPB Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five doll or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. _ ❑ Voluntary Disposal ❑ Other: 3-501.1.4(C) PHFs Received at T'enmerttures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 4t°.F/45°F Within 4'Hoors. PROTECTION FROM CHEMICALS -7,01.15 Coxrling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* _ 3-501.16(3) Cold PHFs Maintained at or below 590.004(F) 41 V45°F* 3-302.14 Protection from Lxrip cued .Additives* 3-501.16(A) Hot' PHFs Maintained at or above 1$ Poisonous or Toxic ic S Substances 140°F. 7-101.11 Identifying 3nfonnntion-Orio nal 3-501.16(A) Roasts Held at or above 130"F_ Containers* 7-102.11 Common Nanle-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-Presenc:eand Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use, 7-20311 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizes.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produee,Criteria* 21 3-801.1](A) Unpastew:ized Pre-packaged Juices and Beverages with Waning libels* 7-204.14 Dr m> ants,Criteria- ;-801.t I(B) Use of Pasteurized Re�s* 7-205.11 Incidental Food Contact.Lubricants` 3-801.11(12) Raw or Pmtiatly Cooked Anhnal Ford and 7-206.1 I. Initiating tricted Use Pesticides.Criteria* Raw Seed Sprouts Not Served. It 7-206.12dent$cit'Snrtio?ns* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13cking Powders,Pest Control and g* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603-11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods that are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate Pathoo' Ee�ce'e vrrloai 3-40L11A 1 2 Eggs- 1.55 C 15 Sec. ins." ( 1O 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell E s-hvmedrau,Servic. 145�F15sec* 3-401..I1.(A)(2) Comminuted Fish,Meats&Game Fags* Animals- 155°F 15 sea * 3-401.11(B)(1)(2) Pork and Beef Roast-130`F 121 ruin* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering,mobile food,temporary arid 3-401.11(A)(3) Poultry,Wild Game, Stuffed I?FIFs, residential kitchen operations should be Stuffing Containing Fish, Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. ^ above if related to foodborne illness 3401.11(C)(3) Whole-masele,Intact Beef Sicaks Interventions and risk factors. Otter 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165`F* - Special Requirements, 3401.17{A)(1)(h} All Other PHFs--145°F 15 sec. 19 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 1-403.11(A)&(D) PHFs 165°.F 15 sec. 4; - (items 23-30) 3-403.11(B) Microwave-165°F 2 Mame Standing Critical and non-critical violations, which do not relate to the Time* foodborne illness intervernions and risk factors listed above can be 3-401 11(C) Commercially Processed RTE Food- .finmd in rhe follorving sections of the Food Code and 105 CMR 140"Fr 590.000, 3-403.11(1.^) Remaining Unsliced Portions of Beef Item Good Retaiii PracticesFC b80000 Roasts' k8. Mane sment and Personn_e_I FC 2 .003 18 Proper Cooling of PHFs Food and Food Protection FC-3 .104 E m meat and Utenstls FC 4__ (_ .005 3-501.14(A) Cooling Cooked PHFs from 1.40`F to Water,Plumbin and W asie FC 5 A .00_6 _ 70-F Within 2 Hours and From 70°F Physical Facility FC-6 -007 to 4 t .17145`F Within 4 H urs.* Poisonous or Toxic Materials FC-7 .008 3-501.14(13) Cooling PHFs Made From Ambient S ecial R uirements _ _ .009Temperature Ingredients to 41°F/45°P Within 4 Hours'r ,16-2 d1,1 "Denotes critical item in ilra Lderal 1999 Foal Code or 105 CMR 590.000_ . Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4t Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Type of Operation(s) Type of Inspection �! Os r 1p m et e/ - =Vood Service 0"Routine Address / F��a /-/-- Risk LIZ Retail . E] Re-inspection Telephone Level El Residential Kitchen Previous Inspection ❑ Mobile Date: (.'_ 7-e3 Owner 1 HACCP Y/N ❑ Temporary ❑ Pre-operation G,S Q i1 r?7 e ,E ReAOd ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint Inspector E] O herr `+ � PPin U. ✓1��Jit,�5-tzc k[S Out: Permit No. Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: . Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PICColor_ Additives ❑ 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or 11-,FOOD FROM APPROVED SOURCE , ^- -" ❑ 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME TEMPERATURE CONTROLS(Potentially Haiardous Foods) I ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans [:118. Cooling PROTECTION FROM CONTAMINATION: "` - ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE.POPULATIONS(HSP)_7 El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP E:1 11. ADVISORY-11. Good Hygienic Practices _ '. . - • - ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions 2. G 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 hllth. today, the items checked indicate violations of 105 CMR of C ea590.000/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 2/` 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 FR29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: s:ssainspecForms-ia.aoc n ecto�r.'sna e: Print: PIC's Signatur!�:___ - - Print: c;-/- x �-, d/ Page / of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Gross-cootamh7ation 1 590.003(A) Assignment of Res onsibility* 3-302.11(A)(1) Raw Animal Foals Separated from 590.003(B) Demonsh:ation of Knowledge" Cooked and RTE Foods*. 2-103.11. Person in chargc-duties Contamination from Raw ingredients 3-302.1.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and :1-302.11(A) Food Proteetioa* a �licants" 3-302.15 Washow, Fruits and Vegetables 590.003(F) Responsibility Of Food Employee Or An 7304.11 Food Contact vrith_Equipment and Applicant To Report To The Person In Utensils* Charge- Confamination from the Consumer 590.003(G) Re rordn b Fens<>n in Charge 3-306.14(A)(B) Renutied Food and Rcsevice of Food 3 I 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-70111 Discarding or Reconditioning unsafe FOOD_FROM APPROVED SOURCE FOG& 4 -^ Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Staled Container* S nitization TemperaturcO 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical W'arewashing Hot Water Sanitization Tcm eralures* 3-202.13 Shell E s* ( 4-501.114 Chemical Sanitiiation-temp pH, . 3-202.14 Eg�s and Milk Products,Pasteur zed'* concenoation and bareness. 1 3-2(}116 Ice Made From Potable Drinkin Water* 4-601.1 [(A) Equipment Food Contact Surfaces and 5-101.11 DrinkingWater from an Approved System' Utensils Clean* 590.006(A) Bottled 2612 n Water" 4-602.11 Cleaning Frequency of Equipment Pood- i 5)0.006(8) Water Meets Standards in 3 10Approved CMR 22c Contact Surfaces and Utensils* Shellfish and Fish From an Approvod Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of F ai ment* Shellfish* 4703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing t Game and Wild Mushrooms Approved by Regulatory Authority 2-301,11 Clean Condition-Bands and Acrns* 3-202.18 Shellstock,.Identification Present* 2-301.12 Cleaninu Procedure* 590-004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices S Receiving/Condition 2-401.11 Eatin ,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures;' 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth- 3-101.11 Stood Safe and Unadulterated* 3-301..12 Preventing Contanum ition When Tastina4` 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.13 Shelisto k identification " 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em to ees* - Tags/Records: Fish Products 13 Handwash Faciiities 3-402-11 Parasite Destruction'^ Conveniently Located and Accesslbts 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.00401 Labeling of Ingredients' 5-204.1 1 Location and Placement" 7 Conformance with Approved Procedures 5-205.1.1 Aweesibility. O Aeration and Maitttenanec /HACCP Plans Supplied ndth Soap and Hand Drying 3-502.11 Specialized Processing hlothcxls* Devices 3-502.12 Reduced oxygen packa nm<..criteria* 0-301.11 Handwashin Clcansor, Availabilitv 8-103.12 Confrnmance with Approved Procedures* b-301.12 Hand Drvin,Provision '*Donors critical item in the federal 1999 Food Code or 105 Cil9R 590.000. CITY OF SALEM ' BOARD OF HEALTH Establishment Name: A 19 f- Date:- n Page: 2 of Item Code C-critical ItemDESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY AIS 2 OIX41 O// [! P ✓ Se ems"w r nfir GfsS /x 3 a ( vs �c enc. ,cl rn/ 1 f ry c , 4f_Q u✓� � �z40 OA? NC Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ' ❑ Re-inspection Scheduled i ❑ Emergency Suspension II " comply with all mandates of the Mass/Federal Food Code. I understand that 1 noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure r3 your food permit. --- - -� ❑ Voluntary Disposal ❑ Other: v r 3-501 14(C) PHFs Received at T'etvperatures Violations Related to Foodborne Illness interventions and Risk ?recording to Law Cooled to Factors(Items 1-22) (Cont.) 4 FF/45'F Within 4 Hours. PROTECTION FROM CHEMICALS 3-50135 E)ofiraMethods for PHFs 14 1 v Food or Color Additives 19 PHF Hot and Cold Holding - - -------- 3-202.12 Addnnvs3-501.16(B) Cold PRFs Maintained at or below x 590.004(F) 41'/45°F* 3-302.14 Protection from unapproved Addt6tran` - 19 Poisonous or Toxic Substances 3-501.1 fi(A) Ho¢PHFs Maintained at or above 40°F. * 1 7-101.11 Identifying Information-Original 3-501..1G(A) Roasts Held at or above I301F. -* Containers* 20 Time as a Public Health Control 7-102.11 Connnon Name W orkmg Containers" 3-5Ol.19 Time as a Public Health Control" 7.201.t 1 Separation-Storase" 7-202.11 Restriction-Presence midUsek 590.004(H) VarianceRecuiretrtent 7-202.12 Conditions of Use"' 7-203.11 Toxic Containers-Prohibnions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washin>Prodnce.Criteria* 21 3-801-11(A) Unpasteurized Pre-packaged luices and Bevel i l et with Wanun,Labels* 7-204.14 Drvin- rkoents.Crrteria* 3-8(1L11.(B) Use ofFasteumedEons` "'-205.11 Incidental Food Contact,Lubricants* 3.801 I1(D) Rau or Partially Cooked Animal Food mid 7-206.]I Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served. 7-�)fi.12 Rodent Bait Stations" 3-801.11(C) Unopened,Food Packa>c Nof Rc-served. "` 7-206.13 Tracking Powders,Pest Control mid Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Rain. Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.17A(l.)(2) Et!gs 15-5"F 15 Sec Patio ens re"' 101 Lei*s-Immediate Service 14s'Fl5sec* 3-302.13 Pasteurized F,ms Substitute for Raw Shell 3 401 11 )(2 A ) Comminuted Fish.Meats&Game ( Animals- 155'F 15 sec. " 3-401.11(B)(I)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS 3-401.1 l(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 Plil'is, residential kitchen operations should be Stuffing Containing Fish,Meat. debited under the appropriate sections Poultry or Ratites-165'F 15 sec * above if related to foodborne Illness 3-401.'11(,0 (3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145'F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a � practices should be debited under#29- Miciowave i65 I * Special Requirements. 3-401.11(A)(1)(b) All Other PHFs 145'F 15 sec. p Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403J I(A)&(D) PHFs 165`F 15 sec. * (Items 23-30) 3-103.11(B) Mier(rwave- 165'F 2 Minute Standing Critical and non-critical violations, which do not reline to the True* foodborne illness interventions and risk factors listed above, can be 3-403.1.1(C) Commercially Processed RTE Food- found in the following set tions of the Food Code and 10.5 CYIX 1400Fw 590.000. _ 3-4o3.11(E) Reinainin_Unshced Portions of Beef Item Good Retail Practices FC 590.000 a - 23. Management and Personnel FC-2 .003 Roasts - 24 Food and Food Protection PC-3 -004 ig Proper Cooling of PHFs ----- --- +-- 25. E went and Utensils __ FC 4 .005 3-501-14(A) Cooling Cooke I'HFs from 140°F to 26. Water, Plumbin and Waste FC-5 006 70°F WiCUin 2 Homs and From 70°F 27 Ph steel Fauilit FC-6 .007 to 41 1`145`F Within 4 Hours ^' 28 Poisonous or Toxic Materials FC 7 .008 r 3-501.14(B) Cooling PHFh Made From Ambient 29- S ectal R uvements -_ _ .009 Temperature Ingredients to 41°F/45'F 30. Other __-- --- __ Within 4 Hours* '`Denote,erilical iters in the federal 1999 Fotx1 Code or 10]Cy4R 590.000, 1 �oxwr CITY OF SALEM, MASSACHUSETTS i �v4� "� BOARD OF HEALTH 120 WASHINGTON STREET. 4TH FLOOR �' SALEM. MA 01970 �N -j yBC' TEL 976-741-1800 FAx 978-745-0343 STANLEY 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 : Owner ' s Name : Cesar Guerrero Name of Establishment : Los Amigos Supermarket Address of Establishment : 122 Lafayette Street Type of Establishment : RETAIL FOOD Application Date : 01/06/2003 Restrictions: Permit for Food Establishment 212-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 50-03 These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH " 120 WASHINGTON STREET. 4TH FL0(-1R y�g, �Gp SALEM. MA 01970 s9p TEL 978-741-1800 FAx 978-745-0343 SCANLEV US0% [C7. Ja_ JO-ANNF SCO?i, MPH, RS, CF110 MAYOR HFALIH AGIEN1, 2003 APPLICATION FOR PERMIT TO OPERATE A/FO1_OD ESTABLISHMENT NAME OF ESTABLISHMENT- �� TEL ADDRESS OF ESTABLISHMENT 2 F MAILING ADDRESS (if different) � � OWNER'S NAME ��/ TEL # ADDRESS CITY STATE CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSONrx/� — HOME TEL HOURS OF OPERATION: Mon. ZTue. ✓ Wed. Thu.�Fri. /Sat._V-�,Sun._� 7 ld 1-1,4 7-1-dTYPE OF ESTABLISH ME FEE check only �^ y RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 a more than 10,000sq.ft. =$250 a 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 ICE CREAM, YOGURT, SOFT SERVE Y S NO _ $5 TOBACCO VENDOR 4f YES NO Sd ,03 50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. Signature Date Social Security or Federal Identification Number ------------i --- Revised 11125102 FOO P2.adm Check#8,Date a '-A ,,GG tp7J, - -Z 7rr 7 � a7- ;s..� 7 F��"B.M'a: nr. UPI ,J• -s "� 9 c ix¢an :� { :.� °" ; "eaa k ?;a�` 23£ ' 'i.'lct s. '�.S " 2. '$ al ar E•t, ? w.:, z .', ; i } If F, � mot 1 s }d >r. >Y a kq * ar HA# � '� F.c #'T' �.c •_ & ANY "A j Fl,i.,},nn x 1, 'q�-i. 5 '.� 3'X SS. r3'�SaY � s# ` . . :..F i.£ '� $ n >} ! wy x^ :58 'x` �bt ! ,5{' Fat r4. � �-'cya'4zt' ' z. E t' s •' '*` �a�i•=t 'f �-_ Sv$� �. '� rs ax� � ' �� v'�r �� }]�F { � r � r 3..,{ 15 k c x. 3' a � a f'�$ k j Y r �£�!'$ e a� �k•. '3 d pJ;� 0 We`N' d Com' San n t;c. y r'. �#�' •T Y k � r � i � ; � J Q_ �9 � , h��, � & { s..xd i'��� .�5 • � t3. � ¢ _ �ls� •ss -,. ° ev ' ' � qtr J•G� $ �# � � d f � g t,�s'�'�j � o ,�. �e. .,..,. . . �. , '. . {I� '� ' 4x=P 6 a ,a:;�'�i> s tit � � #� A �J�_•� �Aerr � a t�� .i=x,.��s4e3i —s•;.p �f'�� pF' t • � '� ` }[[�#J kk �i i"`�. { s+ Cn Cx v C�3 iEC y.i l T' ' 4R :i•p',}����.{� F �t t � ( °J r©T•��. # $3 '� �� \ � F N8-i t` Y'�_� Mn MUM } } a ,, r Q} r Yi'V14 1. E { F L ., v 3 > J £., x '� WfQ�} q 4 ' O�� of ORION : 11PAN Mum- 1 {�\t � r r 1 Q Q�wt 4kp` t AiN d 1\ 1 ImQ'Ogiie W JNprx� tit 5 3 E. Q ;'� \ cr. 0 t {: fi F z+fir, r t'01 S . .. *11Yj tit x � skit t < : vQQa. xg Hyp,varax>•'r.# .d #-3 a -' S k fid. < ., t k va . �.3; yEa"r• ,J1 s+ ���Fz3'i> � syss. - zwa.,> x a� dOx <' �r� - 3 -c7C* a x ? +`'- .�Ts" '�` "i .+� �15, yr y.� 3 4£ L '`v's.- 'v,.(4 Td \x. c � 1 c 1`a'a- •Lv} ( \'N .s t fir'r �`� ,crx 3st `�., ,� .� < �' 3« �.•S• r R.h'�,c1py::...�. a 3<+.*,2T"w y� � `L...� ,�>. *-u.zc. �'�-" .,��..•,TS.'g.,'.r; "t '` �'x,�a �. '.r �'`v:n {L�'h�'krt'?.� .�sT�S;.:.� CITY OF SALEM, MASSACHUSETTS LICENSING BOARD 120 Washington Street Salem, MA 01970 978-745-9595 ext. 421 Chairman,Harold F.Blake,Jr. Stanley J.Usovicz,Jr. James A Fleming Mayor ROUTING SLIP John H.Casey Clerk,Judy Davenport The Salem Licensing Board requires each applicant to have the appropriate Departments sign this Routing Slip and ret//urn it to the Licensing Board Office prior to the issuance of a license. BUSINESS NAME Corporate name: d/b/a: C / LOCATION: 1 �a a L/, Tele. T •PE OF LICENSE; Z'/ v6 I/- Lt APPLICANTS NAME: Residence Street: -S C Home tele. #� City: -5*le, State: /Yt?q Zip: TO ALL CITY DEPARTMENTS: your signature on this form is notifying the Licensing Board that all requirements of your department have been met, at which time icen g Board will issue a license. Salem Hisommission 120 Was hi gton Street Sign Review/Planning Dept. r 120 Washington Street S m Health Department 120 Washington Street CFire Prevention 2 - -29 Fort Ave. Building Inspector , /6- 3cr- , 120 Washington Street Department of Public Services y 1 N (Water Dept.) 120 Washington Street routing slip THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor BOARD OF HEALTH Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 NameQs y as J Da/te Typp of Operation(s) Type of Inspection F od Service W Ffoutine Address �y2� /rL Risk - [ Retail ❑ Re-inspection -f- Leve El Residential Kitchen Previous Inspection Telephone /L�`_ ,y ❑ Mobile Date: Owner // N n HACCP Y/N El Temporary L1Pre-operation l� eJUY ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint IIn: El HACCP Inspector �U6 'p- /G! Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands - ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIME/IEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements ❑ 17. Reheating El7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling EJ 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ElEl 10. Proper Adequate Handwashing 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below C N by a Board of Health member or its agent constitutes an °23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of t/ 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: PIC's Signature: 16/ - Print: Page_of,/-`Pages C/` - FORM 734A HOBBS&WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 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 Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and Applicants* 3-302.15 Washing Fruits and Vegetables *' 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 11311 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE9 Food Contact Surfaces 4". Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H, 3-202.44 Eggs and Milk Products,Pasteurized* p"P gg Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* ,Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10<. Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.]7 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* "`12Prevention of Contamination from Hands F-6` Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* E-13 Handwash Facilities Tags/Records: Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* "Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM r BOARD OF HEALTH Establishment Name: le Date: Page: of z Item Code C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY PL/// drJi P L �e .C� G ✓ d e � /Ta! Cir J/ ✓ C// Jam! i / J ✓ Cd rir/7 / i� E �. 6 �r iec� 4r�cli�iz c f qqx Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation*of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: 3-501.14(C:) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41°177457 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 Additivesa' 3-501.16(13) Cold PHFs Maintained at or below 590.004(F) 41'/45'F* 3-302.14 Protoetion frorn Unaiproved Addifiees* 15 Poisonous or Toxic Substances 3-501.16(A) Her * Maintained at oc above 14o°E F. 7-101.11 Identifying Information-Original 3-501.16(.A) I Roasts Held at or above 1.30'F. Containers), 7-102.11 Corrosion Name-Workur^Containers- 20 Time as a Public Health Control 7-201,11 Se ar Ilion-Storaee" 3-501.1.9 Time as a Public Health Control* 7-20111 Restriction-Presence and Use" 590.004(H) Au;ianceRccuucmenY 7-20'3.12 Conditions ofUsc`� 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Crite is-Chemicals* POPULATIONS(HSP) 7-204.1.2 Chemicals for Washing Produce,Ciiteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drym Anents.Crrteria* Beverages with Warning Labels* 3-801.11(B) Use of Pasteurized E-'s* 7-20511 Incidental Food Contact,Lube[cants* 7-206.11 Restricted Use Pesticides,Criteria" 3-801.11(D) Raw or Partially CeKvked Animal Food and Raw Seed S gouts Not Served 7-20012 - Rodent Bair Stations* 7-206.13 Tracking,Powders, Peat Control and 3-801.11(C) Unopened Food Package Not Re-served_ Monitcrrine* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consurner Advisory Posted for Consumption of l6 Proper Cooking Temperatures for Animal Foods 1-hat are Raw, Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eetis- 1 )5'F 15 Sec. Patio ins rr gni r-soar Fc s-Immediate Service 145"Fl.5wc* 3-302.13 Pasteurized Eggs Substitute for flaw Shelf 3-401.11(A)(2) Comminuted Fish, Meats 8c Game Ears" _ Animals-155'F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS _ 3-401.11(A)(2) Ratites, Injected Meats-155'F 15 590.0090)-T) Violations oaf Section 590.009(A)-(Q)in sea * catering, mobile food, temporary and 3-401.1l(A)(3) Poultry,Wilct Game.Staffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr or Retires-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle.Intact Beet Steaks interventions and risk factors. Other 145°F r590.009 violations relating to good retail 3-401.12 Raw Anonal Foods Crooked in a practices should be debited under#29- Microv.ave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs-745'F '15 see. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PI-IFs 165-F 15 sea. r. (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Tune* foodborne illness interventions and risk faclors listed above, car+be 3-403.1.1(C) Commercially Processed RTE Food- found in the following sections of the food Code and 105 CAIR 14WF' 590.000. 3-403.11(E) Remaining Unsliced Portions of13cef Item Good Retail Practices FC 590.000 Roasts" 23. _' Management and Personnel rC-2 .003 i 24. t Food and Food Protection j FC-3 .004 1g Proper Cooling of PRFs -- 25 Equipment and Utensils FC 4 005 3-501.14(A) Cowling Cooked PHFs from 1400E to 26. i Water,P(umbin and W aste FC 5 006 70'F Within 2 Hours and From 70`F 27, I Physical Facility FC-6 .007 to 41'F/45"F Within 4 Hours." 28 Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHs Made Pinto AnibieTemperature Ingredients to4l'Fl4o009 `F 30. Other Requirements __ - - Within 4 Hours* ti ohnrt.z ao� noes eriiical ten;in the tederal 1499 Food Code of 105 CNIR 590000. i' CITY OF SALEM, MASSACHUSETTS 4 BOARD OF HLAIJI-I 120 VASHINGTON SFREET,4"" Fu)OiR TEI. (978) 741-1800 IiIM13I=.RLF,A'DRISCOLL FAx (978) 745-0343 MAYOR lxamchn@salem.com LiVz1n'1umi)N,RS/Itu]iS,cl lO,cP-Ii5 Hral;rn Aap:Nr This Form will be collected during your next Board of Health inspection. QUESTIONAIRE - GREASE TRAPS 2009 1. NAME OF ESTABLISHMENT: LUS 42�, l j l -A Su��m*m -key 2. ADDRESS OF ESTABLISHMENT: 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS ' 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE GLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM?