MACK PARK LITTLE LEAGUE CONCESSION - ESTABLISHMENTS -�4 AGK PARK LITTLE
LEAGUE CONCESSION
MACK PARK
SEASONAL
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
c SALEM, MA 01970
TEL. 978-741-1800
�4'y�yg 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: FOOD SERVICE
Name of Establishment: Mack Park Little League Concession Stand
Address of Establishment: Mack Park
Owner's Name: City of Salem
Restrictions:
Application Date: 05/04/2004
Permit for Food Establishment 301-04
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2004
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
q L$
i
HEALTH AGENT
u CITY OF SALEM, MASSACHUSETTS
3. BOARD OF HEALTH
a 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2004 APPLICATION FORPERMIT��TO OPER-A{�T� A F�O�O� ESTABLISHMENT
// /GI-7
NAME OF ESTABLISHMENT ,n/� /'//6/a//Ye/ e
ADDRESS OF ESTABLISHMENT
MAILING ADDRESS (if different)
OWNER'S NAME TEL#
ADDRESS
TY STATE ZIP
CERTIFIED I OOD MANAGER'S NAME(S) ✓4RTIFICATE#(s)
(required in an establishment where potentially hazardousfood is prepared.) �j 7
EMERGENCY RESPONSE PERSOt� �7/ 61AI� HOME TEL# ! 10 O
HOURS OF OPERATION: Mon.fl--Tue.5'9 WedS `/ Thu.,5 9 Fri.f-7Sat./— `/ Sun/'-' 9
TYPE OF ESTABLISHME9T /20/ FEE check only
RETAIL STORE NO / less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
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 YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership.The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Cha ter 62C, Sec ' n 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge I ha all state tax returns and paid all state taxes required under the law.
Signature i D Social Security or Federal Identification Number
--- - -- ---- - ------ ---- ----------- { ------------_--- ---- ----------------------------------
Revised l l/ /03 FOODAP2.adm Check#&Da 30al 6
?I
1
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4'"Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name/ Dat Type of O eration s Type of Inspection
h o i L lJ Food Service [ Routine
Address v" Risk Retail El Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone ,3 ❑ Mobile Date:
Owner / HACCP YM El Caterer [j
ElPre-operation
❑ Suspect Illness
Person in Charg PIC) 1Time El Bed&Breakfast El General Complaint
In: ElHACCP
Inspector Out: Permit No. ❑ Other
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors 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 z
❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
" - "" - _ ❑ 13. Handwash Facilities
EMPLOYEE HEALTH-
PROTECTION FROM CHEMICALS `
❑ 2. Reporting of Diseases by Food Employee and PIC
❑
El 3. Personnel with Infections Restricted/Excluded 14.Approved Food or Color Additives
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE
E] 4. Food and Water from Approved Source ,TIME/TEMPERATURECONTROLS(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
PROTECTIONS FROM CONTAMINATION '" ' ' " " " ' ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection [120.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
E] 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices "CONSUMER ADVISORY -
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
o' C" "Nh. 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
FR28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
S'S901nspectFoim6 i<..
r
Inspector's Signature: ` Print:
//
PIC's Signature: Print: Page of 2 Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-con tamet a 6011
1 590.003(A) Assignment of Responubi,liry" 3-302.11(A)(1) Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Fads"
L2-103,11. Person in charge -duties Contamination from Raw Ingredients
3-30111(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other"
2 590.003(0) 'Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) Food Protection"
applicants* 3-302.15 Washine Fruits and Vea=etables
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 Utensiis'x
Charee* Contamination from the Consumer
590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Foci*
3- 590.003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and kestrietions Food
3-701.11 Discarding or Reconditioning unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 19 Food Contact Surfaces
590.004(A-B) Compliance with Food Law" 4-501-111 Manual Warewashing-[lot Water
3-201..1.2 Food in a Hermetically Sealed Container" Sanitization Temperatures*
3-201.1.3 Fluid Milk and Mills Products* 4-501-1.12 Mechanical Warewashing-Hot Water
3-202.13 Shelf SatdtizetionTem>erasures'
3-202.1.4 F3 s and Milk Product.,.Pasteurized` 4-501.114 Chemical Sanitization-temp.,pit,
concentration and hardness. "
3-202.16 Ice Made FrornPotable Drinkin Wat& 4-601.11(A) Equipment Food Conant Surfaces and
5-101-11 DrinkingWater 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 4-702.1 1 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food.Contact Surfaces ut E ui anent*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* to Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority 2-301.11 Clean ConditionHandsand Arms"`
3-202.111 Shetlstock Identification Present" 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash"`
3-201.17 Game Animals" 11 Good Hygienic Practices
g Receiving/Condition 2-401.11 Ettin g,Drinking or Using Tobacco*
3-202.11 PRFs Received at Proper ger Ten temmres'" 2-401.12 Discharges From the Egos.Nose and
3-202.15 Paeka e Inteerit * Mouth*
3-101.1.1 Foxed Safe and Unadulterated" 3-301.12 Preventing Contamination When Tastin="
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification" 590.001 Preventing Connuninadon from -
3-2.03.12 Shellstock Identification Maintained* Employees
Tags/Records: Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records,Creationand Retention" 5-203-11 Numbers and Ca asides*
590.004(7) Labeling of Ingredients' 5-204.11. Location and Placement"'
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
fHACCP Pians Supplied with Soap and Nand Drying
3-502.1 1 1 Specialized Processing Methods" Devices
3-502.12 Reduced oxygen packaging,criteria* 6-301_1.1 flandwishinaCleanser.Availability
3-103.12 Conformance with Aroved Procedures" 6-301.12 Hand Drying Provision
Denov,Unreal item in the federal 1999 hood Code or 125 CMR 590.000-
a
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: </ Page: of Z
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OrCORRECTION Date
No. Reference R—Red Item Verified -
/ PLEASE PRINT CLEARLY
a/
CAI
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Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
I have read this
the
to ask
and agree to
untary
ompliance 0 Employee
violations before the next V inspection,oto observe all conditions as described, and Correct all ❑ Rel nsp cttion Scheduled ❑ Emergency Restriction
Exclusion
comply with all mandates of the Mass/Federal Food Code. I understand that y
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. j
❑ Voluntary Disposal ❑ Other:
i
3-501.14((') PHFs Received at TeMperatures
Violations Related to Foodborne Illness Interventions and Risk According to Caw Cooled to
Factors(items 1-22) (Cont.) 41"F/451F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-501.16(B) Cold P1IFs Maintained at or below
3-202.12 Additives* 590.004(F) 41%45°F*
3-302.14 Protection from Unar roved Additives*
Poisonous or toxic Substances 3-501.16(A) Ilet PHFs',Mai ntained at or above
15
140'F.
7-101.11 Identifying information-Original 3-501.16(.0) Roasts Held at or above 130°I
containers),7-102.11 Common Name-1_k rkinCo Containers* 20 Time as a Public Health Control
7-201.11 Searation-Stora*e* 3-501-19 Time as a Public Health Control*
5%004(H) Variance Req uirentent
7-20211 R�stfrction-Presence and Use* -
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-1§ohibitions'` pOPULATiONS(HSP)
7-204.11 Sanitizers.Criteria-Chemicals*
7-204.12 Chemicals for Washing Produce,Criteria" 2a 3-801.11(A) Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels"
7-204.14 Drying Agents,Criteria* 3-501 I I(B) Use of Pasteurized Eggs*
7-205.11 incidental Food Contact, Lubricants* 3-801.11(D) Raw or Partially Cooked.Animal Fax)and
7-206.11 Restricted Use Pesticides.Criteria* Raw Seed Sprouts Not Served. *
7-206.12 Rodent Bait Stations" 3-801.11(C) Unopened Food Package Not Re-served.
7-206.13 - Tracking Powders,Pest Control and
Monitoring'° CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS22 3-603.11 Consumer Advisory Posted fa Consumption of
16 Proper Cooking Temperatures for
Animal Foods that are Raw. Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.1 lA('I)(2) Egg155 F 15 Sec.
Pathogens.* reecn�e a^our
F es-Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.11(A)(2) Comminuted Fish,Meats&Game Hes"
Animals- 155'F 15 sec. *
3-401.11(B)(i)(2) PrkandBefRosst- (30`F12( min* SPECIAL REQUIREMENTS
3-401.11(.0)(2) Ratites,Injected Meats-155'F 15 590.l)09(A)-(D) Violations of Section 590.009(A)-(D)in
sec.'" catering, mobile food,ternporary and
3-401.11(A)(3)� Poultry,Wild Game, Stuffed PHI's, residentialkitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. above if related to foodborne illness
3-401.11(C)(3) WInsle-muscle,Intact Beef Steaks interventions and risk factors. Other
145'F 590.009 violations relating to good retail
3401.12 Raw Anim:d Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3-401.11(A)(1)(b) . All Other PHFs- 145'F 15 sec.
17 Reheating for Hot Holding VlOL.ATIONS RELATED TO GOOD RETAIL.PRACTICES
3-403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30)
3-403.11(13) Microwave-165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the
Time` ,foodborne illness interventions and risk factors listed above, can be
3-403.11(C) Commercially Processed RTE Foot)- ,found in the folloeving sections of the Food Code and 105 CMR
14WF* 590.00(1
3-403.11(5) Remaining Unshced Portions of Reef Item Good Retail Practices FC b80.000
Roasts* 23. Mona ement and Personnel__-- FC-2 .003
1g Proper Cooling of PHFs 24. Food and Food Protecticin _ FC_3 .004
25 __ _Equipment and Utensils _ FC 4 . .005
3-501.14(A) Cooling Cooked PHFs from.140`Ft'o 26 _ _Water, Plumbin and Waste FC 5 .006
.F
70"F Within 2 Hours and From 70" 27. Physical Facility FC-6 -007 _
to 41'F/45'F Within 4 Hours. * 29. Poisonous or Toxic Materials FC-7 .008
3-501.14(B) Cooling PRFs Made From Ambient 29. -Special R uirements _ - .009
Temperature ingredients to 41°'F/45'F 30 Other
Within illnus* ar ,r rnz.a.,c
Denotes Critical item in tha federal 1i79 Food Code or 105 CMR 590.000.
s
1.
a CITY OF SALEM, MASSACHUSETTS
3ya BOARD OF HEALTH
• 6 120 WASHINGTON STREET, 4TH FLOOR
�a. R SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
� I
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 : Salem Little League Inc .
Name of Establishment : Salem Little League Concession Stand
Address of Establishment : Mack Park Field
Type of Establishment : FOOD SERVICE
Application Date : 05/17/2002
Restrictions:
Permit for Food Establishment 299-02
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2002
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
D
14x
Ot
o CITY OF SALEM,,MASSACHUSETTS
3" '� BOARD OF HEALTHi -
3 ♦ 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
'r9q '"••' TEL. 578-i4i-i803
4,� FAX 978-745-0343
STANLEY L_,UVICZ, Jn' JOANNE SCOTT, MPH, ZS, CHO
MAYOR HEALTH AGENT
2002 APPLICATION FOR PERMIT &TOS OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT S'4" L�t ^7✓4- C4n9els)+ 57r"EL# 'fYy- 2 678
ADDRESS OF ESTABLISHMENT M4 C K �ct►-K/ F1*- t t
MAILING ADDRESS (if ddiifferent) ��/�S� (c Z_3 �,�µr 4/T7D
OWNER'S NAME �� 6(451' L¢�Jvt TEL#
ADDRESS ?' O �61/ (¢ l 3
CITY 5a IIeA� STATE "+- ZIP-17.4 8
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.) iWr
EMERGENCY RESPONSE PERSON ya^ �e✓rw.� HOME TEL#
DAYS/HOURS OF OPERATION: Mon. --Tue. ✓Wed: v Thu. Fri. v Sat. 1Sum
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO q �0 $40
RESTAURANT YES NO $40
BED& BREAKFAST YES NO $40
ADDITIONAL PERMITS
MAKE ICE CREAM. YOGURT
SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO 10
NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF TAX
EXEMPTFORM
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 Sapitary 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 ,:to my .
best knowledge and belief, have have filed all state tax returns and paid all state taxes required under the law.
_ _ /)/ ScL s-14- 4 - o19936
Signature Date Social Security or Federal Identification number
--------------------------------------------------------------------------------------------------------------
Revised 11/1/01 foodap2.adm Check#&'Date
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j • �
-THE COMMONWEALTH OF MASSACHUSETTS
CITY OF SALEM Address: 120 Washington Street, 4th Floor
BOARD OF HEALTH Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT , Tel: (978) 741-1800 Fax: (978) 745-0343
Name Date _ T f r i n T f In i
Food Service Routine
Address j4 mL
Risk L1 Retail ElRe-inspection
G• Level ❑ Residential Kitchen Previous Inspection
Telephone G�(� r./� _ / �7T ❑ Mobile Date:
Owner /,/� A( // / /G('O/0 �,/ / HACCP Y/N Temporary ❑ Pre-operation
l °"7/� C� T'��(G- Z�.H u� KCaterer ❑ Suspect Illness
Person In Charge(PIC) Time ❑ Bed 8 Breakfast ❑ General Complaint
In: ❑ HACCP
Inspector Out: Permit No. ❑ Other
Each vio atlon checked requires an explanation on the narrative page(s) and a citation of specific provision(s)
violated. Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health. Local Law ❑
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/ Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH
El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS
El3. Personnel with Infections Restricted/ Excluded L1 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE
El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
El 16. Cooking Temperatures
El 5. Receiving/Condition
El6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating
El7. Conformance with Approved Procedures/HACCP Plans El 18. Cooling
PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding
El8. Separation/Segregation/ Protection El 20. Time as a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
El 10. Proper Adequate Handwashing El 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. 1590.000/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)i 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
A 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� r,/1 Print: y� C
PIC'sSignature: - / Print Page�ofPages
FORM 734A HOBBS&WARREN -BOSTON
t
Violations Related to Foodborne Illness s
Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from
1'; 590.003(A) 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 3-302.15 Washing Fruits and Vegetables
Applicants*
3.304.11 Food Contact with Equipment and
590.003(F) Responsibility of a Food Employee or an Utensils*
Applicant to Report to the Person in Contamination from the Consumer
Charge*
3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated
°3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
Food*
FOOD FROM APPROVED SOURCE 9 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,
3-202.14 Eggs and Milk Products,Pasteurized* Hardness* P
gg Concentration and
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*
30 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* ''`il Good Hygienic Practices
3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco*
5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and
3-202.11 PHFs Received at Proper Temperatures* Mouth*
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting-
3-101.11 Food Safe and Unadulterated* 12 Prevention of Contamination from Hands
6 Tags/Records:Shellstock 590.004(E) Preventing Contamination from
3-202.18 Shellstock Identification* Employees*
3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities
Tags/Records: Fish Products Conveniently Located and Accessible
3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities*
3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement*
590.004(1) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance
Conformance with Approved Procedures Supplied with Soap and Hand Drying
/HACCP Plans Devices
3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability
3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision
8-103.12 Conformance with Approved Procedures
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: !t 1 `f�(�- ��/7� Date: `> ��Z Page: of 4�_' _
f Item Code C-Critical item a; DESCRIPTION OF VIOLATION / PLAN OF CORRECTION
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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 comply
Exclusion
with all mandates of the Mass/Federal Food Code. I understand that noncompliance may ❑ Re-inspection Scheduled LJ Emergency Suspension
result in daily fines of twenty-five dollars or suspension/revocation of your food permit. ❑ Embargo ❑ Emergency Closure
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❑ Voluntary Disposal ❑ Other '
FORM 734B HOBBS &WARREN - BOSTON
i
Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures
Factors(Red Items 1-22) (Cont.) According to Law Cooled to41*F/45*F Within 4 Hours.*
PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs
x,14 Food or Color Additives LPPHF Hot and Cold Holding
3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below
3-202.14 Protection from Unapproved Additives* 590.004(F) 41*F/45°F*
15 ' Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 140°F.*
Containers* 3-501.16(A) Roasts Held at or above 130°E*
7-102.11 Common Name-Working Containers* "20 Time as a Public Health Control
7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP)
7-204.11 Sanitizers,Criteria-Chemicals* ,21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.12 Chemicals for WashingProduce,Criteria* Beverages with Warning Labels*
7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.*
7-206.12 Rodent Bait Stations* 3-$01.11(C) Unopened Food Package Not Re-served.*
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
22 3-603.11 Consumer Advisory Posted for Consumption of
TIMEITEMPER_ATURE CONTROLS Animal Foods that are Raw,Undercooked or
16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate
PHFs Pathogens.* Enec'm 11"2001
3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs*
Eggs-Immediate Service 145°F 15 Sec.*
3-401.1 HA)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS
Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
3-401.1l(B)(1)(2) Pork and Beef Roast- 130°F 121 Min.* catering, mobile food,temporary and
3-401.11(A)(2) Ratites,Injected Meats-155°F 15 Sec.* residential kitchen operations should be
3-401.1l(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections
Stuffing Containing Fish,Meat, above if related to foodborne illness
Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors. Other
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail
145°F* practices should be debited under#29-
3-401.12 Raw Animal Foods Cooked in a Special Requirements.
Microwave 165°F*
3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
17 Reheating for Hot Holding (Blue Items 23-30)
3-403.1l(A)&(D) PHFs 165*F 15 Sec.* Critical and non-critical violations, which do not relate to the
3-403.1 l(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be
Time* - found in the following sections of the Food Code and 105 CMR
3-403.11(C) Commercially Processed RTE Food- 590.00.
140°F* Item Good Retail Practices FC 590.00
3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003
Roasts* 24. Food and Food Protection FC-3 .004
18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005
3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006
70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007
to 41°F/45°F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature Ingredients to 41°F/45*F 30. Other
Within 4 Hours*
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.