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MARIAS PLACE - ESTABLISHMENTS� Mdf�N�S Pluce Eo hfF t �lfon �f/ �NIVERSAL� UNV-12110 . MADE IN USA SUSTAINABIE Mg�p�y� FORESiIN �� irnnnT vr CertifieCRbvSourelnp �T'�� ' www�fipmprem.ory � muCA I � _— — _ . ...._ _ I Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Maria's Place File Number.BHF-2004-000068 10 Jefferson Avenue Salem MA 01970 LOCATEDAT: 0010 JEFFERSON AVENUE 201 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions Notes FOOD SERVICE BHP-2011-0253 Jan 1,2011 Dee 31,2011 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMITEXPIRES IDecember3l, 2011 YA Board of Health ILY 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 I CITY OF SALEM, MASSACHUSEITS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KENIBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUNIna SAI.EN1.CONI DAVID GRFENBAum,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT MNVW �S 'kkr, TEL# q1t ADDPF-S�� OFESTIABUSHMENT 10 FAX MAILING ADDRESS(if different) 0(1110 EMAIL- Business': Website: OWNERS NAME TEL# ADDRESS T(P)Ct\\� M A-- STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S)MKJ0QH -�ak-TCERTIFICATE#(S) 149bosa (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON MKR�av� 2F- aiyHOMETEL# &I—G&Z D 1-�Wednesday.�,�'J' Sunday 1,DAYS'OF PERATION Mon*'; , i'� Tuesday HOURS OF OPERATION (9!0C>PfM--�I (01 00 -CO 00 0"V1 Please wdte in time of day. (e'O 01"; (For example 11am-11 3100M ! 31�'o"TM 3�1'00po I $,,-0O9rv\ 's WIN) i 2,00M _pm) 1 i TYPE OF ESTABLISHMENT FEE (check onIvI RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 -----146--------------------------------------------ie-s's"t'h"a"n...2,5...s'e-a'is'------------------------- (Outdoor Stationary Food Cart$2, 25-99 seats 1,�-12860 more'than g9 sea'ts zu --------------------�j�§------�1[6----------------------------------------------*------------------------------------$,1-60------- CKLOCARE SERVICES/NURSING HOME k6bi;f(6iiADyffkMffi�-------------------- MAKE (notjustserve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES 0 $135 ALL NON-PROFIT(such as church kitchens) YES $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter62C,Section 49A,I certify underthe pains and penalties of pedury that 1,to my best knowledge and belief,have filed all state tax aid all state taxes req�lrso under the law. 013 S,�P- -3j—il!!� O Signature Date Social Security or Federal Identification Number Revised ionli I FOODAP201 Ladm Chmkit DatZ�tj $ 1 � No. DATE, TO: A"OUNT RF"ITTEEII IYIA I.W_ t/ -7 1))9 W7 15-A-F Ahr "Al, WITtl',IUR AFDATTANCE. .-IUR CANCELL�D CHECK 15 I�Ufl RECE-V PREVIOUS BALANCE*$' Adethori in A a -a- fg*t is general craw"% msitt 4-�-z iUZ U5' �,,P- f f A,'!L N NC2583 C5 No . -JIA14CUNT RE[Al-TEO 7 9!V COS, /lAo - i j�k)A),�q 7' jo czrr)p�tt4p- P R ly B A L..TI C.E "Od is hrw��J spir lar4et is g�-nera i :fawlin j in M L�- C5 E XTE R BANN,ATColl?3 ? 78, ,?F�5 , " ,P cgT 41 TO: mlop-)-t) ",<-� AggSEMITTEDI /b �Tcrr�lj f-w- 5,9�ejv, **44 7W- /dp/7 DETACH AND MAIL WIT11 Y008 REMITTANCE.YOUP CANCELLE0 CHECK IS VOUR RECEIPT. CREDITS�JIBALANCE PREVIOUS BALANCE :�L5 Moffvod Is Nip"son*.ce- is STATEMENT Thank You Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED, 01/04/2010 ESTABLISHMENT NAME: Maria's Place File Number:BHF-2004-000068 10 Jefferson Avenue Salem MA 01970 LOCATEDAT: 0010 JEFFERSON AVENUE 201 SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions Notes FOOD SERVICE BHP-2010-0068 Jan 4,2010 Dec 31,2010 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMITEXPIRES IDecember3l, 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 1 CITY OF SALEM, MASSACHUSEITS BOARD OF HEALTH 120 WASHINGTON STREET,4n4 FLOOR TEL. (978) 741-1800 KMERLF-Y DRISCOLL FAx(978) 745-0343 MAYOR DG'REEN13AUM(0).SALFM.COM DA-%TID GREENBAUM, AcTiNG HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT--N- A-�R '-S P6,9- 1-/� TEL# ADDRESS OF ESTABLISHMENT FAX# MAILING ADDRESS(if different) /0 )e�.50 117 )911^� EMAIL-Business': Website: OWNER'S NAME TEL# 1'20' (fl�7 e: ADDRESS x, A STREET J-U CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) PWVC-1-tA) 7-,t&7 74-� CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON 0 2,Z'-7,� HOME TEL# 11020' de�� 9-3 -0 R 0 y n a *W6clhE is HOURS OF OPERATION I Please write in the of day, (Forexamplellam-11pirn) 1 6 - �5 1 tl,'. -3 6/-- 3 6-- 3 11 '2- -2-- TYPE OF ESTABLISHMENT FEE (check onIv) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 --------------------------�ff§------�id---------------------------------------------I e-s-a'ih-a-n...2,5...s'e-a,is,--------------4-1-4-0,---- (Outdoor Stationary Food Cart$210) 25-99 seats more than 99 seats =$420 ---------------------�ff§------f4d--------*--------------------------------------------------------------------------$-1-0-0------- CHILDC.A-RE-S-ERVIC�E-S�/.N.URSING.-HO.ME............................................................................................................................... ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURTISOFT SERVE YES NO $25 TOBACCO VENDOR YES 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 underthe pains and penalties of pedury that 1,to my best knowledge and belief,have filed all state tax at d paid all state taxes requi.red order the law. o/ -3 3, Si'gnature - Date Social Security or Federal Identification Number Revised 4/24/07 FOODAP2008.adm Chmk#&Date 12 - V $ -��eeq �k /3,)0 ( IMPORTANT MESSAGE FOR �Th n ja0A.M DATE TIME i P.M. m CornDl �� OF PHOrIJF- AREA CODE NUMBER EXTENSION 0 FAX Ll MOFU I F AR,.... NUMBER TIME TO CALL TELEPHONEO PLEASE CA L &i�E TO SEE YOU WILL CALLIAIGAIN [W�A�NTS TO SEE YOU RUSH TC TU RETURNEO YOUR CALL 1, j\MU-FAXTOYOU VESSAGE"i"r\ dl-�51DOSina el r (j S SIGNED FORM 4009 MADE IN U S A NOTES 71(7�67 Ale 111146h�4�_;Wa -.-mum 4- Commonwealth of Massachusetts City of Salem Board of Health lQrnbedey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo&Retail Establishment Permit DATE PRINTED: 01/08/2008 ESTABLISHMENT NAME: Maria's Place File Number.BHF-2004-000068 10 Jefferson Avenue Salem MA 01970 LOCATEDAT: 0010 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0309 Jan 7,2008 Dee 31,2008 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMITEXPIRES Decernber31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 9 of 12 QTY0F SALEM, MASSAOiUSEM BOARD OF HEALTH E 120 WASHINGTON STREET,4�FLOOR TEL. (978)741-1800 U) 5 0 a: �_ KINMERLEY DRISGOLL FAX(978) 745-0343 ;E� MAYOR iscoTfi@sALEM.00M W�� Cd cf) JOANNE SCOTT, HEALTHAGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT # NAME OF ESTABLISHMENT TEL 9 :7 qL/ - ADDRESS OF ESTABLISH M ENT lIn T� FAX# MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAME FIWKi�J PNBM)fW-5 Wc� TEL ADDRESS rn k-Tf RQ D'V� mi"�_ STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) M-t:K)N 7-a CERTIFICATE#(S) 33/ Itl 7(o (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON M KEM(TUN 70K) HOME TEL#(�]f) 86!7_6363 DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS OF OPERATION Please write in time of day C;00w— �:00 PCM G�()oKM 6,'00A-M T'ooA1W (For example 11 ann-1 1 pm) sioofm -3�oofm -�Iodllvl 3!9,0 em 3;0--f M 3�chopm a"oorm TYPE OF ESTABLISHMENT YES FEE (check oniv) RETAIL STORE CN 0 less than 1 000sq.ft. =$70 1000-1 0,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 ---------- ------------------------------------------------------------------------------- (YES less than 25 seats �J�4Q (Outdoor Stationary Food Cart$21(�� 122�5_ VZZ3 =$28 more than 99 seats =$420 --------------------VIES---------- --------------------------------------------------------------------------- 1 0 0 CHILDCARE SERVICES tv----------------------------------------------- --------------------------------------- ---------------- MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES 0 $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 tax returns and paid all state taxes r4uired under the law Ik �10 /-Av� ' '__ 0 D Signature Social Security or Federal Identification Number ------------------------------------------------------------------ ---—--------—--- Revised 4/24/07 FOODAP2008.adiii Check#& Date ziv 0010 Jefferson Avenue Maria's Place City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: El Item Status Violation Critical Urgency Telephone: I PROTECTION FROM CONTAMINATION 744-7817 Food Contact Surfaces Cleaning and Sanitizing PASS Critical RED Owner: Comments:The is only one bucket of sanitizer in the main kitchen. Sanitizer to be readily available at all work stations with proper Hasan Zepaj concentration. PIC: Marenglen Zepaj Handwash Facilities PASS Critical RED Inspector: Comments: Back hand wash sink has a temperature of 158*F. Sink to be reading between 11 0'-130*F. John Gehan Date Inspected:Correct By: Same sink has no paper towels. Provide towels. 6/1812007 Restrooms have paper towels on back of toilet. PT to placed in dispenser. Risk Level: Front hand wash arae requires general maintenance. Permit Number: BHP-2007-0351 Status: SIGNED OFF #of Critical Violations: 0 Time IN: Time OUT. Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS&2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 19,2007 Page I of 3 Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection PASS Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comments: Gold n Chef Refrigerator holding at 600F. Unit to be maintained at 41*F or below as mandated. immediate corrective action) Back Kenmore freezer has uncovered foods. All foods must be covered. Back off white freezer has uncovered foods. All foods must be covered. There are personal items stored on food products. Personal items to be stored in designated area. Equipment and Utensils PASS BLUE Comments: Back coke refrigerator requires general cleaning. Fast food refrigerator missing visible thermometer. Provide visible and accurate thernometer. Same unit requires general cleaning. Can opener requires general cleaning. Microwave requires thorough cleaning. Meat slicer requires general cleaning. White kenmore elite freezer has no visible thermometer. Provide visible and accurate thermometer. Back white kenmore freezer has no visible thermometer. Provide visible and accurate thermometer. Marketeer unit in back has no visible thermometer. Provide visible and accurate thermometer. Back Pepsi unit requires general cleaning. Floor beneath units in back require general cleaning. Floor beneath dressings requires general cleaning. All shelves in front require general cleaning. Salad/sandwich unit requires general cleaning. Green World unit requires general cleaning. Gold n Chef unit requires general cleaning. Pepsi refrigerator at wait station missing visible thermometer. Provide visible and accurate thermometer. Physical Facility PASS BLUE Comments: Grease barrels are directly on the ground. Battris must be stored elevated. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA01970(978)741-1800 GeoTMS@ 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 19,2007 Page 2 of 3 Item Status Violation Critical Urgency Trash barrells are uncovered. Barrels to be covered to prevent rodents. Womens restroom has a missing grate in the ceiling. Replace grate. There are water stained ceiling tiles. Find source of leak and repair. Replace tiles. GENERAL COMMENTS: All violations from June 6, 2007 have been 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. Jun 19,2007 Page 3 of 3 0010 Jefferson Avenue Maria's Place City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-7817 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: Comment:The is only one bucket of sanitizer in the main kitchen. Sanitizer to be readily available at all work stations with proper Hasan Zepaj concentration. PIC: Maurenglen Zepahj Handwash Facilities FAIL Critical Lvl RED Inspector: Comment: Back hand wash sink has a temperature of 1580F. Sink to be reading between 110*-130'F. John Gehan Same sink has no paper towels.Provide towels. Date Inspected:Correct By: 6111/2007 Restrooms have paper towels on back of toilet. PT to placed in dispenser. Risk Level: Front hand wash arae requires general maintenance. Permit Number: BHP-2007-0351 Status: Open #of Critical Violations: 3 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 19,2007 Page I of 3 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: Gold n Chef Refrigerator holding at 600F. Unit to be maintained at 41*F or below as mandated. immediate corrective action) Back Kenmore freezer has uncovered foods. All foods must be covered. Back off white freezer has uncovered foods. All foods must be covered. There are personal items stored on food products. Personal items to be stored in designated area. Equipment and Utensils FAIL BLUE Comment: Back coke refrigerator requires general cleaning. Fast food refrigerator missing visible thermometer. Provide visible and accurate themometer. Same unit requires general cleaning. Can opener requires general cleaning. Microwave requires thorough cleaning. Meat slicer requires general cleaning. White kenmore elite freezer has no visible thermometer. Provide visible and accurate thermometer. Back white kenmore freezer has no visible thermometer.Provide visible and accurate thermometer. Marketeer unit in back has no visible thermometer. Provide visible and accurate thermometer. Back Pepsi unit requires general cleaning. Floor beneath units in back require general cleaning. Floor beneath dressings requires general cleaning. All shelves in front require general cleaning. Saladisandwich unit requires general cleaning. Green World unit requires general cleaning. Gold n Chef unit requires general cleaning. Pepsi refrigerator at wait station missing visible thermometer. Provide visible and accurate thermometer. Physical Facility FAIL BLUE Comment: Grease barrels are directly on the ground. Battris must be stored elevated. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 19,2007 Page 2 of 3 Item Status Violation Critical Urgency Trash barrells are uncovered. Barrels to be covered to prevent rodents. Womens restroom has a missing grate in the ceiling. Replace grate. There are water stained ceiling tiles. Find source of leak and repair. Replace tiles. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 19,2007 Page 3 of 3 COURT DOCKET NO. CITATION NO. CITY OF SALEM a VIOLATION NOTICE PD 6012 NAME(LAST,FIRST,INITIAL) 727-! 2/1 �- v, STREETAIDDRESS ciTyrroWN STATE ZIP CA)� LICENSE NO LIC EXP DATE DATE OF BIRTH IOWNER'S NAME(LAST,FIRST,INITIAL - i IZ-5ej/? STREET ADDIFtESS pVY/TOWN STATE ZIP 6 &-/, 6��0� j-d 0;q/a� REGISTRATION NO/ I STATE � EXP DATE I MAKE�`TYPE I YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRI [I AM El Pm LOCATION OF VIOLATION j 4, i� E!!FORCING DEPT A OFFENSE 11AP SECT FINESI A 4:��d 'Z�, i-; OFFICER I D NO, TOTAL $ FINE I DUE I OFFICER CERTIFIES COPY GIVEN TO VIOLATOR .ElnHAND x MAIL DONOTMAILCAS -PAY ONLY BY POSTAL NOTE,TAONEY ORDER OR BY CHECK MADE PAYABLE TO CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL 0 MIR-W-� MEMO . .. ........ ac oFSALEW�---` 4N 61j =11-111111`110N WaMnCEI NAME(LAST.FIRST,INITIAL) um) c? - Z STZ AD RESS CITYJTOWN STATE ZAP 'e 0 91 i P'i 4 LICENS XP.DATE I DATEOFBIRTH *OWN - ER' '7Z y") A Pq 1 .1 S�x ss� PTYfFOWN STATE oz/,qp REGISTRATION N(V I STATE EXP.DATE MAKfAYPE YEAR ICOLORI w I I I S. DATE OF VIOLATION I TIME 0 AM DATE CITATION WRITTEN E�L ONO --oYES Lo 1p )CATION OFVIOLATIO[I WFORCING 0 E� 6y� 1 0 L( : ' OFTIE�U SECT FINES A '�2_ I Yr 6�6' I CHAP.L 0 0 B 2�96 Co OFFICER I.D.NO. TOTAL Er FINE DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR Z� 6 HAND x MAIL By ��NOT�MA L'OAS?e PAY ADNL/Y BY Pnq C-- TAL NOTE,MONEY UJI ORDER OR BY CHECK MADE PAYABLE TO Z (.) 4�"'44 CITY CLERK m CITY HALL -6 93 WASHINGTON STREET _j � D (Lzm SALEM,MA 01970 .0 TEL.(508)745-9595 X 251 m w< 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE ul PAYMENT IN THE AMOUNT OF U., $ CASE Z2-< < cf) SIGNATURE Q SEE OTHER SIDE FOR FURTHER INFORMATION LLI ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL 0 <Om 0 mi-o Inspection of Date J—a� Time 9,100 4-0A Nam- Address Owner Tel. No. Type of Inspection 4-zkW 6r7i 0 lat r2 It' Inspector 6-yrnpaid,2 Remarks and Violations are listed below; qA �)A fA r i A,C UFOYN I Ivi Q /7 e-&�, Td i nS t&)a-q ev" v,&,�7(s-,, LAA C�—eA 4(-n-rA-r 1)V1 dtC Report Received by: Inspection of Date Time 9'00 t Nam- RA t4 v c-P Address Owner Tel. No. Type of Inspection 1;;14( 61"P 0 /(;//1 1 Inspector 'T4WWj 4z�A41—j 1)� (-7, Remarks and Violations are listed below: -RA 41 v e,r o u c, /Y vy v/ c� 1 14 1 V u UJOY, I V1 Q 6-� 4-kL �J(d //Owl fj� LAJ a V ., l, rl, V, k Report Received by: Inspection of Date Time '0') Nam- Address Owner Tel. No. Type of Inspection j;;9W 6t?I q /fi/ Inspector 1 tl� Remarks and Violations are listed below: ir ti v �4' c� iA I, V I kk�- V'lt'i LJ _)0 10C 911 1_1AA -�d I*W /I I V A/I Report Received by: " N"i '41110 is V- "M "N Om 7 NO,,, C kv;eal`i�of ommoll 0 Board of Health lQrriberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2007 ESTABLISHMENT NAME: Maria's Place File Number BHF-2004-000068 10 Jefferson Avenue Salem MA 01970 LOCATEDAT: 0010 JEFFERSON AVENUE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions Notes FOOD SERVICE BHP-2007-0351 Jan 5,2007 Dee 31,2007 $150.00 ESTABLISHMENT Total Fees: $150.00 PERMITEXPIRES Decembell- 31, 2007 A Board of Health *,,t4Lt;f� This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 2 of 2 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4TH FLOOR SALEM, MA 0 1970 TEL� 978-741-1800 FAx 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Zf-7 / /329-,S/�-O T��O,TEL# 7 /-/,�/ ADDRESS OF ESTABLISHMENT /0 S 9,q Ale-- FAX # MAILING ADDRESS(if different) EMAIL--Business': Owner's. OWNER'S NAME /1415 a e-y:) TEL# tY ?dF J'32 Cde� ADDRESS STREET I CITY STATE ZIP CERTIFIED FOOD MAINAGER'S NAME(S) 21e�7AJCERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON Al fi- 12- J 0 HOME TEL# 7 ?1�r3 2 DAYS Of OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday HOURS Of OPERATION Pleasewriteintimeolday. (for example llam-110m) TYPE OF ESTABLISHMENT FEE (check oniv) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft, =S100 more than 10,000sq,ft. =$250 -- - - ---- - - - - - - - le ss tha n 2 5 s e a t s $1 00 25-99 seats =$150 L,� more than 99 seats =$200 176iBRE A K-6�sf........YES— N�O- -- ---- ..... Sim-------- ------ ------- ---- - -- --- --- --------------- ----- ----- ---- ---- -- .. ...... ..... ..... ..... ........... ....—---- ......... .... .. ....... ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT. SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I cerlify under the pains and penalties of perjury that 1, to rny best knowledge and belief, have filed all stale tax returns and pa 11 state laxes required under the :aw. Signature D are7 Social Security or Federal Identification Number ---- -------I------------------- ----- ----- -------- ------- ------------------------- ------------- - & Date 4 S r Revised 11113106 FOODAP2007adm Checktl Inspection of 11461 Fz� Ce Date Time 9:oo A4A Nam- If 6 471) 610- A/?1J Address' A,4e, Owner Ma r-o'n ?A� Tel. No. 7tft-i — Pi-I 7 Ll"I Inspector Fd U/U A7-e A.? n Type of Inspection Ir- Remarks and Violations are listed below: /V�- e-Apa';7��wl-r 1--e A WIS-If 26 o-7 ro o �2e e-rn 9.17t he�� - boas lo Id 114 a—�- /,7, k k 4c4,-i P 7c lo.-Ize j- 4-,P� /T d, J- -P 21 A//7 W' 0,M �,_j fp,-�-r 1-,(6� 11f P C7( k/ /t e 44 105L Report Received by: Inspection of C'e Date Time 9:00 '4-t4A Nam- J C. �47� (--? /I/7,j Address ' /'O <,,�.l Al-e Owner to�4 r--e,7 Tel. No. 7 Inspector Fd IhU 47-e ke?in Type of Inspection JI-L4 U J)/< A j Remarks and Violations are listed below: f /v(<, -2oo-7 /b le'( 1'14 /1-) 61f eli(r (7/7/��7 - 7 /Pill IZ41 1--2 /�W/ 1' /,//7( V—), /U —1174�5 66V7 - /11 d1P Az/ ev A�,a 11711 r /d ro t9�1 (4 11 1Crzt,(-- t Report Received by: ��iss:amencats) elette(w-/ch_eese)� .1.95 'ich ".2.95 (add 50i for Cheese) ri dd 759 00 per item: to c Ii (ham,,bacon,sausap.veggies&cheise) ALL EGG&OMELETTE ORDERS-SERVED WITH TOAST AND HOME F I �--ADD 259 FOR ENGLISH MUFFIN. SWISS CHEESE,'CHEDD7AR& FETA 6 j '4m" 4 '"44a.44 XQw Ha acon or Sausage :..2.55 Cold Cereal ............. ... ....... . . - , :,:, � _ -A 00TA, Canadian Bacon .1.1.75 All Bagels :......:'_W%T . . ......... B Corti Beef Hash .. -.--.3.15 ajelsvvithCreaniCheese. .50 Home Fries .......... lJS"' i A. ?j . .... ................ . 5 Hot Oatmeil .1...* 1;25'� - ............ Eng1ish/Raisiri/Rye/Bu1kie'-. .... ........ 5 S �Hot Oatmeal Bowl, 1.75 Toa ite-or Wheat 5 ............. 7 s A N �"F .1-PLENMOR W 4,_w�Vwo k qr" N '�4,, V 4 4, t o T" 0 4 0 96,�r, 19 AF sk!e -r v,ris �,eim- -"A .00"h � a.m. t6,73:00,e�P.' , y-Saturdd�Z6:0Cr, 4 1 a rh;', t6 -2: n ay :00 A FAA I '9 a f 0 _4 L 0010 Jefferson Avenue Maria's Place City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: Ll Item Status Violation Critical Urgency Telephone: I PROTECTION FROM CONTAMINATION 744-7817 Handwash Facilities PASS Critical RED Owner: Comments: Front vhandwash sink has cloth towel in it. Sink to be used for hand washing only. Hasan Zepaj Same sink has no soap hung up or paper towels hung up. Provide soap and paper towels. PIC: Marenglen Zepaj Inspector: John Gehan Date inspected:Correct By: 11/22/2006 Risk Level: Permit Number: BHP-2006-0144 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 GeoTMS0 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 Page I of 3 Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection PASS Critical BLUE Foodborne Illness Interventions and Risk Factors (Require Comments: Personal items being stored on shelves where food products are stored. Personal items to be stored in proper immediate corrective action) designated areas. Knives found with accumulation of food debris. Knives to be thoroughly cleaned and sanitized after each use. There are labeled containers that were unmarked. Any food outside of its original container must be tabled. Labled at time of inspection. Back room requires light shields or cover. Provide protection. Ice scoop stored incorrectly in front. Scoop to be stored in designated tabled container or with handle exposed. Various foods on front line uncovered. Foods to be covered at all times. Sanitizer reading too weak in back prep area. Adjusted at inspection to proper concentration. Sanitizer reading to strong in front line. Adjusted at time of inspection to proper concentration. Equipment and Utensils PASS BLUE Comments:3-Bay container requites relableing. General cleaning of coke refrigerator required. Fast food refrigerator requires general cleaning. Knife rack requires general cleaning. Microwave requires general cleaning. Meat slicer requires general cleaning. Ice machine requires general cleaning. Kenmore freezer requires general cleaning. White freezer in back room requires general cleaning. Back left refrigerator has broken thermometer. Replaced at inspection. Sanitizing log being kept in advance. Log to be maintained daily. Physical Facility PASS BLUE Comments: Back food prep area ceiling tiles are water damaged or physically damaged in various areas. Repair or replace tiles. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 Page 2 of 3 Item Status Violation Critical Urgency GENERAL COMMENTS: All violations from 11/2212006 have been corrected un less noted. Sanitizer to be monitored daily by cfm. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 Page 3 of 3 0010 Jefferson Avenue Maria's Place City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: F-1 Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-7817 Food and Food Protection PASS BLUE Owner: Hasan Zepai Equipment and Utensils FAIL BLUE PIC: Comments: light cover over salad area missing cover. Provide cover. Marenglen Zepal Inspector: Physical Facility FAIL BLUE John Gehan I Date Correct By: Comments: Back room screen door has ripped and torn screen. Repair screen to prevent entrance of rodent and or insects. lanyrJog: Same door requires door sweep.Visible air gap. Seat gap. Risk Level: Back room has exposed insulation on ceiling. Floors walls and ceilings in food prep or storage areas have to be made impervious and easily cleanable. Permit Number: BHP-2006-0144 Electrical box behind dish wash machine in disrepair. Secure box. Status: Hole in ceiling tile above back food prep area. Repair or replace tile. PARTIAL COMPLY Behind juice glasses in front area has exposed wires. Repair wires. #of Critical Violations: 0 Ceiling tile above juice glass area in disrepair. Repair or replace tile. Time IN: Time OUT: Water stained ceiling tiles observed throughout establishment. Find source of leak and repair. Replace tiles. Urgency Description(s): Broken Ight cover over front food prep area. Repair cover or replace. BLUE: Violations Related to Good Note:Owner states new materials have been ordered to correct the facilities physical appearance. Work to start within a couple of Retail Practices (Critical weeks. Owner to contact the Board of Health when work is completed. violations must be corrected GENERAL COMMENTS: immediately or within 10 825: 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 19,2006 ) Page I of 2 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 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 19,2006 Page 2 of 2 0010 Jefferson Avenue Maria's Place City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: F7 Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-7817 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: Comment:The is only one bucket of sanitizer in the main kitchen. Sanitizer to be readily available at all work stations with proper Hasan Zepaj concentration. PIC: Maurenglen Zepahj Handwash Facilities FAIL Critical RED Inspector: Comment: Back hand wash sink has a temperature of 1580F. Sink to be reading between 110*4300F. John Gehan Same sink has no paper towels.Provide towels. Date Inspected:Correct By: 6/1112007 Restrooms have paper towels on back of toilet. PT to placed in dispenser. Risk Level: Front hand wash arae requires general maintenance. Permit Number: BHP-2007-0351 Status: Open #of Critical Violations: 3 Time IN, Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 11,2007 Page I of 3 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: Gold n Chef Refrigerator holding at 60oF. Unit to be maintained at 41oF or below as mandated. immediate corrective action) Back Kenmore freezer has uncovered foods. All foods must be covered. Back off white freezer has uncovered foods. All foods must be covered. There are personal items stored on food products. Personal items to be stored in designated area. Equipment and Utensils FAIL BLUE Comment: Back coke refrigerator requires general cleaning. Fast food refrigerator missing visible thermometer. Provide visible and accurate thernometer. Same unit requires general cleaning. Can opener requires general cleaning. Microwave requires thorough cleaning. Meat slicer requires general cleaning. White kenmore elite freezer has no visible thermometer. Provide visible and accurate thermometer. Back white kenmore freezer has no visible thermometer.Provide visible and accurate thermometer. Marketeer unit in back has no visible thermometer. Provide visible and accurate thermometer. Back Pepsi unit requires general cleaning. Floor beneath units in back require general cleaning. Floor beneath dressings requires general cleaning. All shelves in front require general cleaning. Salad/sandwich unit requires general cleaning. Green World unit requires general cleaning. Gold in Chef unit requires general cleaning. Pepsi refrigerator at wait station missing visible thermometer. Provide visible and accurate thermometer. Physical Facility FAIL BLUE Comment:Grease barrels are directly on the ground. Battrls must be stored elevated. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 11,2007 Page 2 of 3 Item Status Violation Critical Urgency Trash barrells are uncovered. Barrels to be covered to prevent rodents. Womens restroorn has a missing grate in the ceiling. Replace grate. There are water stained ceiling tiles. Find source of leak and repair. Replace tiles. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 11,2007 Page 3 of 3 or 0010 Jefferson Avenue Maria's Place City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-7817' Food and Food Protection FAIL Critical BLUE Owner: Comment: Deceased insects observed resting on tops of several food containers in back food prep area. Have exterminator Hasan Zepaj closely check for insects. PIC: Marenglen' Zepaj Equipment and Utensils FAIL Critical BLUE Inspector:. . Comment: back refrigerator on left requires thorough cleaning. John Gehan Both Back refrigerators have broken handles. Repair handles. Date Correct By: I WSW": Dishwash machine external theremometer not reading. Thermometer to be serviced. Service repair man coming this week. Risk Level: Knives in knife rack found with accumulation of grime on them. Thoroughly clean and sanitize knives. Permit Number: Stove top in back food prep area requires thorough cleaning. BHP-2006-01" Coke refrigerator unit missing vent cover at bottom. Provide cover. Status: PARTIAL COMPLY Shelving that holds apple juice has accumulation of grime on them. Thoroughly clean shelves. #Of Critical Violations: three bay holder(green,orange,blue)that has flour etc in them has broken tops. Provide new tops or repair.tops on order. 2 Same container is uniabled. All foods not in original container in storage must be labeled. Time IN: Time OUT: Daily sanitizing log not being filled out. Log to be maintained daily.Missing paper. Urgency Description(s): BLUE: light cover over salad area missing cover. Provide cover. Violations Related to Good Retail Practices (Critical violations must be corrected Physical Facility FAIL BLUE immediately or within 10 Comment: Back room screen door has ripped and torn screen. Repair screen to prevent entrance of rodent and or insects. days)(Non-critical violations must be corrected immediately Same door requires door sweep.Visible air gap. Seal gap. 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 12,2006 Page I of 2 Item Status Violation Critical Urgency RED: Back room has exposed insulation on ceiling. Floors walls and ceilings in food prep or storage areas have to be made impervious Violations Related to and easily cleanable. Foodborne Illness Interventions Electrical box behind dish wash machine in disrepair. Secure box. and Risk Factors (Require immediate corrective action) Hole in ceiling tile above back food prep area. Repair or replace tile. Behind juice glasses in front area has exposed wires. Repair wires. Screen door on side has torn screen. Repair screen. Ceiling tile above juice glass area in disrepair. Repair or replace tile. Water stained ceiling tiles observed throughout establishment. Find source of leak and repair. Replace tiles. Broken Ight cover over front food prep area. Repair cover or replace. Note:Owner states new materials have been ordered to correct the facilities physical appearance. Work to start within a couple of weeks. Owner to contact the Board of Health when work is completed. GENERAL COMMENTS: 800:All violations related to food protection, in the Food and food protection as well as the equipment and utensils sections are to be corrected by Friday September 15, 2006. 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 12,2006 Page 2 of 2 fun ORKIN INC. Eu ORKIN COMMERCIAL SERVICES C 10B ROESSLER RD Z3065014 WOBURN , MA 01801 CQ11AWERCIAL'SERVICES PRIOR BALANCE : e. THIS SERVICE : TAX : TOTAL AFTER 1Y)r+ THIS SERVICE A i� L C �32941 Amount Paid 1QM STOP# ; Date Scheduled Date Prior Service Cash �ROUTE I Time In El Check Ck# Time Out TYPE OF SERVICE C3 Regular e� C3 Call Back or Follow-Up U Start E3 Odd Job ZI Extra Service r"Cul _STONER Sl"TURE ARE YOU SATISFIED 0 YES 0 NO TECH Up Pervice Date "no"anew I ers under comments.) Use the Codes on the reverse side for Products _NVIRONMENTAL INSPECTION INDICATES THE FOLLOWING CONDITIONS. (Explain Sites,Method and Equipment used 8fVIWN6NA-ST8UQ"_RA_L,Au1� MdEiNoNA"PLUMBING CITY indicates quantity used. W. 2.1 g'e wntalnersclemed-imId- proof? 0 Ll Q 2. pers �m ro an insu on :-0,Cove ? U 13 0 2. Exhaust terns screened? 0 LI 0 3. Pipes free from leaks? 0, 1�Elevator pit clean trom litter ar Id 0 Ll 3. Walls/floors free from missing I loose t debris? or broken tiles? 9]I_YW1q§RkFLY�CO R �J�V' NT Q-'Q 4. Food preparation and storage �3 LI U 4. Holes sealed:walls,pipes,conduits b 3 0 1. Is fly control adequate? botts,beverage lines,calling? C3 U 0 2. Is odor control adequate? Ir equipment free from hood debits? 0�-,' 0.-MID ps and broomis stored off floor, on mks? tj 0 0 1. Items stored away from floor and ms clean,clutter free? walls? I — For outdoor application in mates Where required --k MIND TE.1E.uREj HUMIDDY I SDW 10��j. -Lo k@,r:/break mms clew and U L3 Q 2. Canned/bottled goods removed from WIND I CON MON -1_, : 1'r .. I DIRECnON VIEWICITY IS��el ble? wrdboard? "Ell. rage area clean and orderly? Q 0 U 3. Bulk fdod storage Containers covered? Commercial Previous Number Added Reph,014lenin Now Equipment Establishments Inventory Picked-up. (No Charge) (Churvai+ In"Mory Charge S -,IQOMME X Air Scano/OrlIn/Anes Eiderior Star Stations interior Suit Stations Mulh Catch Traps Flylights OE-30 TC-bb,NOT TIGUCH,TREATED AREA nut.DRY D DAMPEN GRANULES TO ACTIVATE MINIMUM 2 HOURS M�DO NOT TAMPER,Wm4'AOOrNIiC1DE PLACEMENTS 0 00 NOT RETURN TO ROOM UNTIL AFrER VENTILATION Customer InIfials, No am r Ited.Pre..Ne d AW C cigd(eigned Teamnent trentrert ra=r,%for Larger pents. tends target Pasta below AV j apbu:I2 a N� 0 German Reaches 0 Rare '5 German Roaches 0 Rate 'L8m,tr 0qiW,iL4i0lIT1Q0A 0 A,rneirican Roaches LI Mice 0 Arnencan Roaches 0 Mice JT_�:3E 0 Oriental Reaches 0 Oriental Roachas 8 41A� 3 Carpenter Ants; L) Carpenter Ants Q Fire Arm 0 Fire Ants 4WA 'M 0 Ants(Other) LI Ants(Other) . if0l;WL &,I',A-! ka,I- U Other LI Other m A A P A I 1 -1 1 omrii,, nl�, 4 A xi iL �OLOOWLEVE CUSTOMER INFORMATION'�_I�g YI;WSPECTION-IfO' -SERVICES Add= &VO Ave COMMERCIAL Shom# Ph.If Time In e. 1� Manager V 14 ri,teout BRANCH INFORMATION 'k�0 C, Date Svc.Tech lo.# Ins Svc.Tlw Frequency M20 Line LOCATION /Yes/No (fl-N Y/ DESCRIBE ACTION REQUIRED lAulkzs 2L ?Innse CZ4" L�a 2. g4a 1 e47L 4. XjjE�.j rr� ZAW!�,c W kll�Z-o 4,&1,/,15,'- 0-A T-49 -A AelteAr 164(L IfleAlt)z AdlAw 61�� 7. 14. is. Additional Comments Del,'AZ See_W,_C_ f-9&> 117,, Does Customer I lave YES NO YES NO Hands Free Flushing Drain Odor present Restroom Odor Control Floor Drams Clean Flying Insect Traps Door Sweeps Needed Floor Care Prolp am in place Inspec r Customer Signatlune Z� silmanne 20-035-2 REV. 3/2004 ORKIN,INC. COPY DISTRIBUTION. WHITE-CUSTOMER CANARY-BRANCH(CUSTOMER FILE) PINK-TECHNICIAN COPY GOLDENROD-REGION '67u -4 ;�7 Re oAns� G 24,Hdur-' SP arahteed When You see i pest, ce right away. Orkin makes it easy with you need se�- a direct priority line to our natio�al customer service department and to your local branch where your request will be responded to within 24 hours. Satisfaction Guarantee Total satisfaction or you don't pay. If, during your regularly scheduled treatments, you are not completely satisfied with the results, Orkin will retreat to your satisfaction or refund your last monthly payment. If, after 60 days of service, you are dissatisfied with Orkin and decide to cancel, Orkin will pay the reasonable cost of an initial service by another pest control operator of your choice. *Reimbursement Guarantee Should your company be fined by a regulatory agency due solely to a pest infestation, Orkin will reimburse you for any fines paid, not fo exceed $50,000. Applies only to Foodservice and Hospitality Establishments. Should your customer see a roach, rat or mouse in your establishment after 60 days of service, Orkin will: (a) Repay, either you or the customer as appropriate, the reasonable charges incurred by the customer at time of sighting not to exceed $50 for a restaurant or$100 for a hotel, if applicable. (b) Invite the customer back as Orkin's guest for a meal or room charge not to exceed$50 for a restaurant or$100 for a hotel,if applicable. Applies only to Healthcare Establishments. If, after 60 days of service, any occupant's room in your facility has to be vacated due to a roach, rat or mouse infestation, Orkin will pay an amount not to exceed$100 per bed for lost profit during the time the room is shut down. ORRIN REPFtSEWATIVE DATE CUSTOMER. DATE *Your account must be current, under contract for over 60 days, and your business must be compliant with sanitation and structural requests as noted on Orkin service reports. m -r, - "A6S,40 Sia, -*aet** If W� �*� -W11344 6§1 Ng Opt g�iGREEMENT.iS6DNhkGYNTUPONtHEI AND K—fird- SIGNATURE OFA REPRESENTATIVE OF ORKIN Co SIMACES WHO HAS AUrHORFTY,TD EXECUTE ITION I#ALF 0 ION 4 .q. c e_" Date CustonserNames, Eight Address, ZI Code Cfty ip J P ki� 'Iry A_ This AWO�Is Intended to mwbhfbi. haUhdaqMqddqg�,MIm I (the Customer)adel ORIGIN PEST CONTROL S. The specifications l�services to be mMemd by Orwn at the bunKfing(s)and prandians of ft Custionfor located at(service address): IiZ_ C.*N.: 4n,'ddle S& Isthisediflanceyfirects 0-Yes, �W It. SCOPE AND KATURE OFWORK 1Y A Orion agrees he provide sametco for Mas falkywring peels. OrRaffandrool, 0��an�* 0 Coninnionspiders 0 Ries 0 Oxfor 0 Me, Service musands Me peroffic�tmnt to help coming,14combat the targeted panic.Service corm,6u�tee Me targeted peses will not return,but if May do,Orion witl street,as set out undfur Me Triple Guarafte allbsoll h�aral mossurporsted Into this AgMmnL'Addrional monthly char "oussed to caqw .geas �aft B. Serid.Excluxteres.I R,,,.,.q,mrit.AMeement. MIS Agreement cloes ned cover Cmpant.r A9.1 Fire Ards,Bad Bugs,or Moseutpes Service for flesse posts nexperes a seigqMMS Agreement or Addendum.The himummovent of a v,,Parsts agrearres."14ikicindurn can act be,shaVed by I CusXvnev ou,vuh,employed,or again of Order.2 Attended Exgessid This Agreement doors act cover Shown RMINsi Spided,or ands sup,nold-Iflevi conditions ne,hoodulkion can holftsew"by to Customer or mfk employee or egaron of Orldn' In. cu' A This all andearmonewconsurructeen measures as Me, B Whannowar�&�.conduci to the hationfind and!hadsomige at Paris cowned by this Age ORION am retarded!W I Customer in wrong by Oron,the Customer Shelf under the moosseepary,Ml to coinnect buch corn"Ons. C no Cusbooper di ressfusapable for communicating with all persons In Me promises about Ithe tradoments and I nature of services offered hereunder,moreover I Customer acknowdscigas Main Iffess no Mr them communicated to Orion In writing any information 0 does haw,Met any peachis in%a phyrdheas have any removal condition or sens"which may be affeceed by Me servicaus conternplated by Ift agreemont. D Should Me Cusionser discover my taggeted!pecons during to earn of Mis Agreement.May must follow Me applicable notification and documentation precasses as set out in the sappas of samospe,preandecl by Orion. E. Failure of Me Customer to auto necessary Maps 0 comest conditions reparked to It or to offsommose comply with me customer obligations wil relieve Catch of its obligations uncer Me Triple Guarantee and will poirmilt Chun,at Ils dicareflon,to terminate they Agreement wim Sony gio)days warden notics. W. SERVICE SCHIEDULE A. Orion sarrome smagesentafirds Most service Me Customer(comics frequency) D 1 Time D 21ginuess 0 4 Timans Par morill, D Offm, At alone maturing affention Met be treaten as deemed reacessary by Orion -1 B. Orion opposseentatuars Mall make additional Was and treentionent as mey am deemed necessary at no addinforall Marge Such service Were shall also be made promptly when Requestool by a designated mp�of Me California. V. TERMSOFAGREEMENT A. 0 1 0 2 0 3 Were and shaffame,hand frj�month to monsin thereafter until terminated by either party upon sixty days'varten notice * Far multiple year agreements,Me=nMly scovess,Merge will not increase for owe Were after Me suffial trearment Thereafter,and for all hommultiple War agreements,Orion shall have Me right hinnessivens Me an.charges e�anytime after thas anniversary tons of lim mital timantment. * no Customer tat Me terms and candillons between the Customer and Orion are true Stated In Me Commercial Services Agreement,Mat MIS is the entire agreement,and Met have be no of terms or pincrackens which apply Any modification of change to flose terms and conditions must baby a wrinen Addendum signed by each pargy,subject to Me proadicons;of succeed 11 B atoom * Orion Sell the relfieved of he obligations under Me Triple Guarantee and Orion noug,terminate Me Agreement on sixty(60)days written Hours,if any of Me obligations"I fourth in Mis Agreement am not met by Me C fromer,or in Me event of a change in Mike or Radial law Met materially affeens Orlarfs obligations under his Agreement Moreover,Orkin may terminate if it cannot Beffloring its offsponestairses due to note of G%.Inducing eaffilqualess,Stearns,fires,Bonds,or because of material change in circumstances,excluding,but not limited to,acte Of war,stnikes,ureavalability,of pesticides,or offer suppleastrons ondnary Sources It any prommusin or portion thereff,of this Agreement is found to be mXyecI or unenforceable,it shall not affect Me valklity or enforceability of any star part of ths,Agreement Provided,however,Met as to the paragraph on MEDIATIONUARBITRATION,if I sentence precludug,Me normal from conducting an arbitration guncepocing as a MISS,representabW or private attorney general action ou found to be Invalid or unenderecaske ten to entirely of the MEDIATIONIARBITRATION pagagoin shall be daemon to the deleted from his Agreement in. PAYMENT I - A. The Fast of Me Services descobed homen shall be$-plus tax of IS-far Me PAYMENT SUMMARY (includes 0 larst 0 fly 0 odor 0 other in Net nVmh and$ plus tax of IS-Par month thereatter for a pams!of I I� INITIAL PAYMENT CHECK THOSETHAT APPLY YL MA.Ms.You viel reserve a mondly invoice Payment shall Ml due upon nexpept 0 mance RIALS a. Initial I Stan-up Semake $ A The materials used shall conform to Federal,State and local laws and ordinances and ME11 be a��.wm.cum., In.;Oft-Tims Changes $ B The maderadessuall Ise used in acoordamoswith Me labels arelspecificadvans c Products.1s. � $ WI. LIMITATION OF LIABILITY'.The Customer expressly releases Orkin train liability for any claim for PC nal d Sales Tax(of applicable) injury(including s1mgS or bites hand tire ants,spiders,or any other costs)or packem,damage(to Include to dominant,or contents)caused by ary,pests The Customer agrees that under.chemnsfutrica,shalOrkm TOTAL (Is.1to�to.ld) be liable for any amount greater than the amount paid by the Customer to Orkin for the...ces to be 2 MONTHLY TREATMENT SERVICE CHARGES Provided In no event will Orkin be nesporal be for consequential damages for loss of use of property Any claim by the Customer far damages must Me made in writing within one(1)year of the incident at issue or 4 a Monthly Treatment Ser,ice Charges $ ,,If be daemon wasual b. Sales Tax(I applicable) $ EX. EQUIPMENT REPLACEMENT A The Customer agreve to use the leased equipment or Orion provided equipment(the"Equipmenf)in a TOTAL(2a+21h) ...... .. proper Real and upon Me cancellation of this Agreement to return Me Equipment in good condition usual wear and tear ancepted All Equipment(which includes roment barrier equipment,Orien/Ames of 3 MONTHLY LEASE CHARGES insert light Imp)that is manager,lost or destroyed On the Customer premises will be replaced and a LewM Component Charges S charged to Me Customer Charges will be in accordance with the cument existing equipment costs 0 Sconce EJ Standard El Immedual 0 Oranlares El Air Scents B Orkin Mail retain owneratip of leased components Upon termination of she Agreement far any reason. the Customer agrees to make the leaced!components awalable to Orion At Orkin's discretion,Orkin may 0 Other in a lawful manner and without breach of the peace,enter upon the Customer's premises,take IS Sales Tax(if applicable) IS profession of and hernow,the leased compamems Orkin will not be respinsible for any damage to the Customers property,upon moll of the davent components except SuCh damage solely caused by TOTAL(3a.31h) S Orkins negligence X. INSURANCE:Upon request.Orkin shall furnish to Me Customer a certificate of habinymnimmice coverage 4� Producli Sales/One-Time Charges plus tax(if applicable) $ In affect XL CHEMICAL INFORMATION WARNING.Virtually all pesticides haso,some odor which may be present for a FIRST MONTHS INVESTMENT(Total of la,to,c,and d) IS short time after application At War request.Orkin will proolide information about the sherrecas to be used in treating Me premises (Total of 2.3) $ XIL MEDIATIONIARBIVIRRATION:ANY CONTROVERSY OR CIUAIM ARISING OUT OF 09 TREATING YO THIS MONTHLY SERVICE/LEASE PAYMENT AGREEMENT,OR THE SERVICES PERFORMED BY ORKIN UNDER THIS AGREEMENT OR ANY OTHER AGREEMENT,REGARDLESS OF WHETHER THE CONTROVERSY OR CILAIM AROSE BEFORE OR AFTER THE EXECUTION TRANSFER OR ACCEPTANCE OF THIS AGREEMENT,INCLUDINE BUT NOT LIMITED TO ANY TORT AND STATUTORY CILAIMS,AND ANY CLAIMS FOR PERSONAL OR BODILY INJURY OR DAMAGE TO REAL OR PERSONAL PROPERTY SHII BE SETTLED BY BINDINC ARBITRATION UNLESS THE PARTIES AGREE OTHERWISE,THE ARBITRATION SHALL BE ADMINISTERED UNDER THE RULES OF THE AMERICAN ARBITRATION ASSOCIATION(-AAA*)AND SHALL BE CONDUCTED BY AAA IF ADMINISTERED UNDER THE AAA RULES,A CLAIM SHALL BE DETERMINED UNDER THE AAA SUPPLEMENTARY PROCEDURES FOR CONSUMER-RELATED DISPUTES IN CASES WHERE SUCH PROCEDURES ARE APPLICABLE ANY OTHER CONTROVERSY OR CLAIM SHALL BE DIETERMINEO UNDERTHE AAA COMMERCIAL ARBITRATION RULES THE CUSTOMER ME ORKIN AGREE THAT THE ARBITRATOR SHALL FOLLOW THE LAW.INCLUDING THE TERMS AND CONDITIONS OF THIS AGREEMENT THE ARBITRATORS POWERS TO CONDUCT ANY ARBITRATION PROCEEDING UNDER THIS AGREEMENT SHALL BE LIMITED AS FOLLOWS ANY ATSITIRI PROCEEDING UNDER THIS AGREEMENT WILL NOT BE CONSOLIDATED OR JOINED WITH ANY ACTION OR LEGAL PROCEEDING UNDER ANY OTHER AGREEMENT OR INVOLVING ' H-ME-M1,5ES AN#WILL NOT PROCEED AS A CLASS ACTION,PRIVATE ATTORNEY GENERAL ACTION OF N SOMIAR REPRESENTATIVE ACTION THE AWARE'RENCEREY BY THE ARBIf1IA'T"0R(S) it AND BINDING JUDGMENT MAY BE ENTERED ON THE AWARD IN ANY COURT RAVINE JURISDICTION T�iEREOF CUSTOMER AND ORKIN ACKNOWLEDGE AND AGREE THAT THIS ARBITRATION PROVISION IS MADE PURSUANT TO A TRANSACTION INVOLVING INTERSTATE COMMERCE AND SHALL BE GOVERNED BY THE FEDERAL ARBITRATION ACT BEFORE HAVING RECOURSE TO ARBITRATION,CUSTOMER AND ORKIN EACH AGREES TO TRY IN GOOD FAITH To SETTLE AN) CONTROVERSY OR CI-AIM BY AT LEAST FOUR(4)HOURS OF MEDIATION ADMINIEFFERED UNDER THE AAA COMMERCIAL MEDIATION RULES WITH ORKIN AGREEING TO PAY THE COSTS OF THE MEDIATION THE AAA MAY BE CONTACTED AT THE TOLL-FREE NUMBER 80�8 7879,OR THROUGH THE FOLLOWING WEBSITE run ffawlm our Ong XIII. AMOUNTREMBETED: IS 0 Cecil 0 Check 0 Credit Card 1 0 PO Number ITS Ail CuUN11 ExIMATION Of lo-Seckh Name(PRINT) Employee ID 9 or C oreficown 4 Mourch Stre of Address Morch Teleprene Namem Ca, Spite Z,Code THIS AGREEMENT IS NOT VALID UNTIL APPROVED BY ORKIN MANAGEMENT Branch management Shimmies Date Customer x Signature Dole 162181 REV 12/2004 IMPORTANT MESSAGE FOFI-j��- ly- DATF 9A-16 TIME I'lo M Ilia A/c OF PHONF AREA CODE NUMBER EXTENSION Q FAX Ll MOBII P AREA CODE NUMBER TIME TO CAU- I TELEPHONED L--rPLEASE CALL CAME TO SEE YOU WILL CALL ArAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE I-ddl-eack,4) "VA-cs , SIGNED,��-�b MFORM 4009 V Ops MADE IN U S A. NOTES Salem Board of Health Massachusetts Department of Public Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name '� 1, 1 - I Da 9 Tyt*of Operation(s)" Tyge of Insnection I EJ Food Service El Routine Address Ribk n Retail El Re-inspection I Level E, Residential Kilclen Previous 71speclion Telephone Mobile 13?17� El Temporary U Pre-operation Owner 1V HACCP Y'N [] Caterer Suspect Illness Person in Chirge -P rc) n Bed& Breakfast General complaint 1T HACCP Tin. al:0 Permit No. Other Inspector Each violation chect6c req2uiCires; an explanation on the narrativerpage(s)and a citation of specific provision(s) violated. Non-compliance with: IN Anti-Choking Tobacco Violations Related to Foodborne Illness Interventions and Risk Factors, 5%.009(E) El 590.009(F) Violations-marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. FOOD PROTgPTION MANAGEMENT [3 12, Prevention of Contamination from Hands El 1. W.GAssighed/Knowledgeable/Duties k� 0 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS 2. Reporting of Diseases by Food Employee and PIC El i4.Approved Food or Color Additives 3. Personnel with Infections Restricted/Excluded 15,Toxic Chemicals FOOD FROM APPROVED SOURCE TIMErrEMPERATURE CONTROLS(Potentially Hazardous Foods) 4. Food and Water from Approved Source 5. Receiving/Condition [116.Cooking Temperatures 6. Tags/Records/Accuracy of Ingredient Statements [] 17. Reheating Ej 7. Conformance with Approved Procedures/HACCP Plans El 18, Cooling PROTECTION FROM CONTAMINATION [119. Hot and Cold Holding El 8. Separation/Segregation�Protection D 20.Time As a Public Health Control REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) N 9'Food Contact Surfaces Cleaning and Sanitizing >c- I El 21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing CONSUMER ADVISORY E) 11. Good Hygienic Practices 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/tederat 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 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590�004) cited in this report may result in suspension or revocation of 25, Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food \_26. Water, Plumbing and Waste (FC-5)(SW006) 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. 130. Other DATE OF RE-INSPECTION: A- A% eLl_�& 41 I'nI Inspector's Signature: Print: PIC's Signature:' V -Za Print: IPage of_,;?ages 9 A) Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT Crrs�-;r ntn-nnaton 1 1 590.003�,A.) Pu�,�gnjneru of Rcsponmbilitv� 3-302. �A)(f t Pa% Animad Focis S�t..aruted front 590.003(B) Cook,-dand PTE Foods 2-1( Person in charge-duties 0ontal-inaitor,irom,P�,,N Ingredients 3_302.i J(A)(2) Raw A'niural Frmd,,,Separated from Each EMPLOYEE HEALTH Otber, 2 �q(rhwi(c) Re,�punsibility of the person in charge to �;ont&rrikipdor frcm the Lriviteamen., require reporting by Foot ewploycc�and 3-31 i2.i i(A) 1 Food Protcc�iig t' applicants� 3 302,i5 Washing Ftailsond Vcgetable'; 590J)OXF) Responsibility Of A Food Employee or An 3-304.1 Fcw Ck IntaL I �N i�C �,pphcant To Report To The Pcr;on In 1 Equipment art,, Charize' frci�ff;e C orsamer 590.003(G) RePorting by Person in Chiirve-�' 3-306.14(A)(D) Reunited Foid aiJRcscr,,ice J Foo6l 3 5o0J)03(f)) Exclusions tied Rcarictions#i Contaminated 590.003(E) Renio%al of Exclusionsand Regrictions Food 3-70i.] ! D�sc,rdm_,_, oi-Recondfliom;,,g Unsnf,, FOOD FROM APPROVED SOURCE Pood Food arid Water From Reguluted Sotrrce� 4 ; I 1 9 Food Contact Surle"s 5r)0.0041A-B) Compliance Nvuh Food Lrw, t-5c.1.:1 ! NAnnui;I Nvarew,shing-Hot Water 3 201.12' Fomi:na 11crincticalb,Scaled Contioncr� iiiation'rmircratures, 3 2ol I Fluid Milk and M'Ik Flroducts� T 4-�u 1.1 12 Mv�,tlanic�d Viarcw�,shijw_ Hill wat�r �-?02.13 Slitit E�s Sar"o i e"Amit T'n,'reratur�s� -,20114 Fl,*sand Milk FioJuiz� PaNteurize(F 1.1 H emical S�mil;IA11011- i-olp.,pH, i ccuccn-,itioo and haidness. ;': -2o-1.16 ]cc_Mide FrCel potable Drinkinl-Water� I "I I �-Wl I [(A; EquiptaCut F00d COW-1. SUI-faCCs and 5-!of,I I Drinking Water from an Approved Sv.srrrw1 I T 59G.006(A) Bottled Drinking Watcr-� 2n�ils Clean- -60 7.1 i �90006(1`1) Water NI-elt,Standaids in 3 10 CMR 210'� Clean�jig FreqUency if Equipment Food- Shwilfish and Fish Ficint art Apotoved Source CountO Stwtaces arid Utensd,�� 4-7 2.11 Frequencyof S4nitization of UlensiN iffid 3-201.14 Fish and R�crcizLonally Caught Iyfollu.,.can Shellfish' 4__iiv13.l i Nleihtyk of Sanitization Put Water and Fo,,,j Con.act Surfaces o"Equirinient' 3-201.15 Nfolinscan Shellfish frout NSSP Listed Sources� Chenn,aF 14) i Proper,Adequate Handwashing 2'a' and W#rJMuqhrrnm5 Approvedby I Reguel3icity/luthoittv 2 '01.1 11 Clc,,i Condition-Hands and Ainis' S till.1-1 Pro,:edurc* S 3-202 IS stock IdentifiLation Pre�ent 59.9.004(C) Wild Nfiishrvoriis� 2-101.i4 When lo Wash- 3-201.17 Gww Aninwis' If Good Hirgienic Practices Receiving/Condition Eiitimz.Druil,inlg��r Using Toba�;_-01: 3-202.11 P111's Rcccived,vt PioperTemperiewres:1 1 1-40 1,12 Discliaree�. From da- Fys, Nlow and .3-�02.;5 Packal-e fntc_�rit)' Mouth� 1 7-30 1,12 Prevcnt:r.�,Coutiimir:i1i.m �qicn Ta;tiitgt 1-101.11 Food Safe and Uni..dultetated I I Prevention of Crmanomation frorn Hands v Taqsfflecords:Sbellstock 5�r) �04(7,�) Preve%tijw Coutimanai iov rTom 3-202 18 sh-'ll.,toLl,Identification 3-20_;�12 Shelistock ln.nu&cation Mwritamcd� TagulRecords: Fish Products v H=dwish Facilities 3-402.11 Parasitc Destruction� 5-203.11 Nunibc:s md Capacanes-� 1 3-402.1-1 Recordq,Creation and Rclention* 1 5-204.11 Location ano i�ijccutenit 590.004(J) Labeling of Ingredients' i 11 Acccssjbiht�.Operation and Miotacruinc- 7 Conformance with Approved Procedures I /HACCP Plans St�pp#cd vv;'th Soap and Hand Drying 71-502.11 Specialized Processiu Metho;10' 3-502.12 Reduced ox�geu packulzing,criteriat I Handwashing0cau,er Ava;labilitv 6-3(t 1 12 Hind Diving Pwvimoll Conforinance with Aprrowil Procvitures" I �n,te�critica;irvni!q the ii�deod 1991)[wd CWC'), 10�C%, it j 11' �00 0( CITY OF SALEM BOARD OF HEALTH of 3, Establishment Name: rz U 8 ?(Ce c AC_ Date: fa I ty Page: Item Code C-Critical Item DESCRIPTION OF VIOLATION/PIIAN OF CORRECTION Date No. Reference R-Red Item PLEASE PRINT CLEARLY Verified 1�e -,,? L/ A-.l,- 1,0 r�)t I-+- fS Ot'Vll,e )A-114 ruy�n-N pt 6<z r4 0 Iff "fl7j-(�' 4'r, 64_�l - - A� _ _ 3 .M I- 0�1* 11VA AA,40%1� 1. L.P_ Aioe)l- T Discussion With Person in Charge: Corrective Action Reci No 's t rect all U Voluntary Compliance 0 Employee Restriction I have read this report, have had the opportunity to ask questions and agree to cor Exclusion violations before the next inspection, to observe all conditions as described, and to ��Re-inspection Scheduled 0 Emergency S uspension 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 0 Embargo 0 Emergency Closure your food permit. El Voluntary Disposal 11 Other: �--"01 14(C) ?HFs Received at Iennx�raturc,� Violations Rellt?dlo Foodborne lllne�s Inter"etuiors and Wait According to Law Cooled it) Factors(items f-22) (Conf.) I I'F/4S'F Within 4 Houis. PROTECTION FROM CHEMICALS 1 Cooling Methods for PHFs 19 PRE[fat and Cold Holding 14 F000 or Color Additives 3-,S0 1.16(B) Cold PflFs Maintained at or beloy, 3-2(,,2.12 Additi�eV 590 004(F) 4P/45F- 3-30214 Prin�cnon fr0ei Unappioxod Additivcs,� 3-501 16(A) Hot FHF� Maintained at orabove Is Poisonousor1rxicSubsiances 14WF. 7-i0l.1 1 Identilving Inforination--onginal -5bl.16(A) R,)asfs field ator nbove 130"F� V Containeiz,�' 7 U)2.11 1 29 Time as a Public Health Control I'vinnion Nqm�--W--vkin" Cenwijc�rs� I i 3-501.19 Time a�a Public Healdi Conuot` 7-201 11 Sepnmdon.-Swl-V�,e- 590.004(H) Variance Roquirement 7-29111 Re�lcivtion-Prcscnc�and t lse�: 7-202.12 Conditions,)f(T,;C I 7-203 11 Toxi�-Contidn� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 1�aei6zets,Criteria-CheniicLds� POPULATIONS [HSP) 21 3-801 11(A) Unp.iscorized Pre-packageti Juiccs an,[ 7-1-04.12 for W,,,,.;huezI3roduce, Ciileria�' Bevetuges with Warning 7-'-)04.!4 DrvinP Agcais,Cnteria` 7-20-5.11 lncidtr!,�d Fo,d Contact. L,:�ri,,,;ens� 1)(B) Use of Pasteurized I-P-. 7-206.i i R�striclrd Use Peti,ides Cricrip 1, 3-'a)1,11(D) Raw or Partially CO(Aed Animal Funit and 7-206,i 2 Raw Seed Sprouts Not Sm�ed. Rod-nn 13�.il Station,- 3-W 1.11(C) Unopened Food Package Net Re-stayed, 7-200,13 'finclang Pcmdci�,Pelf Conn-cl and CONSUMER ADVISORY 11MEITEMPERATURE CONTROLS 22 3-603,11 Consumer Ad�isofv Posted for Consureption of 16 Proper Cooking Temperatures for Animal Foods, fhat ary Ra". Undercooked ot pfirs Not Othemi.w Proces,.,,ed to Eliminate 101.1]A(!��'2) E�,,gs- 15�-F 15 Se�. Uggl-hnoiLfiatc Servicc 145'Fl 5se�l 3-1 302.13 P1StguoZ0d Fgs.S Substitute for R'M� Shell 3-4111,11(A)(2) Comminuted Fisb, Meats&Gaine Eggs r An:-,mls- [55'F 15s2c. 3' SPECfAL REQUIREMENTS 3-40J.!!(H)ql)f12) P. 4, a.id liv� Roiist- 130 F 121 oin* 3 401.1 I(A)(2) 590.009(A)-(I)) Violations of Section 590.009(A)-(D) in R'nnvs: injc(Acd Mc-at:�-- 155JF 15 cat-rin a. mobile 1504.0, temporary and ,we. � ' ll 3-401�I I(A)(3) Pculti-y, Wild Gime,Strifi'l-d dfif-4, i resodential kitchen operahons0iou!d be Stuffing,Contanan., Fiqh,Isleat, debited under the appropriate s-clions Poulif y or above i"related lo foodborrieflIness 3401.1 (Ci(1) Whole-muscle,Inun I Beef'Steaks interventions and risk factors. Other 145�f`": 590.009 violalion�relatin.,to yood r'-'Iqj'l 3-40 1.12 Raw Animal Fook G-s-&ed in a practiccs should be debited under§29- lvficrov�ave 165 F l' Special Requirements. -1401.1 l(A)tlgI,) All Other PHFs- I 45"F 15 wc 17 rcheating icr Hot Holding VIOLATIONS RcLATED TO GOOD RETAIL PRACTICES 3-403A I(A)& D) PHFs I IS-F 14;see, * 1 1 (Items 23-30) 3-403.11(B) M tcic�xave- 165"F 2 Munne Standing, Critical and non critical violafions, which do nui relaie to the Tj,me foodborne illness inten,entions and riskjactors hyted above, can he 3-403.1],"C) C,-,Tnmcrc.,di.y Piocessed RTE Food found in Meftfloo ing seclions of the Food Code(aid 10.5 CWR 140'F' 590.000. J-Gov� 660---- -i-403.�I�F) Rcjn�imw,,Unsi;cccl portions of Beef Item d etail-Practices Fr- 590 RoF"is 23 ManapproprIt and Personne! FC- 2 .001" �2 -1 'Food and Rood Protection FC 3 .004 Proper Cooling of PHFz 3-501. _I(A) Cao�cd PI-IF-- 'mai 1-101 F 25 Eruipment and Utensils FC-4 .005 26 -1 Water,Plumbino and Waste FC-5 .006 70'F Within 2 fkw-�and From 7V 27, Physical Facility FC-6 M7 ul 4!'E/4.�r'F W;th�n 4 Hours. ;?11. Fo sonous or Toxic Materials FC-7 3-501 14tB,, C0J:--,-,-,I`HF,,fvTLde Frtn Ambient 29. Specie:Requirements 0109 Tempe-ja,11rc Ingledients to 411Y451F 30, Other wellin.1 Hou"11, 1 5 b�j 6-2 J, I)tnot",rat,al,�e-n a i i ho I�Jc-d 19,10 F,;f,l Codr 1), 1 �0�3)0 -,CNAR 5 CITY OF SALEM BOARD OF HEALTH Establishment Name: r) C�c Date: I Page: of ?(r- Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dat Ver? No. Reference R-Red Item Ified PLEASE PRINT CLEARLY a U451 Ch-?( � k) C_)�A 1\)Q -MO Al- U01 C-s'-dDa A f -7/11,/In r I to 01 IA ke LeiA A4"4r%y1 _�r LJLf..n Q'( DfAT C\a",IOJ 4� 41, 1,� C�1_� R�a bakaA, i(-tc4x—A) ��c(- , Las 4y— �-/'-)J/'C47 �s Fe 7QntAr f7lq-z' 0 i�o A)Z'� o(4-A 0a,k— ;R�rp_ Ot L� 4t )n ve� ck' <�" A C-u C� --k) �__-yj_or V_�A4 Discussion With Person in Charge: Corrective Action Required: U No fes I have read this report, have had the opportunity ask questions and agree to correct all zi Voluntary Compliance 0 Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to Up/Re-inspection Scheduled Ll Emergency Suspension 6 comply with all mandates of the Mass/Federal Food Q _.�de. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of C] Embargo Ll Emergency Closure your food permit. U Other: 0 Voluntary Disposal ,-50jJ !'(,I PHFs Rei.eivedm 'Temperatures Violations Related to Foodbeirse fitness Interventions and Risk Accordin,it)I,aw Cooled it) Factors ilterns 1-22) (Cont.) -4 I'F/45''F Within 4 Hours. PROTECTION FROM. CHEMICALS Cooling Methods for PH Fs 19 PHF Hot and Cold Holding 14 Food n� CL ter Additives 3-i0l.16(Bi Cold PHF.,MaintainvO.ator below 3-202.12 Additj�es� 590`)04rF) 41'/45' F' 3-302,14 P1,0tecimn!'-'Mi U!�aqptined A,'ic:riv,sl 3-501.16iA) Ihil PHFs Mpinrained at r:ibove 15 Poisora�us or Toy'c I 140"K ldentifpilg 3-501J6A) -it orDbove Roasts Held� - I 10"F. 7-102-11 Cuffurnoo Nato, -Woikin�!Ckwunners- 20 Time as a Public Health Control 7-201.11 Selmration-Stroran�" '3 501 19 Time as a Public Health Crints;it 7-20.1 11 R,-.!,trictiorr-Piesviice D�.i Us,1. 390.00,41-1) Variance Requircrneji� 7-202.12 Ccncfitii�ns�ir lise" 7-20'1 11 -oMc(,'ontainc-,-PfohihitDmO REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2011 it criter..',- Cllcl:ocals� POPULATIONS(HSP) 7-204 12 Owlllicn�s for Washice Pr;o1k;ce, "rit-cia, 21 3-801.1](A) Unpoistein ized Pre-packaged Joice;and 7-204.14 Dr)�ng Agcot�.Criferla Beverages with Warning I-abcls Lttlnrcarc;1 ;-801 A I tD) Raw or ParnalIv Curiked Aninial Fticciand -7-205.11 ln�idetuotl Food C,,ntac 3-80 1.11(B) Use of Pasteurized kgm* 7-206.11 -Rc,tro led Cs, PciaicAes.Cntvrni� Raw Seed Smo als Nor Ser\ed. 7-206.12 RoJi.nh Bair Slittnins* Unopened Food Package Not Re-served. 7-206.13 T,j.kncr Pcmder,,P.-st C�intro� and CONSUMER ADVISORY TIMEITE,MPERATURE CONTROLS 22 3-603�11 Consumer Advisra.v Posted for Consumption of 16 toper Cocking Temperatures for Arturral Foods Iliat are Raw, Undercooked o,, HFs Not Odicmiw Processed to Eliminate F 3-40 1.1 IA(t i(2) I"., s- I S�-F 15 See. Pathrogens.9- F"' E.9 -Stdrs gli Inintediate Ser,.ice 145'Fl 51et,- --'()2.13 Pasteunced Egg, [little for Raw Shefl 3-401.11(A)t2 t Comminuted Fish� Meets&Game Fggs* Allhoalt, - l5s�l` I� sec, " SPECIAL REOUIREMENTS 3401.1 �B'Kll(2) r irk Did Rc�I'Roasl i-(j'F �21 noc* 3-401.1 VA)(2r RD'ite's,Injectod Mv�rs- 155�F 15 590 009(A)-(D) Violations of Section 590.009(A)-(D) in !ec. catering. mobile food, temporary and 3-401.1 I(A)�3) Foultr-Y,Wild 6firne,Shu"tud PHFs, residential kitc[fen operations should be Stuffinz Corn,ittatt, Fish,Meat, debited under the appiopriate sections, Puulury or Radler-105'P 15 sec. 1E above if related tir foodborne i Ilriess 3-401.11 iC')(,-,) Intact Be.-f Steaks interventions and risk fictors. Other 1-15'17- 590.009 violatjon�relating to good retail 3-401.12 Rem Anitint! Foods Coiiied in;, practices should be debited under#29 - Nficowav, 165 F" I Special Rccluircments. 3 401,1 I(A)(i)(in) All Otlt�i PHF�- 145'F I S ;cc� * i 17 Reheating for Hot Holding VIOLATIONS R:-LATED TO GOOD RETAIL PRACTICES 3-4W4.11 i,A,)&-(D) 111-117s, 15 sec. 4 (Itents 23-30) 3-403.11 Mjt %licrowave- 165' V 1.Minutv Standing Criticaland non-critical violallonv, which do not rclare it)fhe Tillie, foodborne illizess inten Pinions tord i�Skfioc tars IL ted above. con be, 3-4o1l i(C) Cominerciall*v Prcce�sed RTE Food- found in the follmrine sections of the Food Code and JQ5 CNIR 140'Fy 59(roov. 3-40'.j I(F; Rz�o::unin.-Uyisliccd Portions of Beef in Good Retail Practices FC .000 23. Manallement and Fleisonnel FC -2 509003 24 Food and Food Protection FC-3 1 .004 Proper Cooling of PHFs 25 Equiratichi arid Utensils FC-4 005 4010 Cool�tit,Cookcd PH i�from 140`17 10 6 2 Water,Plumbincland Watte �c-5 006 ju"f;\�3dr;n.1 Hours and Front 70'F 27 Physica!Facility FC-6 007 jo 4!'F!45--F Within 4 Fluui�. 2 8. Poisonous or Toxic Materials FC-7 .003 3-501 14(b) Coolioc, Made Front Ambi t Special ReQUIrErcrents Tarrificizame Iricre(ocnts it,4 I'Fcll�'F 31, Other 11111iim 4 Hours .........T't-tl' Dcrtol,!critical itom it,ni, t,�le,al 199�!oc"I Code or !1�s CNIR 590 Isjo. 'Massachusetts Department of Pdblic Health Salem Board of Health D I ivision of Food and Drugs 120 Washington Street, 4 t Floo r Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (97,8) 745-0343 Name Dat Type of Operation(s), Tyqe of Insoection 47-rIlA, , t97 Address 4-C e- 4jof, Food Service El Routine Risk Retail DRe-inspection .4, Level Residential Kitchen Previous Inspection Telephone F1 Mobile Date: In Owner HACCIP Y/N 1:1 Te' porary E] Pre-operation I/� I El Caterer [I Suspect Illness Person in Charge(PICV I �j Time E] Bed&Breakfast [] General Complaint In:t_&> - El HACCP inspector Permit No. E] Other 71-�Cc-�� (7,Y00 out: I I-D Each violation checkeir!�uires 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) [_1 590.009(F) F1 action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT E] 12. Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/Duties Ej 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS El 2. Reporting of Diseases by Food Employee and PIC E] 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE D 4. Food and Water from Approved Source TIMErTEMPERATURE CONTROLS(Potentially Haiardous Foods) El 5. Receiving/Condition E] 16. Cooking Temperatures El 6. Tags/Records/Accuracy of Ingredient Statements Ej 17. Reheating El 7. Conformance with Approved Procedures/HACCP Plans El 18. Cooling PROTECTION FROM CONTAMINATION El 19. Hot and Cold Holding El 8. Separation/Segregation/Protection El 20jime As a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing �1. Food'and Food Preparation for HSP El 11. Good Hygienic Practices CONSUMER ADVISORY El 22:,Po�tt�of Consumer Advisories I Violations Related to Good Retail Practices Number of,Vidlated Provisions Related Critical (C)violations marked must be corrected To Foodborneillinesses Interventions immediately or within 10 days as determined by the Board and,RiskFacto'rs;(items 1-22): of Health. Non-critical (N)violations must be corrected I � _ immediately or within 90 days as determined by tAe Board Official Order for Correction: Based on an inspection cf Health. today, the.'items checked indicatd-VIolations of 105 CMR 1C_-N 590.000/federai Food C6de. This report, when signed below by a Board of Health membe'r or its agent constitutes an 23. Management and Personnel (FC-2)(690 003) 1 24. Food and Food Protection (FC-3)(59',0.004) order of the Board of Health," Failure to correct violations Oi5;��25. Equipment and Utensils (FC-4)(590.005) cited ind6is report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590'.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) �,_hay-e-a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order, 30. Other DATE OF RE-INSPECTION: S 14 d. Inspector's Signature: Print: PIC's Signature: Print: Page ofjfl Pages 0 lvo,4d lfioiafion,�:Rolailed to Foodborne Illness interventions and Risk 1-22) PROI ECTIO�j F fiCtil CONTAMINA'rt.-N FOOD rwrECTION MANAGEMENT 8 RIm It hom n in ch'.fge kltltic'� Cqnmmvwit�n ftxr P,�,Y!ngr&,Iwits 3 302.1 i(A)t 2) Ri)W Xii m,! XIS Sepa;--t��d hom F�ich E1.41P.WYEE HEALTH i(to,wrx, Rcsponsibiflt�of the peoon in r,hiig��v from the F,:vkonmaot require reporting by focd eturIloye,*,� nnd !')2.11 m: Prorccni'fl- appkcant�* '09.1.1 Fwit!.r,�A' 590 003(-) N12SVOIISibili" 01-A Fooj Elnpkv�ee OrAn 3 304�: Equiplumt ajt'� Uren�: s" A"11iCafff R)Repf)IJ"To The llertaj III Charge, irrm r`I9 00tSt;Mer "'0 003(G) Reporting!ji, Peisi�n in Charcc* Reluj��d Food awI of lon&' 3 590.00-3,(D) Exclumons nd R�stricticlm* Ren;oval of Ex�lusions ar.6 R,wictiow unsah- FOOD FROM APPROVED SOURCE Food and Watot Frnm Re,,,wat&d Sources Fnod Co�s!acz Surtacer; 5910.C.N(A-B) Complias,�e witi, Fecal Lak� Mauu��I Watcw�Aijrig- Aca 12 Food in a liermetica�!Y:Wvlcd Container, Tni,poratun-s- _N1cJinuicr� 3 2(�1, Fluid Milk alr,c�Milh ProdvcW (it �N:.ler 1-202.!3 sh(Al i-'—,-S* nical pH. -3-202.� and IWk Pj'Wnct, 3-202.16 ku;le Front Potabiu Drinkin��Wut,r Clnc�,-A r�,�ion -�d i�.urcipes,�. I)rnjkip7,Wzjlcr�- 1 4-601'� �IA) Equiplfv--r�� F. on �I"0.006(A) Bottled Prinkiog W-acr* 390.006ffi) Wai-r WN�;Stan,'Krds in I 10 CMI', 22.01 4-602'�I Cl�;Innlg I-req,jene,ut !�qn�pme;,.z Fo,),-!- Sh,01,1�h an 1 F;sh From'�n Apjsro,�ed Suorot C,,7,tao,Surr"ac-,s aj'Ij tj�"'ISIII',�L 3-2 1 1.1-, 'I'll I Fish mil Recreadoaalk,Cauldrt-'Ylolluscm Fo,a Co:�:";ct sur�a�lel'N �(Alipincrlt� slicMI"J", 4-it�"4 ul simitiz.�;:on- ilot'Watv-and 1 201 15 Molluscan Shellfikh from NSSP IJwd C� - S,,urcc.�. I Oame andNiki hitm-,rooms Aporvvrdt�y Prwea. Ham'washing Renufatory A�t,'tollpv Cie-,Condition-H-m,k ,�nd Aom- -2')2,1 Sho'14ock fdentificano.-, �rcll�ni 1 2-36 2 5')Q.004(Q Wild Nfi;shroonns- 2-30:.1 'Wh�r n-, 3-201.17 Garm Aninrn.,J.�k it Cood Hygivni,P�,a,�j-,cs Receiving!Conditron 2-lol I I halure Lociuking,or UI,:.�I"T'4�acco* 3--702.i I TPHFs Rccejve�i at Proper cjnn)��r,itnqe�� I)i ich,!c,L�t; Floor the Noseand Mouth- 3-202 i5 I Fack,ipe lnnpsml',� 1 3-J;01.11 NA)d Sa!eand Unadall,,tated Prov-'rutni.Co:;�":-.ieition AlIcz,Ta�lma� 6 Tags!Records:-21,.eftitock Wav�ni;on.'f Contamination fmm Hands 1 She;lstock Identific.nion. :390.00d:I I,, P-evelding Conzamillation fp�:;� Sh�dstock idertfificalmn Nlaintaim-i 4 Fpcillties TaggiPecords:Fish Prodocts Locued 3-462.i 2 Rr-,ords. Creirion and ReLt.!i',mn* 590.00V,I I Labeling of Ingredients' lmouti,n and ph"colneaLl 1 Coliforninince with Appl-oved rroneduree Ac��s,�o;i ty, 'Crot.awn and Mainlenarr:c iVACCm Plans SLImp'lkd n""In Soap aiio Pand Drir,q I DoW... 502.i I ,*-,)02.1 Reduced mv�zvn packaging.cr.t o-3fil I 1 1 �aiiahllq� li-lw,12 Cunforwar�e",;:I Approvcd Pio�edulres 6 10L I It CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Z 61� Page: Z_ of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item PLEASE PRINT CLEARLY I Verified A ie;, '9 r-'J -UA I Moe_ t j .11� /It, I A)DO --L) K1, J _tl A bl:�,2 F—D—iscussion Wito Person in Charge: Corrective Action Required: 0 No 1dX,-fes I T have read this report, have had-the opportunity to ask questions and agree to correct all *5--Y-Qiuntary Compliance Lj Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described', and to U Re-inspection Scheduled ZI Emergency Suspension c.bmply 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 Lj Embargo 0 Emergency Closure u r food pe rm it. LI Voluntary Disposal El Other: YP ? - - i 3-SQ11�1(C') � :PHFs Received at'i'emperacuzes Vlolafions Rslated€o Foodbore�e Ntness Interventions and Risk .4ccacding to L.aw Cooled to I Faators(ltems P-22} (Coni.) ' 41°F/�45`F 4Vith'rn d Hours.` � PROT�CTION PR9M CNEMIC/ilS 3-501.15 Cooiind Metl�udsfor}'HPs -��--��--- 19 PHF Not and Gold Holding 1q Pood or Color Additives 3-202.12 Additiv�s" 3-501.16(B) Cotd PF�IPs Maintained at oc beYqw 590.004(P) &I°!45°F` 3-302.1d Protection front U&a}��roved Additives" 3-501.16{A) Hc�t PHFs Maintained at or above 15 Poisonaus or Toxic Substances 1d0°F. " 7-101.11 klentifyit�g Infocmeition-Oaiginal 3-SO1.16(A) ftoasts Reld 3t or above 7 30°P. �* Co�itainers"` 7-102.11 C:ammon Ntitne-Workln�*Coutainars* 20 Time as a PuGlic Health Controi 7-20L11 Sa aration-SYora e" 3-�OL19 TimeasaPub6eHealthC�ontrnl* 7-2C}2.11 P.estdctian-Pmsence and Use'� S9U.00�I(H) Varizwce Re uirement 7-202.12 Conditi<>ns tsf CJse�* 7-303.I 1 'foxic Containurs-Pral�ibitions� REQUIREMENTS POR HIGH�Y SUSCEPTBLE 7-20d.1 L San'rNzeis,Cnteria-Chemicals� P�PULATiONS(HSP 7-204.12 Cheiiiicals for W&ishin�l7xoctnec,Giteria" �l 3-&61_i t(A) Unpastew�ized Pce-}�ack�ged Juices a��d 7-20d.14 Drvina t\ ents,Criteria'" Beverflges iuitl�lX'a�nin�;tabels* 3-86Lll(B) UseofPastev�'rzeclL'T�tas* 7 205.11 L�cict¢ntal Foud Contnct.l'.�bricants* 3_AOI.l l 7-20b.1 t Restrieted Iise Aastieicles.Csiteria* CP) kuw oc Peirially Caokad AnuiTal I�ood and Ra��Sced S ro�its Not�Served. 'x , 7-206.12 RaientBaitStaeions' 3_KOl.11(C) Unu.enedP�w�iPacka>eNotIZe-serced. " 7-206.13 Tcacking Pow�ers,Pesi Conttol and Monitarin�= CONSUMER ADVISORV TIMFJTENIPERATURE CONTROLS Z� 3-603.1 i Consumer Adaisory Pcksted fnr Consntnprio�ot Animal Fuocls'1'hat arc Raw,iJndercooked or 16 Proper Cooking Tamperatures Pos Not Otherwise Processecl to Elimii�ate PHFs rr�e�e,rozooi 3-40L L lA(]�(2} F�gs- 155�C t5 Sec. i'arhaRc.ns � ` �, s-Lrmied'rateService145°PlSsec* 3--��2�1'� FasfauricedFggsSubs[iCute'(orRawShell 3-461.11{�1){2) Commi�mted Fish,Mea[s N Gnme Ee s` tlni,mxts- L55°F 15 sec.'� � 3-0.07.11(S)(1){2) For,k imd Seef Raast - t3O°F 127 ntin* �PECIAL REQUIREMENTS 3-�LOl.il(A)(2) Ratites, injeaedMeaYs- 155°Ft5 590A09(A)-(D} Violatiou5oCSeeCionJ90.00)(A)-(D}in � sec. "' cateruig, mot�ile foc�d, Cemparary and 3-401.1 t(,a)(3} Poultry,Wild Game,Stufted F'HFs, cesidential krtchen operations shoiitd be Stu�n�CoBi<uidng Fish,Meat, debited widcr Che appropriate sections Poult��or R�dtes-165°P 15 sec. * abovc if related to food�borne illness 3-4011 L(f.)(3) Whole�miisele,L�tact Beef St�exks interven(rons sud risk factors. OChec 145°P' S90.009 violatians relating co good retail. 3-FtUi12 R:av Animal Fooels Coakul ir�a practiees Should be debited under�t29- Miccnwave I(i5°F x Specini kequire�ments. 3-401.11{A)(2){h) All 6lher PH�s-� 1&5°E'l5 sec. * 17 Reheating far Hot Holding VlOLATIONS RELATED TO GOOD RETAlL PRACT(CES 3-d03.11(A)R�fD) PHt�s 165'P 15 sec:. � (Items 23-30} 3-d03.11(B) Mir.�'uwuve- Ib5°r 2,Ltinul'e St'anding Gr-iticrd mtd reon-critrcal viokrtic�ns, which do t�otrelate to Ilee Timc"` foodborne i!lne,ss intc�ventions and risk fnct�rr lis�ed nGnve, cnra Ue, 3-403.1.i(C) Conitnercially Processed R'CE Fo�d- foun�l�3e[he fol(nwirEg sections q/'the Fnad Code ari�!10�CMR '140'F* .590.00(�. . 3-103.11(,F,) Reivainina Uuelice.d Portions ofBeef R� em Goad Refart Practices _ FC 5SD.000 -� ----- Roasts" 23. Mana ement and Personnel FC-2 .003 -___...._____---� -�- 18 Proper Cooling of PHFs 24. Food and Food Protection __ FC-3 .004 25 EquiRmeni and Utensils FC 4 .065 3-SOL 1A(A.) Ceo7ing Cooked PHFs ffom 140°F to �g6 W ater�Plumdinq and W asie PC 5 006 70`F Wlthin 2 T-tpurs aud From 70°F 27. Ph sical Factli FC-6 .007 -_ t ___ to�7.°'.F14�°F�thin 4 Hoius.* 28. Polsonous or Toxic Matariais FC-7 .008 3-50'L 14f B) Cuoling PFIFs Made From Arnbiei�c 29. S ecial R uirements i .009 , Temperaaue Iliy�edients to�47°F(47°F 30_ _ Other _____�__ �. WiSltin 4 I3oufg'z ssvom�nm,�a.z.�� -4 Denotes critic:il item in 4hn f'eder�l t99y Foed Codc or IQS CMR 59p.Qp0. IMPORTANT MESSAGE ) FOR DATE 1 )h (a TIME �Pm.' 4-� M OF PHONF AREA CODE NUMBER EXTENSION J FAX Q MOBII F: AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WtUL CALL AGAIN WANTS'ro SEE YOU RUSH REtURNED YOUR 6ALL WULFAXTOYOU MESSAGE k:�2e-D PAO S Qj- ij C11A SIGNED FORM 4 09 9 FORM 410A M MADE IN BA NOTES IMPORTANT MESSAGE ) FOR OATE TIME M azz OF PHOW AREA CODE NUMBER EXTENSION Q FAX D moall P: AREA CODE NUMBER TIME TO CALL TELEPHONED 1 1 PLEASE GALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALLI 11' WILL FAX TO YOU MESSAGE 6c )- -� QD,a� SIGNED TMMADFOR E IN U S A. M 4009 NOTES 45 7-b M -Vi- ff fahl - � � , � �_� 1 IMPORTANT ME66AdE- ) FOR I A.M. OATE �5 �V�e aO—TIME —P.M M La I L\ Ave PHONr= AREA CODE NUMBER EXTENSION D FAX D MOBIJ P AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU VIALL CALL AGAIN WANTE TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE JJA r Vj Y SIGNED-f-- CT30A 11AXI V I FORM 4009-� Mrops MADEINU.S.A. bcoV5 NOTES LQ 6p S E LE Cr* FOR RESERVATIONS 1-800-HOLIDAY Z CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 0 1970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Maria's Place (a 3 50 Address of Establishment: 10 Jefferson Avenue Owner's Name: Hasan Zepaj ,Ltq Restrictions: q-lq q Application Date: 11/22/2004 Permit for Food Establishment 56-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. H=ALTH AGENT CITY OF SALEM9 MASSACHUSETT BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 0 1970 NoV TEL. 978-741-1800 FAX 978-745-0343 C/7-yop 192004 40 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, IRS, CHO 130-IRI) OFSAL�m MAYOR HEALTH AGENT 11E�QH 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT nK\W S ?Lf�(J-Z TEL# �CN) IH4 - 1�8 ADDRESS OF ESTABLISHMENT �0 Tc;��t�soN PoiF- stupm W\W 019 -�o MAILING ADDRESS (if different) OWNER'S NAME "WIF3W TEL# ADDFZEQ'z ( - ?..K Pf C--%C� - - CITY STATE V\W zip UH("�n CERTIFIED FOOD MANAGER'SNAME(S)kL?s&EMGLQ\� 2J:J%--\ CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON MK0\J(A-0J -LEM-JHOMETEL HOURS OF OPERATION: Mon.C--aTue.6-'5 Wed._�-3T!hu.�-'� Fri.�--�Sat. 6-_LSun. (n- 1 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1 000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 1 0,000sq.ft. =$250 RESTAURANT NO less than 25 seats =$I Q!9 25-99 seats $1 50 00 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-PROF1 T(such as church k"chensll 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 tax returns and paid all state taxes required under the law. lot o'01+ *a ure Date Social Security or Federal Identification Number I a4 -- --------------------------------------------------------s4-0+?--- 's 1 11 4 --- --7P*a D -1 e, ed 03/03*VA d h�ec k ate a 1, Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4 1h Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name D It �/ aej TV f Operation(s). Tvpe of Insoection AfAlf,Jo A4Cj 747 g2o(d Service f�J-Routine Address Risk E] Retail [] Re-inspection Telephone/64 Level El Residential Kitchen Previous Inspection "7 4/q- lqj 7 Im [-] Mobile Date: Owner HACCP Y/N E-1 Temporary E] Pre-operation AfOQ" 7,5-PW [] Caterer Ej Suspect Illness Person in Charge(PIC) Time El Bed& Breakfast El General Complaint llooik�jd-elj ?Aj*Ai In: [-I HACCP Inspectorj),jj"/4.jjA _j4 �, Permit No. El Other Out: Each violation checked rekluires 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) E] 590.009(F) E] action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT E] 12. Prevention of Contamination from Hands F-I 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities EMPLOYEE HEALTH Ll 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El 3. Personnel with Infections Restricted/Excluded E] 14.Approved Food or Color Additives [] 15.Toxic Chemicals FOOD FROM APPROVED SOURCE [:]'4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) 5. Receiving/Condition E] 16. Cooking Temperatures El 6. Tags/Records/Accuracy of Ingredient Statements E] 17. Reheating EJ 7. Conformance with Approved Procedures/HACCP Plans [:118. Cooling PROTECTION FROM CONTAMINATION El 19. Hot and Cold Holding [1 8, S-eparation/Segregation/Protection El 20.Time As a Public Health Control P119. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) [3 10. Proper Adequate Handwashing El 21. Food and Food Preparation for HSP El 11. Good Hygienic Practices CONSUMER ADVISORY E]22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board Official Order for Correction: Based on an inspection of Health. today, the items checked indicate violations of 105 CMR C "W- 590.000/tederal 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 cited in this report may result in suspension or revocation of oi& Equipment and Utensils (FC-4)(590.005) (FC-5)(590.006) establishment operations. If aggrieved by this order, you 26. Water, Plumbing and Waste the food establishment permit and cessation of food ,ff. 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-INS�ECTION: S 5Mns�CtFo�14 dw eto , Si e: Print: I Yls,�Iow 1 Print: f Pages PIC's Sigfia-ture: I V, ///�fil Q I�/' I V I Page /0 Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT ct"'s-contanc"7L for 1 _51)().003(A) A�si.,.,nment�)fResi)(wrsibility" 3-302 1 I(A)(i N, Raw Animal F00�1.0�9,e:,ael fioin 5 Derrionstntlionof KnooklcdPe* lock, I and R"I'L FiNxi s'� C 2-103,11 Per�oon in chat�,e --donic, Contamonatio,7 finm Riv,lr�qiodenis; 3-30111(A)(21) R�ivv Anirm! Frl-ids Separatcol fion,Eadi EMPLOYEE HEALTH 0!11f'r� I 2 590.003(0 Rcsp,ms;bflityofLhe person in clianre to Contamionation from.1he Environment require iepoitin.-by focid employees and 3 302.11(A) Food Protectiowl applicants, '3--io 115 Washing Frojit�an,,(Vegutabls �90 00-1117,11 Responsibilit) Of A h�txt Employee 01 An 3-3(A.11. Food contiict vuh Equipmentand Applicant TO Report To Tho ficrion lit Utelui!0 charl"e;' Contam.bation from f1w Consumer 590.001(6) Reportiril-by Persian in Charge* �-3(A.14(A)(B) Returned Food ii!id Rcs�-��ice Of Fooi,',* 3 590 0113(f)) Exclusions,ani Restrictions,* Di�po�ihiun ol'Adufte,-oitcdor Comarninoted Removal of ExcluLdons and Restricliom Food 3_701�I I Discarding or Reconditioning Uuiatb FOOD F IOM APPROVED SOURCE Food� .4 Food and Water From Regulated Sources 9 Feed Contact Surfaces 590.()04(,A,-B) COmpliance with Food Laoo*� 4-501,111 Nl"autl Wjrcwa�h;nt,- Hot Wi,:cr 3-20 1.12 Ftood in a Hermetically Scaled Conlainer� Sanitizatirm fetriveralor's, 1 4-501�112 Mechanical Warewasldn-_ Mot ';Vaer 1 3-201,13 Fluid Milk and Milk Products* 3-2()21�1 3, Shell Eo�� 3-2102.14 Eggs and lefill, Proclucts'. Pasteurized' 4-501,111 Cherilical Sanitizarion-tealp"PH, I concennation and 1,ardness �-"()2,16 Ice Made Heart Potable Drinl:uoc Witter" 1 5-101.11 Drinkim, Watei front an,-kroproved Svstoin* 1 4-6o 1.11 t A) Equiptnefit Food, Contact Surlacesand Utensi is Cleoim* �;90.006(A) Bofflei&inking WateO 4-602.11 Cl�anidg Fiequency of Equipment Food- 59o)�00603) Water Meets Standatols in 310 CNIR 22,0* Contaa Surfaces and Liensils* Shefifish and Fish From an Approved Source 1 4-702.i I !;'_1quc1icV Of S'�uaizatioa of Utensils and ,,-20 1.14 Fish and Recreational I y Caught Molluscan Ford Contact Surface,,cifFquipmef Shellfi"'h* 4-T13.11 Methoolso-fS.Ouit/,ation Hot`voat�.,rouai 1-20 1.15 Molluscan Sli-Ilfish fronn NSSP listed Chemicjl� Sources* to Proper,Adequate Handwashing Game and WildMushroomis Applovedby Pegularory Authority 2-10 1�I I Clean Cn,:ci�'ii.n - Hands 9nd Ai ri):; 3-2t)2 I l; Shellstcock Identification Present� -3(')1.1 Clcouang Proc"Juic" 590.0(P(C, Wild 2-30;.14 -violien rr)Wash* 3-2.01.17 Gaine Animals" Good Hygienic-.Practices Receiving/Condition "i 0 1.11 Eating,Drinking at Usaw TobaccW 3-202.11 PIlFs Received at Propoa Temperatures" 1-401.12 Discharges Frs�m the L�cs� Nos�and 3-202.!� Packn=fritutTity* moutb� J_i 0 L I I 5oOd Safe and Unadulterated 3-301,J 2 Pi�entiiw C.,ra,annation Whcn Tastirlg�� TagstRecords:Shellstock 12 Prevention of Contamination from Hands 3'-2011.1 X Slud tsiock-Idunlificatiojit* 990.00-I(E) Preventiril,ContananaLtoort from ;-203.1.1 Shelistrick Identification Maintained' InnfolweeS4 Tags/Records: Fish Products 13 4andwash Facilities 3-402.11 Paiasito DeEiruction' Conveniently Located and Ac,�essibfo 3-402.12 Recor&,.Ciearicin and Retentiojil 5-203�I I Numbers arid Capaciui�s;' 590.004(J) Labeling of Ingredients* 5-2,04.11 Location and Placement, 7 Conformance with Approved Procedures 5-205.11 Accessibilitv, Operalicri and Maintenance Supplied with Soapano Hand Orving 1HACCP Plans 3-��02,11 Specialized Processing Nlethoods,� Device5 I ;;-1()1.11 1 I,,.ndova`hi;a2 Clc:�nscr.Availability 3-502.i 2 Reduced oxyeen pac�aging,crnera:� 6 '101.12 1 lond Di-vint,r1ru%ision 8-103.12 Coriffirmince�orith ApproNed Proceduros" lool)f"ood(cideoi 10SCIVIR)"MM00 CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: be- Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item PLEASE PRINT CLEARLY Verified /rd J,,(, I'd*9 k �17 f) a /'V q/na7' /Ch�7 71�71 �r4 Ae ll-lelf'l IA/ W%0,0/7 1,4 P .'zz�'4'7 Al 1z A 7)71Y'4��/,9 /7�� W 142� -11 ripl A,�f'r' C., e r).e AV h//,P/- /7/j-74�"-, Xelry F-D-i-scussion With Person in Charge: Corrective Action Required: El No Ll lea I have read this report, have had the opportunity to ask questions and agree to correct all 0 Voluntary Compliance L3 Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion comply with all mandates of the Mass/Fe4eral Food Code. I understand that E) Re-inspection Scheduled CD Emergency Suspension noncompliance may result in daily fines of twenty-five dollars or susp n/revocation of Ll Embargo 0 Emergency Closure your food permit. C3 Voluntary Disposal El Other: V 1 A�C'I PHFs Violations Re!ated to Foadfroque Mums#rrPrvPnPic,.--s and Pisit According I,Law Cool,d to Factors(items 1-22) (Cont.11 -11'E/4�'F Witlii it 4 Houm PROTECTION FROM CHEMICALS ;-501,15 Cooliro,Metho&ftr PHIs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202,1 AddiLt,,_.;* 3 ��O I 16(B) ('01d PfIFT.Mainouncel al:cs belov, L302.14 Protection front Unaatt'l trVed 590.004(F) 4 1 11151 F, Poisonous or Toxic Substances 3-501.16(A) Flot PHF,, Maintained at oraboie 7-1()].Il klentityinz efornrrtion --Original :40'F, I Cowai,iem ts Field at or abo%c 30'K 1 3-501.16(A) Roas 7-102.1 Nautz� - Workilt,C,:Tw,�,ners' 1 20 Timeas a Public Health Control I 1 3-501.19 Time as a Public Health Coorroll, 1-20 1.i I sep':falion-Storavu, 590.004(ltl Vat ianee Requirement 7-20111 Ret,iriction-Prc�vncv tuil, Us��' 7 ?02.12 tonchfiuns of I sot REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-1p3�I I Toxic Containt-,-Prothlution,v POPULATIONS(HSP) 7-204.11 Ctiterm--('t,,_!,TJ,_aF* 7-204�12 Clicitrucais for tVazhing Mixinix-, Cril.,,ri, 4 21 3401.11(A) Unpastein izod Pre-packagcd Juice,and 7-204.14 Bevcnaatt,with Warnoi2 I A)cls� Drying Agen's.critelia- 3-80i.I I(P) Use of'Paluctifized Eggs, 7-205.11 Incidental Food Contact I.ubric-,alts� 3-801�I I iD) Raw or Partialtv Cooked Aninial Food md 7-206.11 R��strkcied IT p jle�:jCltle., Criten 7-206.12 Rodent How, Statiom' Raw Secd Sprouts Not S-i ved. 7-206.i I,I_ 1-801.11(C) Unopened Fond Package \-Tt Re-served acking PowdcrI,Pest"'Oran] and CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-663�11 Consumer Ad%otojy Posted frir Con�urnptirar of 16 Proper Cooking Temperatures for Animal Foods I'luit are Raw.Undercooked or Not Otherwise Processed to Eflininate PHFs; 3-401.1�A(!)(2) Eggg� 15��F15,Se.. Pathogcns�� Eggs-lu2mp.diate Seri-rcco 145�1'15se,,� i-n2.13 Pasteun/ed Eggs S absLitute to,. Raw Shell 3-401.1 (A)(2l *Corumilluttf4 Fish';vicatv&Came Etuto' Anitnal.;- 3 401.1 I(B 1)(2) Por�, and Beef Resist- 130�F 121 nim' SPECIAL REQUIREMENTS 3-40 1.11(AY.1) Ratittst Injecucil Meats -1 ttPF 15 590.00Y(A) (D) Violations of Section �90.009(AJF(D) in catering. mobile fn�)(I, temporary and 3-401.1 I(A)(1) Pouht%-, W�!d Game. Stuffed PffFs, residential kitchen opcintions shoald be Sluffille Containing Firli, Meta, dcbitcd under the appropriate sections Pnuloyor Ratites-165 T 15 %cc. above if'related to foodborne illness 1-401.1 I(C)(3) intact Beef Steaks Interventions and risk foctors. Other 145'F 590.009 violatiorts relating to good r,;t,-jl i 401 12 Riu,Arvifud FoTds Cooked �n a practices should be debited under#29-- Micro-Aav, 165�tz I Special Rquircifients AE ()i�;ci filil"S- i4b�F 15 sec. 17 Reheating for Hot Holding VIOLATIONS R_-LATED TO GOOD RETAIL PRACTICES 40qAI(A;&(1)') PHF� 165T I )sec. (Items 23-30) (11.) vv!ic!ov,,tve- 165'r 2svinne, �tardiju, Ci iw al and nor.-critn.cll viotalions, ithich do not i elate to rile Tnii_�' I foodhorne illnesi into ventionsand fiskjo(lors litied above Call be 3-403.11(C) CoTnraorciallv Processed RTE Food- finaid in thejollowinA set.tions of the Fund Code and 105 Cttlitl? i 4t)tE r 590.000. (E) Rcuriaijurq� Llnqlk-ed llooivn�of Beef Item I Good Retail Practices FC_ 590-000 Rogsts" 2a. Marracientent and Personnel FC 2 .003 18 Proper Cooling of PHF-s 24, Food and Food Protection FG-3 004 00, 3-501 14(A) Coctlit;:-,Cooked PHK from I-0"Ft 25, LouipmPlu and Utensils FC-4 j 26, Water,Plumbincl and Waste rc-5 1 .00-6 0:1-Wilbur 2 Hours and From 70"r' 27, Phvsical Facifitv FC-6 i 007 to 4 JF/45"F Within.1 Hours. 1 28. 1 Poisonous or Toxic Materials FC- L-008 3-501,1,4(B) I Cooling PFIF�,,Made From Ambient 29, Stiecial Recuirements Fcfav�raturc sn�prediltlltq ro 4 1`17145T 30. Other Willoi 4 flours� I Dcivote,a w(al iinitni tl�o!'-dcral 191W F,md C,vie or 105 CNIR 5v()Out). Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Maria's Place File Number.BHF-2004-0068 10 Jefferson Avenue Salem MA 01970 LOCATEDAT: 0010 JEFFERSON AVENLTE SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0144 Jan 3,2006 Dee 31,2006 $150.00 ESTABLISHMENT Total Fees: $150.00 PERMITEXPIRES Decernber3l, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted ill a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 8 of 12 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 STANLEY J. LISOVICZ, JR. FAx 978-745-0343 MAYOR WWW.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL# ADDRESS OF ESTABLISHMENT J�--f�90�J KENUC ��kLEM 01C MAILING ADDRESS (if different) T OWNER'S NAME TEL#�JT&)S11-08gq ADDRESS CITY wlky�k\� STATE Vl*- zip UN(0 C, CERTIFIED FOOD MANAGER'SNAME(S) Fftla)bt4iJ �7ETC_CERTIFICATE#(S) 3V2d,�6 (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON V1*0 HOMETEL# HOURS OF OPERATION: Mon.��- Tuekn�rWed.o TYPE OF ESTABLISHMENT FEE Icheck onIv) RETAIL STORE YES 0 less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$1 00 more than 1 0,000sq.ft. =$250 -------------------------------------------------------------------------------------------------------- --------- --------------- NO less than 25 seats =$100 t-V (25-99 seats' — =$150 more than 99 seats =$200 ......................................... -- -------------------------------------------------------------------------------------------------------- BED/BREAKFAST YES 6�O $100 A1515if ----------------------------------------------------------------------------------------------------------------------------- MAKE (notjustse,-va') ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES *0 $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 kn:owled e and belief, have filed all state tax returns and paid all state taxes required under the law. t_ -�l — _ A )�'J C)I JOS .<7 Date Social Security or Federal Identification Number signa)(11, Revised 1 1103105 FOODAP2.adm Check#&D; CITY OF SALEM9 MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 0 1970 TEL. 978-74 1-1800 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: FOOD SERVICE Name of Establishment: Maria's Place Address of Establishment: 10 Jefferson Avenue Owner's Name: Hasan Zepaj Restrictions: Application Date: 12/4/2003 Permit for Food Establishment 131-04 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. HEALTH AGEN Ar CITY OF SALEM, MASSACHUSETTS Pit N2-.51V 117� 120 WASHINGTON STREET, 4TH FLOOR BOARD OF HEALTH SALEM, MA 0 1970 NOV 17 2003 TEL. 978-741-1800 FAX 978-745-0343 oP SkkLEM STANLEY LISOVICZ, JR JOANNE SCOTT, MPH, IRS, CHO AR D 0,F H E A LT H MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT K TEL# qJS JL19 1@1+ ADDRESS OF ESTABLISHMENT 10 k)F- MUF MAILING ADDRESS (if different) OWNER'SNAME TEL# ()88(-f ADDRESS C' W\� CITY veiktn)y STATE M PC ZIP uft(of) CERTIFIED FOOD MA NIAGER'S N A ME(S%MWQek)C-A-F:� 7 FICATE f2ft1_C=RTIr (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSONMK�WN F:TJ ZIEW,-L H 0 M E T E L q_�-5 6 3 HOURS OF OPERATION: lvlon.�-?;- Tue. L-3 Wed. �-5 Thu. �-3 Fri. 6-3 Sat.�-3 Sunli—I TYPE OF ESTABLISHMENT 0 FEE check only RETAIL STORE YES No less than 1 000sq.ft. =$ 50 1000-10,000sq.ft. =$I 00 more than 1 0,000sq.ft. =$250 RESTAURANT YES ) NO less than 25 seats =$1 00 QaI99 seats =$15W more than 99 seats =�200 BED/BREAKFAST YES $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 YES NO $25 ALL NON-PROFIT(such as church kitchens) A 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 be�t knowledge and b have filed all state tax returns and paid all state taxes required unde, t a law. 9 - 0L4�?- I I X 7, Flg�gture' I Date - Social Security or Federal Identification Number ------------------------------------------------------------------------------------------------------------------------------------- Revisedll/03/03 FOODAP2.adm Check#&Date lj—jo —o � CIA e�14 wl 1 . CITY OF SALEM BOARD OF HEALTH Establishment Name: Marl'dls Al ti-1— Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item PLEASE PRINT CLEARLY Verified A .11 d,"L.19kl -172 1-7 AP 5me U 0mv*�,7f- bq W4,0, aOW-el,,�- 'AQ J?4-V-X- rot&,/ 0,/,d A Vo A le.-o no 40 #W 47 bw Vsecl *.a CIA A4.14- bit _Ak_kA_14_ 0 44 Discussion With Person in Charge: Corrective Action Required: El No LI Yes I�h, U Voluntary Compliance El Employee Restriction have read this report, have had the opportunity to ask q2tions and agree to correct all Exclusion L violations before the next inspection, to observe all conditions as described, and to U Re-inspection Scheduled o 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 U Embargo 0 Emergency Clos I ure your food permit. u Voluntary Disposal 0 Other: '�.(C) PHFs Rcceived at Ternprraturcs Violations Related to Foodboi ne itiness and Firsk Accurding to 1�iw C Factors(Items (Coa) A I'F/45"F Wit III n 4 PROTECTIO14 FROM CHEMICALS Cootirta Mediods for PHFs PHF Hot and Cold Holding 19 14 Food or Color Additives 3-50 t 16(B) Cold PFIR, Mniniabied at or b-low 3-202.12 Additi%c,,y 590.0'04(F) 41�t450 F, 3-302,14 trout L':Iajrpro,,cd .Addili-,e0 3-501,16fA) Hot PHFs Mainturted at or above 15 Poisonous or toxic S--.bstancos 7-101.11 140"E Identifyine �nfonnitio� -Ongi.nal 3-50 1.1 6(A) Roists Held at or above 130"F. Co!I t f-�n ers Time as a Public Health Control cofam'at-Name-Worij o'C�vl 20 7-201.1 i Separation Slont, 3-:i0l 19 Time as a Ndlic Health Coniro!* 59rti-,04flli Variance RcquiremeDt 7-20111 R�mr;jwn P-cwnce and U5e" 7-202.12 Condr�')n-'of Usc�' 1-2o".11 -1foxic C(,nafireo;--ptohibiron."'� REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 sanitiz"I-�.Clitc)-o'--ChernicAls, POPULATIONS(FISP) 7-204�121 21 3-8t)1,11(A) Unpastenri led llre-packa�ed Juices and Chemical s f�x u ito"ia, 7-204.14 Do-ynig Atictim Craer:�t: Bever.ues with Warning 1-� I-W 1.11(R) U�e kJ'Paswurized Eggs, 7-205.11 ln,i6eioal Food 0,ntact.Lubricants* 3-801.1 l(D) Raw or Natially Co,-iked Anon.fl F,Kid ji�d 7-206�11 Rc�tfict-d U;;e PcqficideF,Criteria* Raw ScedSprouts Not Set 7-206.12 Rodont Ban 7-206,13 T!ackx,-Pw.ders,P,�,t Coi.uol and 3-801.11(C) Unopened Fotxl Package Not Re-served� CONSUMER ADVISORY TIME/71EMPERATURE CONTROLS 22 -1-603.11 Congurier Advisory Posted lot Con�uroptien of In Proper Cooking Tem.p�Vrakures for Anint,il Fraids fhatnic Raw,UndvrLOOked 01' P417n Not Otherwise Procr�sed to Eliminate 1-401�I I A(l)(2) 155c F I"Scc. llatho.pens.': Eg-es-lnurlediatll �5tfv�,c N5715scc* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-461.1 I(A'i(r!" C-,oIin;mo;-d Fish,Meav, &Gaine A;:ooal�; 15-i'l" 0 sec. t 3 40 1.11(Ll,�f 10 1 llwk and Beef Roast �30�F 121 min' SPECIAL REQUIREMENTS 3-40 1.1 !(A'(2) Raines, lnj�octl I�i eats- I 1.� �90)09(A)-(D) Violation�ol Section 590.009(A)-(D)in set. �! catering, mobile food, temporaryand J 10JAI(A)(3) Pouhry.Wiitl Gaine,Stufled PHF�, residential kitchen operations should be Smffing 0,ntaiow�,,Fish,lvle�i, debited under die appropriate svctoin� Poulir),cr Ratites 16-,�F 15 �ec. above.if related to foridborne ilhics's 3-1,01.1 IfCjt'3) nitact)--�A Sicaks interventionsand risk factors. Other -590.009 violations rclatino,to good retai i 3-41-11.12 Raw Ai;;,oul Fou'ds cok,d ina practicesshould be debited under #29- Nliciowmp 165'P* Special Requirements. 3-410 1.11(AP0)(b) Al: Other PILPs- 145'F 15 see, 17 Reheating for Hot l-Jo!d:qq VIOLATIONS RcLATED TO GOOD RETAIL PRACTICES 3-4�)3 11(A�&(D) ill-IFs !65'-'-' 15 .,ec. 1' (1 terns 23-30) 3-40111(6) ?VIiL;-o%avc- 165�F 2 Minute Standinj; Craicaland non-crilwal violations, which do nor relaw o,th, I I roc'� toodblorne illn�ss inte,vewiom� and iiskfarrors listed abovc. �an be 3-403.11(C) COnmicrndIv Ptoc.-,�sed RTE Food found iT,4iefollumeng so-lions qrthe Food Code and 10�C1WR 4WP'� 590.00o. Good Retail Practices FC 59OX00 'i-40', I VE) Pennaining UashcM 1 onions of Beef Fir—ern ---—--------- 23. Manatiament and Personnel FC Rox,!s�' I —i 2 .003 18 Propet Cooling of PHFs Food and F Piotection FC-3 004 2 cuiomc 'ot F)� E and U ensils FC-4 '005 3-50114t;\) oorny Coovc 4 Pf Ifs floor 140'F to 1 26 water.Plumbirat and Waste FC-5 1 006 70�F'V,':th:n 2 flours Dlid i-rom 70"T 27 Phvsical Facilitv F-C - 6 .007 to 41'F/45-F Within a H�,Lio,. 28 Poisonous or Toxi, Idaterials FC--7 .008 3-50 1.1-1113) Cool:n,- Ma&Yrons Ambient 009 21, 1 Soocial Re�,uiremenls Tempe,utti,c lnarc":cins, to 4 1�F/45L F 30, Other Wiflim ilours,;� s,,dmil .... �r 1�;s("NIR 5af" Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4 1h Floor Salem, MA 0 1970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date Tyild of ODerationisl Tyge of Insoection -)T)l P4&7 al le Rr Food Service Eyl Routine Address Risk El Retail Me-inspection Level Residential Kitchen Previous Inspection Telephone 17 21, 5?/1/ El Mobile Date: 6V Owner HACCP Y/N El Temporary El Pre-operation El Caterer El Suspect Illness Person in'Oharge(PIC) Time Bed&Breakfast El General Complaint Inspector In: El HACCP Permit No. El Other I/ MA&X�� Out: 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) E] action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT El 12. Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/Duties F] 13. Handwash Facilities EMPLOYEE HEALTH E] 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El 3. Personnel with Infections Restricted/Excluded [] 14.Approved Food or Color Additives FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals E] 4. Fo6d and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) I 5. Receiving/Condition 16.Cooking Temperatures 6. Tags/Records/Accuracy of Ingredient Statements 17. Reheating 0 7.1 Conformance with Approved Procedures/HACCP Plans E] 18. Cooling PROTECTION FROM CONTAMINATION 19. Hot and Cold Holding El 8. Separation/Segregation/Protection 20.Time As a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) [110. Proper Adequate Handwashing E] 21. Food and Food Preparation for HSP El 11. Good Hygienic Practices CONSUMER ADVISORY E]22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N)violations must be corrected immediately or within 90 days as determined by the Board Official Order for Correction: Based on an inspection r,' Health. today, the items checked indicate violations of 105 CMR 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 2f. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. ater, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you Pt 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 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-WSPECTION: S 50MV�Wo�-14 Print: Print: Page.Lof 2-Pa es 9 77 Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTLC'I'iON FROM CONTA?V..INA71ON FOOD PROTECTION MANAGEMENT Cioss-c.or�13minafior, I I 5,)0.003(A) I Assignment of Ru�pon�difflt,' �'-.'02.11 M Raw AniritiFnods Sepi I t in 590.003(B) Demonstration of Knowled'-c COoked' and RTE Fo�,Lisl 2-103.11 Pei�ouiti charge --duties ko,�iRaur lngrodiemts 3-302. (A)(2) Raw Anim;d 5.ods �,'ez-ajoited licin Fach EMPLOYEE HEALTH Othel I 2 S90 003W) Responsibility of the purson in charge to lonfamiriator,�orr,The Frivironmem iequire jetiotting by fo 1 3-302.11(A) Frtod Frot�ction- applicants* 3-302.:5 Wa-,Jung Frj':,i and 590 003(F) Responsibility Of A Food Employe Or,'Lu 3-304.: ! !�nod Contact with E,,�uipnieiu and ApplicajaTo K-pori To'rht Per,'on.lo ljwllsj�'S-� chajae, L-ovalii?'�,�IKIPTrrn the C,'0,j3UaT9r 59�1.003((i) Reocatiago bi Pelson in Chjao_CT 1-306.i 4(A)(B) R s�ttrue0 �d and IZ e�,,cr,�ce of Fool 131 Exclusioos aa�RcstriLtions%t 013pos-aa-i of A,%iforcivi or Cor. -00,003(E) RenanNal of Exclir,,ionqand Req-tictions 3-70 LI i iz'�jid:n'"a.Rec�.. FOOD FROM APPROVED SOURCE 4 Food and lValet Frout Reguicaed Sources �ood Contact Surv6ces Walcwa�!ImL "un aw* hio' Water 111)11 ia a� '90.004(A-B) . c will Food L 3-201 Food in a Hermetically Sealet Coiu�nnerl S.tnit:,afion'!ejnlj�r, 4-5 6 1. J 2 -lotkkater 3-22-0'1 Fluid Milk and Milk Products� I �'-I 3-21)2.13 Shcil Eggs� ;miti7ation Tenipcoauoss� 4 R, s and Milk PiAtwL,. Pas 4-�ul.114 Chemical Sanitization-temp.,PH, 3-20' 14 19 tcurized� I I 3 202.16 lc�Made From Potabl� Drinking,Water- �oncelar,,,ont,and lt�dalex-.. 4-60 Lil (A) Equilumm P.v�d Coi,,�ct SU)faOtS and 5-101.11 Drinking Watec front an Appiovcd SN�Leju- I 590 006(�) Bottled Drinking Water* Aeusl 1,clea:r' -Moncv ol Equipment Food- 590 006(ri) 'Atlet Meet�Swrdar&i;� I 10 CMR 22.0* 4-602.1 (Aenmo� prc�- Shefffish and Fish From an Approvoct!Souxo I CoruW and Utensfl,' 1 4-762.11 F'.*,-',Iuen('v.�f'��,,i:6zatien of Uteredis and 3-201.14 Fisit and Recreationally Caught Moiluc�a F(wxj C�o",,,Ct Stfl`!�CCS 01'EuUuaturm� slitillish* 4-703 i I M�J.WS 01 SaauiZ�a'011,-'flut Water and 3-201.15 Molluscan Shellfish from NSSP Listed Ch-rrxal' sources* ILI P�opee,Adequate Handwashaig. G�me and VIM Mushrooms Approicd by Rt�qufatorf,AWhorih; 2 MIA 1 00,�i(201,,�Itjou--Hands ind Armis" -2-0 2,18 Sh�ilswvlk Identification PresenV� 2-30:.j 4" Cle-vvn�i I uoj.�zj 5)0.004(Q Wild Mushrooms* W11-n lo wasb- --i-201.17 Game Animals� if Good Hygianic Practices neceiving/Condition USijs�oba,Co, Pfll`� Receive([at Propei Temperatuies 4(,-1,i 2 Di�chaiges Front da-Eyes, Nose and 3-202.11 3-202) 15 Packalpe fntegrity� 'vlouth� h)I L! Prcvcnt:ng Cout jn�wilwn Wlicn Tisting4c 3.101.11 Food Safiewd Urjadtdterato,� '4 1 Prevention of Contamination from,Hands Tags/Records:Shellstock 3-201 i 8 Shellstock Identifivitoon* I 3-203.12 Shellstock Identification Ma;ntained' Elliploveese Tags/Records:Fish Products 13 fiandwF7h Facilities 3-1-0111 pa'-asitc Corwj,1,-vnt,4,Located arid/locs�c siblo 31-40112 Records.Creation and Retention' 5-203.11 Nuuih-rs and Capaoots� -'-Ma 11 Lxx,lion and Placern�nV: 5,)0 0040) Labeling of Ingredients' 5-205.11 Ojvn�don �.Ttd Coliformence witt,App,oved Procedures &,ppi'ed with Sea,and Hati'l Dryog MACCP Rans 3-J02.11 i specializc'i Processing Meth*ds* 9pvic-7'5 i 6 30-1 Availlab6;',y 1 3-102.12 Keduc,t!oNygen packaging,criteria" 8-101:2 6-30 1,!2 quad L)rvi,,.-,Prov";ion I Confo,-rruipe.e with Approved Proi;edtue�i' D,tt,te�;,,ndual acrn ia Vie�edewl ;�199 Fwd Codeoi 105 CsIR�90,0(0. CITY OF SALEM BOARD OF HEALTH Establishment Name: Af, Date: -0 1-/ Page: '�2 Of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PI FAqF PRINT CLEARLY h A� '-7A9'L� -y4- �Z_/ 'Z 11��tk (_A/ /�/,w-.e' 011W Ae-7' 6 �-X 157 7-d- I Z/ L Corrective Action Required: 0 No Lj tea Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all U Voluntary Compliance U Employee Restriction Exclusion fore the next inspection, to observe all conditions as described, and to U Re-inspection Scheduled U Emergency Suspension violations be 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 LI Embargo U Emergency I-osure your food permit. Ll Voluntary Disposal U Other: W -501.14(C) PHF� Receiv-dat Viotallcers Reloted to F=1bvtnr Illness Inforvonflon-,and Risk According to Law Cooled to Factors otems 1-22) (Coqtj 41 F/4s'F Within 4 Houts 3-501,1 Coohne it-1-fth"ds fo:PER; PROTECTION FROM CHEMICALS t )4 Fund or Color Actdiihics 19 PHF Hot and Cold Holdiqg 3-501.16(B i Cold PItFs Maintained it or below 3-202.1 1 S00.004(F) 41 '/45�F* 3-302.14 Pr-,Aection Unap:)t.M�d Ad is Poisonous of I oxic substanca:� -501.16(A) Hot PHFs N4,4-intained at cs abc-e 140,1F. 7-10 1.1 Identifyin,2 !nl�',nmatjon-On inal 501.16(A) Roasts Held at(I: above I-,()'F, 26 Time as a Public Health Control -?-102,11 co-aw"on Nlinic-Workin-�("wiailiv,10 Z-%L 19 Time it,;a Public Heaftlk ControP' 7-101 11 S,--paraihm-Slonige' soO.004(H) vWtunce Rectur'-tactill 7-202,11 -Pre;ence and (.3c, 7-202�12 Conditions Us�, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.I I Foxi,Coritain,-r�-Pnl�b;boioni;- 7-21)4.11 CrItelia-cheinicei" POPULATIONS(HSP) 7-204 1 henllca;�for Washine Produce,Ctilei ia 1 23 3 801 1 I(A) UnpaEicurifed Pre-Imckaged h6ces and 7-201.14- Bevcraize� With Wta-11in, I"Ibels* Di vin, A-�ent,Crja-�rhi 3-801.1 l(B) Use Of Pastem izvl�--s� Incidental F,od C,ntict,Lubri,,a-.--, - Raw in Pat tiallv Cooked Animal Food a 7-?06,11 Restricted Use Nsticidics,Crner;al' .1-301 J(D) Raw Seed Sprouts Not Served. I'd 7-206.12 R,dent Bail Siatiotiis' -, I 1 3-801 �I(C) Unopened Food PacLauc Net Re-sQc\-�d. - 06.0 trackint,Pow&t.,,Pe,,t Cootrol aud Nionitormel CONSUMER ADVISORY 22 3-603.11 Consumer A6iskny Posted for Consumption of TIMEITEMPERATURE CONTROLS Ammid Foods That are Raw.Und-rcookedor 16 Proper Cook;nq Tempeiatures for Not Otherwise Processed to Elinintaie P111's Ir U0111 3-40 L 11 A�1)(2) Eirus- 155'17 15 See '0113 paillogeres" tpn:.'ediate Scrvi�e 1451 l5f-cl PasleuiiiedE,, �Substituh: lei Riot Shell 3-10i�1 I(A)fl) ,10mndnutc.,� F,sh. M,Zats& Game E.ggs� Aninails-15��F --�see SPECIAL REQUIREMENTS 3-40 j.: I(1b)(1)(2) Pork i�nd �,c�'Roast- 13VF 1-'l mul' '90 001)(A) 3-40 i.I j(A)(2) Ratite�,indected Me-as- 54"j-, I -(D) Violations of Section 590.1-)09(A)-(D) in catering, mobi le 1'(xxl, temporary ai id 3-40 1.11(At�1I Re'llry, Wild Garne, Stuffeti PH!'s, residential kitchen operations should be StuFline 0jitainiruw Fislo. k4tal debited undet the appropriate sectjon,� Poultryor Ratites-165"F 15 set 1 iboNe if related to Foodborne illness 1 40IJ IkC)(3) Whoie-initscie, VAact Bcot Steaks interventions and risk factors. Otber 145'F* 590.009 violalions relating to good i ei-ail 3-401.12 Raw Animal Fo�id,;G,,,kcd in so practices should be deNied under #20- Special Requirenients. 3401.11(A)i I I(b) At I Othei PHF� 145'F I� see. 17 Reheating for'lot Holding VIOLATIONS Rv.LA TED TO GOOD RETAIL PRACTICES 1-103.1 1 1 A)6D) PflFs lfi�'F 15 sec. * I" (Iteins 23-311) 3-403.11(B) Mio owave- �65'F 2 Nfinule Standim, Ctitical and non-o-areal I ioialiuns, which do isor rclate to Iha Tini-� fivdhortte dfisess intervoitionsand tim�:.J�cso,i listed above, ccm be 3403 j I(C) Commercial1v Piocessed RTE Food - finitid in ihefollowing sc(tioilt b(,o(I Codt, ald 105 01R 140-'Fo 590.000. 3-403J !iE) R,maiwn,Unslice.-I Pottioni of Beef* item Good Retail Practices FC 590.000 Rlt);ists' "'3, ManatternerIt and Personnel FC-2 003 18 Propef Cooling of PHFs 24, Food and Food Protection FC- 3 004 25 1 Etimpment and Utensils FC-4 005 3-J0!�141,%) Cooi:ng Cot,ked PHF� front 1401'to �6. 1 Wate Plumba-(j and Waste FO-5 (1106 70'F N�ifll;n 2 Houts;in([Fr,ni 70'F '17 11 Phvsi,'al Facilitv FC--6 007 28 -1-Poisonous or To=Materials FC-7 C-08 3-50 1.i 4(b) coo�:IIL PHE� Mode Fmin. 29, Spe-daij Requiramems '009 - Other lemperatute Ingredient�it)-I F/45 F oo Within 4 Hours- D�no,e, ,ilieit v�fn in tkiedta! 11a;1)Fsal Cvd�o, 105(',\it<�qo.000. Massachusetts De&rtment of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4 1h Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date T�yrc(f Ooeration(sl IV( a of Instlection Fo At Food Service [111 Routine Address Risk El Retail El Re-inspection /^ �,i A,- x,,re57- Level Residential Kitchen Previous Inspection Telephone - 7 �q_- A)7 ?4 El Mobile Datex.9, .2 3 0 lv,4 HACCP Yftl 0 Temporary El Pre-operation 61' El Caterer El Suspect Illness Person in Charge(PIC) Time Bed&Breakfast F-1 General Complaint ?4_Attj ti -7/--Mj In: [-I HACCP Inspectora rXhr,0_Afi2,A_ V� /%/" Out: Permit No. El Other Each violation checked requires 6n 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) [_1 590.009(F) El action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT El 12. Prevention of Contamination from Hands F� 1. PIC Assigned/Knowledgeable/Duties El 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS E] 2. Reporting of Diseases by Food Employee and PIC [114.Approved Food or Color Additives [] 3. Personnel with Infections Restricted/Excluded El 15.Toxic Chemicals FOOD FROM APPROVED SOURCE 0 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) E:1 5. Receiving/Condition El 16. Cooking Temperatures E] 6. Tags/Records/Accuracy of Ingredient Statements 17. Reheating El 7. Conformance with Approved Procedures/HACCP Plans 18.Cooling PROTECTION FROM CONTAMINATION El 19. Hot and Cold Holding El WSeparation/Segregation/Protection El 20.Time As a Public Health Control Q/9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing [121. Food and Food Preparation for HSP Ll 11. Good Hygienic Practices CONSUMER ADVISORY El 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N) violations must be corrected immediately or within 90 days as determined by the Board Official Order for Correction: Based on an inspection of Health. today, the items checked indicate violations of 105 CMR E_-N- 590.000/federal Food Code. This report, when signed below 2 . 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 ater, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: A- S 5�lns�ctFo�14 d� Cns*ctq,,1,spfnat r Print: PIC's Sign�iure: 11)q I?'�,Al 6 -IV 4?1-p I Print: Page_4 or 2�p ages Violations Related to Foodborre illness Irterventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGFMENT 8 1 I 5000(�13(A', As�lj�iiuleat Of Res,(ns!Vliw i I 3-31)`_ 1 ItA)N) R�v. Aninial Fo,,,�.s Sepa(aLed horn 590.00-1(B, Cookedand RTE,Frx)dO 103.1 i I'Li-son in cb,.m�c--dutir-, Oo.maruirari�nfront[?�,vl 1,grodients 3-302A I�A)(21) R;lv,Anim2i F,.03 Separated front Each EMPLOYEE HEALTH Uthcrl 2 590.003(C) Resp,)nmbility of thcoerson in charget." onann�jtio:�intin th&Eriv,,toorricni irclaim o.purting lb� fl-lod cruployeei and 1 3-302.1];A) Food Fr,irectio'l, 3-302.J S Wa;hing FrutF anIJ Veietabie�, 590 00-,(F) Reponsibilitv OfA F�w)d Ftriployee OrAn 3-304.11 F,.xxl G�ntactw;th Equiptueni and Applicant To"Rcpo,iT,,,rbe Pam I I Chat�pc* Cor"arm"atior'lorn the'C'onsainor 51,0.003(G) Reporting by P�rso.n in 0�,iri_,e 3-306.1 R,wimcd Food and Rcsci vicz of Food- .1 �130.G'030�') ExchiFionsand ResuictionO Dispmdiun ci Adifirerred or Contaminated TY 0.C,0 1(E) Reiftovalof Exciusionsand Restrictions F",I i Re, Unsafe FOOD FROM APPROVED SOURCE Foo(i 1� I 41 Food and Water FromRvgulated Sourres 9 Fvod Contact Sudacx� 1 590.004(A-B i Compliance with Food Liw�� 501 1 i i Nlautu�� Warewashini,-Plot Wat,f 1 3-201.12 Food in a HertriencalN Scaled Container" Sar6ti7n,on'l 3 "ol 1; Fluid Milk and NI'lk Products* MeLhanical Warcwash;.ITO Water � 2u-.13 She]I E'-s* -4-?',)2 11 E,,Is and Mi'k Products. Pasteuri7eir 4-5�)LI 14 Cileinical pit. 3-202.16 to- Wide Mein potable Drinking Water- 4-6tJ 1,11(A) Equipinold Food Contact Surface�and Drinking Walei boot an Anproved Sysican, I�ten�;ib(']can' �90.006(A) Buttled Drinki ng Watei-'�: -6u2.1 I Cleaning, Frequrrtc,,(it Equip.m.,tit F.-s,,d- Water M"ts Stardaids iii 3 10 CYIR 22.0)1 1 I Contaci Surfac�s and U�tn�qk Siledish and Fish From an Approvod Sourcq I I FrPqiw,-.;_-v of Sanitization vi Uttamis and �t 201.14 Fish and Recreationall) Caught M(,.Ilu,,.can Foo�j Contad S�rfaoes,of Fquipment� i Shellfish, 11 Nlatho&of S.ainizatiort-I lot Water and 3-201 1� Nqofluscan Shellffi,h front NSSP Liried I ( I Sources' 10 Proret.A'claqveie Hvn6warthinq Came and W)d Mushroom Approved by Rc�vueifory Authority 2-V 11.11 C!,aa 0�raljtnq)-11and'sand AnnO 3-202,18 Shellsto,k ldcntific�,tion Prescin* Cicanin-Pmcdur�� i 590.0(WU Wild Mushroorrts,� 2-3M 14 When Ic Wrsh- 3-20 1.17 Gnu, Animals* Good Hygienic Practices Receeflng/Condition 2-40LI 1 1-:u;;:_,, Tobacco'z i 20-7.11 PIFF;Received at Ptolitr Teuiperatuies 2-401�1 14 i Dirdialgo,Fro:Z1,he"'Y"s, No3c and �-202 15 PaLkage integrity* 1 MwUM �01.11 Food Safe and Unadulicrated 3-30 �.12 Prmentim,Coreantination Wficn T-isting' 12 Pm%,-qi:on of Conlarninittion fmrr Hands 6 Togs/Records:Shelltac.1i 3-202.1 S�ellstcrclz Idt-o.:ttication 590.001�F) f1rcNe,ioo, f.orn S 3-203.12 hellstack Iderifificalion Ntaintaiae&' 13 Handwash Facikvz3 TagstRecords:Fish Products Canverventi,Lxatpd ondAccessitee 3-402.11 Parasite Destruction7l 3-102.12 Revords,Coeation arA Rctention* Num'hlr;and qjucn�cs� 1 5-20-1,, 11 li,�efi:ion and PlaccunQnt-, 590.L;04(J) Labeling of Ingredients* 5-205.11 Ao-ersibility,Cipcianor, al Conformance with Approved Procedures /HACCP Plans Supphbd with Sop and�iand Dqing 3-502A 1 Speciahzed Procming Methocf;* 7vvices 3 i02.i 2 1 Reljuced f�x�yen packaging..criteria' i 6-30;.1.1 ifindwash;m,O,Ntu�oi,Ava:l,hht�, f Conforaimice with Approved lltocedure� 6-�101 12 Hand D-mm,Prov;�inn l0()9F,,,od0x1eoi MCMR.,Q0.1)00, CITY OF SALEM BOARD OF HEALTH Establishment Name: 1(4vfy(,)A 'r ip L-,f aL Date: '-Z/ Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item PLEASE PRINT CLEARLY Verified '"JO17,e A&4zk- //,:2" g A�P_ /7 /1'�147/V_7 m7j r- /'r 7V&C hl '�F�1'/ 1:-676 P - A14 -0/5'MA171'e '0 CI_ a Saw,, r 41 aX11— A'4�e'e 9"a5?'_71S /7)�� 11r--z'ed4 /�—ff //t/cipd R 7 -2 �C-d(� 7-9ZZ) _'A"6'F'e T""M' AleP�X_ L/ Discussion With Person in Charge: 2 A1411F, Corrective Action Required: 0 No U yes 4(11,011v I I I e-�Z I*riae� 1 correct all LI Voluntary Compliance 0 Employee Restriction r I have read this report, have had the opportunity to ask questions and agree to Exclusion violations before the next inspection, to observe all conditions as described, and to 0 Re-inspection Scheduled 11 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 0 Embargo D Emergency Closure your food permit. 11 Voluntary Disposal El Other: 3-401 40 PHFs Received at Temifcr�vo�s ViolationsRelated to Foodborne illness aucrvenrionr and Risk 'Aacoldint,it,Law('00"d to Factors(items -22) iCard.) 41 T/45�17 Within 4 lionts 1-:,()1.i 5 Cooling Methods lor F'rIFs PROTECTION FROM CHEMICALS 14 Ford c, Color Add,'hias 19 PHF Hot and Cold Holding 1 1-50 1�10(H) Co!d PIfFs' Mainunned ator bc!t,w 12 Addill�es* I 14 �90.0040F) 4 1'/45"F,' 15 Polsilnous or Toxic sub'Aances 501.161A� Hot PHF,IvLantainci,t(i alycrtz 140'F. * I i Ir)I.Il hicifif3r.,io, Information-(jogine! Roasts Held ot oi above 130'F. ontainc.s Time as a Public Health Control -,-Io_'.I! Common NLqrx:- Wo4ing Contam, 3-501 F) Tini, as a Public Health Cojaro� 590 004(H) Variant,e R�quiocnreni 7-202-1 1 P��:riction-Prcs�ncc an.d Uscl' 7-202.12 G nchtoor.s(if tl�el 7-203,1 i Toxic Ptohibitiem':- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.i 1 Salliti7er�'.Cl ter4t' - "llellu'als* POPULATIONS(HSP) ?-1-04.12 C: 21 1 3-80 1.11(A) lmi�votcuriz,_-d Prc-packaged luicc��an,,- '.effll�ab. i�jr riteria� Bevcragc�,vith Warnin'-, Lkibels� 7-,i(A.14 D1011",A'�`nts. iat: 3-80 1.11(B) Use of li`a�teuijzed E�,,** 7-205 It lncidenta�l Foot:Cont�:,t. _,�rlwants 3-80) 1 1(D) Ka\v cii Partially Cooked Aninial Food and 7-206,11 Rcstrited USC POt�oL14,,e", Cr!�,Mt� 7-20r, 12 Rodent Hatt StafionO' Ra� See,(Sprouts Not Scri,2d. 3-801.!1(C� Unopened Food Packilize Not Rc-�crvcd. 7-206.13 Po%vdot�� Pest C�,,jlroi ;aid Moritorinal CONSUMER ADVISORY 22 3-603.11 Consumer Ad�isotv Pasted for Consunipliori TIMEITEMPERATURE CONTROLS Anonal Foods'lliat"are Raw. Untoro-,ked or Pieper Cooking Tumpamiures,for Not Otherwise Proces.wd to Eliminate 3-401.1 IA(l�(2) PHI's Erys I�3'17 15 So, 3-302.13 Pasteurized F,'�Substitute foi Raw Sht-11 Lg,,,s- Ini:n,thate ScLvic� 145' Fl '3-40�,1!(Al(2) Comminuted H."n. Mz-:11s&0"ono Egg Animals- I�5+ Inec. �� 3-40I.1;(R)(I)(21 F'o;'L it' Bt-f Roa�t I�()'F 121 ffrin'� SPECIAL REQUIREMENTS 3-401.1i(All(2) Ratitet.. ho�ctrd Ivlcol�- 155'F t� 500 009,'A)-(D) Vlolaflcrm� of Section 390�009(A)-(D) in catering, mobile itiod, temporary and 3 401.1 I(A)(,) Poohry, Vold Oamt Stuffod PHF�. residential kitchen operations should be Staffing Containing Fish,Me--t. debited undei the appropriate sections Vouhrvur Ratiws-165'F 15 cc, t ahove if related to loodlitanc illness 't461 It-,C)f3) wh."!�-O'a�sce� !;",:),;t Hoot Ste�'�'s interventionsand risk factors. Other J45-F 4 590.00c) violations relating to-0od retail 3-401.11, RaNV Aflinvil Foods Cooked wa practices should he debitod under #29- If.5,F� Spectil Requirements. ov'a" 3401.1 FA)(it�b) All Othe. PHFs 145 F I 17 Reheating for"at Holding VIOLATIONS RJLATED TO GOOD RETAIL PRACTICES -3-403 1 I(A'&(D� PHFs 16�-F 15 s�c. - (Items 23-30) 3-405.1 It 11)) !v`jicrowavL- 165�'F 2 TYlopile Slandin, Critical cold non-erithal violations, which do not relou.,it)1hr, Tl 1�oodborne dioess hst,,dabove, be '1-403,1 Vc) G-,n-,nwciaII%1 Piix�esled RTEFood- jolind ill l/lefit-Roo Ing'e(tolliv qj"Ille kooel Code and 105 CAIR 140nF �()0.000. 3-403�11 kF) F,.trairang Litshced Pianons of Beef item Good Retail Practices FC 590.000 R, i 2& 1 Manaciement and Personnel P�c .003 18 Pieper Cooling o4 PHFs 1 24. Food and Food Protection 1 FC 3 1 004 25 Equipment and Utensils 1 FC- 4 .005 Water, Plurnbinci and Waste 1 FC 5 006 3-501 14�'A) Cooliln,Cookel PHFs firom i 40-F iOT Within 2 Hoursand Frow 70'F i 2- Physical Facility FC-6 �007 �o,l I'+/,I��F Within 4 Hour,. 28, Pasupous or Toxic Materials FC -7 .008 3-501.14illt Cooling,PHT's NI-de Fivin Anibwrit �29, i Special Requirements 0109 Femperature Ingretherti,,to 41 fj'-1,S'F 30 Other Wilhin 4 Hour-,� Donoic,,,;rici�[ii,q)i i thc[,&ral 199��Food Co&o, 105 C'Ak z90.1100. CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 1 20 WASHINGTON STREET, 4TH FLOOR SALEM, MA 0 1970 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 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 : Hasan Zepaj Name of Establishment : Maria ' s Place Address of Establishment : 10 Jefferson Avenue Type of Establishment : FOOD SERVICE Application Date : 12/16/2002 Restrictions : Permit for Food Establishment 85-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. q"144EALT/AGENT CITY OF SALEM, MASSACHUS BOARD OF HEALTH ETTS 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 0 1970 TEL. 978-741-1800 CI-I Y U'F- 6ALLM FAX 978-745-0343 BOARD OF HEALTH STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT—Jr-q TEL# q1d--7i-1Q ? 2(1-7 ADDRESS OF ESTABLISHMENT 1 /1 MAILING ADDRESS (if different) OWNER'S NAME A r\1 P Pr TEL# 4-P'I(V--S 3Z- ADDRESS e- 1P 71P ,3 Ci-if P�-D(6 Al F�4- STI AT E W1 0 CERTIFIED FOOD MANIAGER'S �AME(S) Map_( o 7, S) _I,CERTIFICATE#( (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON M A P,16 �Z -C-- P a�S HOME TEL#A7)( HOURS OF OPERATION: Mon.--�—Tue.__� Wed. Thu. 0 Fri._�_Sat. Sun._�_ -4— TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO less than 1000sq.ft. =$50 1000-10,000sq.ft. =$1 00 more than 1 0,000sq.ft. =$250 RESTAURANT y 0�s NO less than 25 seats =$1 00 25-99 seats =$150 k,� more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowled andbelial?have filed all state tax returns and paid all state taxes required under the law Sigi Date i 0--q-0-LSocial Security or Federal Identification Number Revised 11125102 FOODAP2.adm Check#&Dat.-J,)A,—C>rL- TI41E 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 / / Jyne of Onerationts) Tvoe of InSiDection / /ZA�o K Food Service Ll Routine Address Risk El Retail El Re-inspection Level Ll Residential Kitchen Previous Inspection ITelephone �211Y 2�51V-IPI 2 1 El Mobile Date: IOwner HACCIP Y/N 1:1 Temporary El Pre-operation Z,�� F- 1 0 Caterer El Suspect Illness Person In Charge(PIC) Time El Bed& Breakfast El General Complaint Inspect I In: [I HACCP ot (?C/\ C4�:� Out: Permit No. El Other Each violation Checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. j I Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red IteITSI. Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) 71 590.009(F) El action as determined by the Board of Health. Local Law Lj FOOD PROTECTION MANAGEMENT 12. Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/ Duties El 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS El 2. Reporting of Diseases by Food Employee and PIC El 14. Approved Food or Color Additives El 3. Personnel with Infections Restricted/ Excluded El 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIMEJEMPERATURE CONTROLS(Potentially Hazardous Foods) El 5. Receiving/Condition El 16. Cooking Temperatures E) 6. Tags/ Records/Accuracy of Ingredient Statements 17. Reheating El 7. Conformance with Approved Procedures HACCP Plans 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION El 20. Time as a Public Health Control El 8. Separation/Segregation/ Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 9. Food Contact Surfaces Cleaning and Sanitizing El 21. Food and Food Preparation for HSIO El 10. Proper Adequate Handwashing CONSUMER ADVISORY El 11. Good Hygienic Practices El 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 CIVIR o Health. 590.000/Federal Food Code.This rei5ort, 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 revo6ation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: X4A /7 1.7/7 Inspector's Signature: e, 1,/1 0 Print PIC's Signature: Print: Pagf/of;��ages 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 i 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 thi 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 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 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 Temperatu 3-202.13 Shefl Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products, Pasteurized* Concentration and Hard 3-202.16 Ice Made from Potable Drinking Water* 4-60 1.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved Systenn* 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* Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* J 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* J Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 11 Good Hygienic Practices 3-201.17 Game Anintals* 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 ol 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* Tags/Records: Fish Products 13 Handwash Facilities 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 Placennent* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenan-cel IConformance with Approved Procedures /HACCP Plans Supplied with Soap and Hand Drying I 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: Date: Page: —<f of Item Code C—Critical Item DESCRIPTION OF VIOLATION PLAN OF CORRECTION Date No. Reference R—Red Item PLEASE PRIW CLEARLY Verified C Discussion With Person in Charge: Corrective Action Required: Q No U Yes I have read this report, have had the opportunity to ask questions and agree to correct all U Voluntary Compliance U Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to comply U qe-inspection Scheduled U Emergency Suspension with all mandates of the Mass/Federal Food Code. I unde�stancl that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of your food permit. U Embargo U Emergency Closure Voluntary Disposal Q Other FORM 734B HOBBS & WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 41'F/45*F Within 4 Hours.* PROTECTION FROA CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHT's Maintained at or below 3-202.14 Protection from Unapproved Addifives* 590.004(F) 41'F/45'F* 15 Poisonous orToxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 1400F.* Containers* 3-501.16(A) Roasts Held at or above 130'F.* 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 3-801.1 I(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels: 7-204.14 Drying Agents,Criteria* 3-80 1.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact.Lubricants* 3-801.1 I(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Critena* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations� 3-801.1](C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIMEfTEMPERATURE CONTROLS Animal Foods that are Raw. Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Eflectve 11112001 3-401.11 A(l)(2) Eggs- 155'F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145'F 15 Se'.-� 3-401.1 l(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155*F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D) in 3-401.1 l(B)(1)(2) Pork and Beef Roast- 130'F 121-Min.*1 catering, mobile food,temporary and 3-401.1 I(A)(2) Ratites,Injected Meats- 155'F 15 Sec.* residential kitchen operations should be 3-401.1 I(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodbome illness Poultry or Raines- 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 r29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165'F* 3-401.11(A)(1)(b) All Other PHI's- 145'F 15 See.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165'F 15 Sec.* Critical and non�critical violations, which do not relate to the 3-403.11(B) Microwave- 165'F 2 Minute Standing foodborne illness interventions and riskfactors listed above, can be Time* found in thefollowing 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 Rcasts* 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. 01 CITY OF SALEM, MASSACHUSETTS 0 BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 0 1970 TEL. 978-74 1-1800 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 : Hasan Zepaj Name of Establishment : Maria ' s Place Address of Establishment : 10 Jefferson Avenue Type of Establishment : FOOD SERVICE Application Date : 07/30/2002 Restrictions : Permit for Food Establishment 310-02 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 CITY OF .4 MASSACHUSETTS 0� HEALTH 120 WASHINU,QN STREET, 4TH FLOOR SALEM, MA 0 1970 TEL. 978-741-1800 a FAX 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, IRS, CHO 6�_ MAYOR HEALTH AGENT 2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT PP L TEL# qr7 ADDRESS OF ESTABLISHMENT—/O MAILING ADDRESS (if different) OWNER'S NAME '�J TEL#_W- 5 2 (�Xf ADDRESS 17 nAAnQ,;�_-#\ j T CITY STATE 4/114 ZIP to I CERTIFIED MANAGtRS_NAMQS) lt<hC) ; CERTIFICATE#(s)' �� 'p"h- VQ , (required in an establishment where potentially hazardo'usTAd is prepared.) EMERGENCY RESPONSE PERSON 0) ell AZ_Zr-_L Y 74"1 DAYS / HOURS OF OPERATION: Mon. �77 %OME TEIL# _\�,__Tue_\,L-Wed_6L-3hu.kc Fri.-V—Sat.AA—Sun^/ TYPE OF ESTABLISHMENT FEE check only RETAIL STORE & $40 RESTAURANT NO $40 BED& BREAKFAST YES $40 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT SOFT SERVE YES $5 TOBACCO VENDOR YES $10 NO CHARGE FOR NON-PROFIT(suc s 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 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 tax returns and paid all state taxes required under the law. ,,4^d, F Y�1, 5,A �/ 1,Y,6 2- 0 1-;,> �r 2- D 7 6 (-) Signature/ 'It/ Date Social Se6unty or Federal Identification number -------------------------------------------- ---- ------------------------------------------------------------------ Revised 11/1101 foodap2.adm Check#&Date THE COMMONWEAI-TH 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 Dale 1) Type of lnsDecligll TyDg gf 9ofirgligri 00 KFood service W'Routine Address r, El Retail ED Re-inspection L I, ,els vel El Residential Kitchen Previous Inspection ITelephone 2X 2 Irl 7 F1 Mobile Date: IOwner HACCIR Y/N El Temporary E3 Pre-operation OF)-_� El Caterer El Suspect Illness IPerson in Charge(PIC) Time El Bed&Breakfast 1:1 General Complaint I C), In: El HACCP IInspector Mc-- Cn- L_�; Out: Permit No. El 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) El 590.009(F) F action as determined by the Board of Health. Local Law E] FOOD PROTECTION MANAGEMENT El 12. Prevention of Contamination from Hands El 1. PIC Assigned/ Knowledgeable/Duties 13. Handwash Facilities EMPLOYEE HEALTH X PROTECTION FROM CHEMICALS 2. Reporting of Diseases by Food Employee and PIC El 14. Approved Food or Color Additives 3. Personnel with Infections Restricted/ Excluded El 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) 0 5. Receiving/Condition El 16. Cooking Temperatures El 6. Tags/Records/Accuracy of Ingredient Statements El 17. Rehealing El 7. Conformance with Approved Procedures/ HACCIO Plans El 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION El 20. Time as a Public Health Control 8. Separation/Segregation,/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 9. Food Contact Surfaces Cleaning and Sanitizing El 21. Food and Food Preparation for HSP 10. Proper Adequate Handwashing CONSUMER ADVISORY El 11. Good Hygienic Practices El 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food,,Code.This report, when signed below C__N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: P PIC's Signature: Print: Pag/0,�Z Pages FORM 734A HOBBS&WARREN -BOSTON Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMIIIATION 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 k EMPLOYEE HEALTH Other* Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Charge* Contamination from the Consumer 3-306.14(A)(B)l 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 FROM APPROVED SOURCE I Food* 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 Temperatur 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sannization Temperatures* .t 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.14 Eggs and Milk Products.Pasteurized* Concentration and Hardness* 3-202.16 Ice Made from Potable Drinking Water* 4-60 1.11(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 3 10 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 Shellfish* Food Contact Surfaces of Equipment 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Game and Wild Mushrooms Approved by 10 Proper,Adequate Handwashing Regulatory Authority 2-301.11 Clean Condition-Hands and Arms* 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* it Good Hygienic Practices 3-201.17 Game Aminals* 2-401.11 Eating,Drinking or Using Tobacco* 5 1 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 Placernem* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility.Operation and Maintenance 7 Conformance with Approved Procedures IHACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 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: vv:'� Date: /-f, Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION PLAN OF CORRECTION Date No. Reference R Red Item PLEASE PRIW CLEARLY Verified 0C 43 U -:;;i� V 9 r6 Q CA 5-- C_C>Cvo - d-) 6T 5� -n Vj> —k C�p cce- (A--�r_x_-�� I V-)-C 6 le7 1,7'1'-)Am E — 0/0 [,--7 r 'S7- I z/4 C) P5- V\'-�C>__�F_ r, rD r-N F_' ef-e')rvn 6n- C Ic -+-c 1 12; g-�i 1_?1e<0,; rt,--) -4 '..-n-'6S� Discussion With Person in Charge: Corrective Action Required: Q No U Yes I have read this report, have had the opportunity to ask questions and agree to correct all Q Voluntary Compliance Q Employee Restriction violations before the next inspection, to observe all conditions as described, and to comply Exclusion Q Re-inspection Scheduled U Emergency Suspension 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 your food permit. J Embargo U Emergency Closure U Voluntary Disposal Ll Other FORM 734B HOBBS &WARREN - BOSTON Violations Related to Foodbome Illness Interventions and Risk 3-501.14(C) PHFs Received at Te�nperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 4 1*F/45*F Within 4 Hours.* PROTECTION FROA CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41OF/450F* 15 Poisonous orToxic 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'F 7-10111 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-Chernicals* 21 3-801.1 I(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels' 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.1 I(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206 13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* ElleclvO 11112001 3-40 1.11 A(l)(2) Eggs- 155'F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145'17 15 Sec 3-40 1.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS I Animals- 155*F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D) in 3-401.11(13)(1)(2) Pork and Beef Roast- 130'F 121 Min.*1 catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 Sec.*1 residential kitchen operations should be 3-401.1 I(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodbome illness Poultry or Ratites- 165'F 15 Sec.* interventions and risk factors.Other 3-401 1 l(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* 3-40 1.11(A)(1)(b) All Other PHFs- 145'F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165'F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165'F 2 Minute Standing foodborne illness interventions and riskfactors listed above, can be Time* found in thefollovving sections ofthe Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 1400F* 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. CITY OF SALEM BOARD OF HEALTH Establishment Name: Marill' s Pj'5t"_f' )o Je,17�-sw A.,e Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION PLAN OF CORRECTION Date No. Reference R-Red Item PLEASE PRIW CLEARLY Verified M .11pj e )19a..1 R 6-4((j�e 'y 0 e1ll 3A_P� 10 PAO rd 4 Q ^10 a� be C'pe�'-rl kl"A a&I a 1 4 7j,j f'L� I -74'/5 S/74 )4� 47 u qw�J xy 4 t2ii 0r 'JbI' C' f""�' 0 V Discussion With Person in Charge: Corrective AoVtKo_n_Requlred-`-'�' U N Yes ru U Voluntary Compliance U Employee Restriction I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion violations before the next inspection, to observe all conditions as described, and to comply Q Re-inspection Scheduled U Emergency Suspension 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 your I od permit. 0 U Embargo Q Emergency Closure Q Voluntary Disposal El Other FORM 734B HOBBS &WARREN - BOSTON Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Te�nperatures Factors(Red Items 1-22) (Cont.) According to Law Cooled to 4 1 OF/45OF Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 4 1 OF/45'F* 15 1 Poisonous or Toxic Substances 3-50 1.1 6(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 1410F* Containers* 3-501.16(A) Roasts Held at or above 130'F. 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590 004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* 7-204.14 Drying Agents,Criteria* Beverages with Warning Labels* 3-801.1 I(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders. Pest Control and Monitoring* CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for not Otherwise Processed to Eliminate PHFs Pathogens.* Effecfte 11112001 3-401.IIA(l)(2) Eggs- 155'F 15 Sec. 3-302.13 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145'F 15 Sec.*� 3-40 1.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155'F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.1 l(B)(1)(2) Pork and Beef Roast- 1307 121 Min.* catering, mobile food,temporary and 3-401.1 l(A)(2) Raines,Injected Meats- 155*F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodbome illness Poultry or Ratites- 165'F 15 Sec.* interventions and fisk factors. Other 3-40 1.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relatim, to.-ood retail 1450F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165'F* 3-401.1 I(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) 3-403.1 l(A)&(D) PHFs 165*F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165'F 2 Minute Standing foodborne illness interventions and riskfactors listed above, Call be Time* found in the following sections of the Food Code and 105 CMR 3-403.1 l(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 4 VF/450F 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/45OF 30. Other Within 4 Hours* Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C—Critical Item DESCRIPTION OF VIOLATION PLAN OF CORRECTION Date No. Reference R—Red Item PLEASE PRIW CLEARLY Verified 4)11)D,-) I '7L r C—,!:n�" 4f Rv� Discussion With Person in Charge: Corrective Action Required: Ll No Q Yes I have read this report, have had the opportunity to ask questions and agree to correct all U Voluntary Compliance L) 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 J Re-inspection Scheduled L11 Emergency Suspension result in daily fines of twenty-five dollars or suspension/revocation of your food permit. U Embargo L11 Emergency Closure Ll Voluntary Disposal L11 Other FORM 734B HOBBS& WARREN - BOSTON Violations Related to Foodborne Illness In[erven[ions and Risk 3-501.14(C) PHFs Received at Temperatures Facrors(Red Items 7-22) (Cant.) According to Law Cooled to � 41°F/45°F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14'" Food or Color Additives 19 PHF Hot and Cold Holding � 3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below 3-202.14 Protection from Una roved Additives* 590.004(F) 41°F/45°F* � �.f��P�:';15;;. Poisonous orToxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°E* � � Containers* ' 3-501.16(A) Roasts Held at or above 130°F.* 7-102.1 l Common Name-Workin Containers* "�`20- Time as a PubliC Health Control �. 7-201.11 Se aration-Stora e* 3-501.19 'Iime as a Public Hea][h Control* 7-202.11 Restriction-Presence and Use" 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTBLE 7-203.11 ToxicContainers-Prohibitions* POPULATIONS (HSP) 7-204.11 Sanitizers,Criteria-Chemicals* ��21f` 3-801.1 I(A) Unpastwrized Pre-packaged]uices and 7-204.12 Chemicals for Washin Produce,Cri[eria* Beverages with Waming Labels* 7-204.14 D in A ents,C[iteria* 3-801.11(B) Use of Paste�rized E s* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Panially Cooked Animal Food and 7-206.1 I Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served." 7-206.12 Rodent Bait Stations* 3-g01.11(C) Unopened Food Packaee Not Re-served.* � 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY ' 22� 3-603.1 I Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw, Undercooked or � 16�� Proper Cooking Temperatures for not Otherwise Processed to Eliminare ,: .'. .. PHFs e�u�e vvaom Pathogens.* 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 Pasteurized Eggs Substimte for Raw Shell Eggs* Eggs-Immediate Service 145°F l5 Sec.* 3-401.11(A)(2) Comminuted Eish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A}(D) Violations of Section 590.009(A)-(D)i❑ 3-401.11(B)(1)(2) Pork and Beef Roast- 130°F 12t Min.* catering,mobile food, temporary and 3-401.11(A)(2) Ratires,Idecred Meats- I55°F 15 Sea* residentia]kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Smffed PHFs, debited u�der[he appropriate sections Smffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F IS Sec.* interventions and risk facrors. 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' 3-40L11(A)(])(b) AIIOtherPHFs- 145°F ]SSec.* VIOLAT/ONSRELATEDTOGOODRETAILPRACTICES �=�17��. Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Criticnl nnd non-critica!violations, which do not relate m the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness in�ervemions nnd risk facrors listed nbove, rnn be Time* found in the following sec�ions of the Foad Code nnd]OS CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. �4�°F" Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Ponions of Beef 23. Mana ement and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 "">18`; Proper Cooling of PHFs 25. E ui ment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbin and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Ph sical Facilit FC-6 .007 to 41°F/45°F Wi[hin 4 Hours.* pg, poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. S ecial Re uirements .009 Temperamre Ingredients to 4I°F/45°F 30. Other Wi[hin 4 Hours* "Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. � � R ,,� m � � �� S , �_�o�✓ � ��o�R . � ��:�d � w�-! _ � � � � � A � o �' � � � � 4 � J �C� � Sr� "�. 3 ��5� �` � � � ,a�e � � �. � ��- ��,� � I.�oov ' � p�kQ �k��-� ��, �� ; � ,� .� � q , ��s 0 �, p�� f e��, .� �� J�_____— � f ,, � 0010 Jefferson Avenue Maria's Place City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: Item Status Violation Critical Urgency Telephone: FOOD PROTECTIOWMANAGEMENT 744-7817 PIC A:ssj�gneKnowledgeable/Duties FAIL Critical RED Comme Owner: Comments: No Certified food manager on duty at time of inspection. PIC to be trained and on hand at all times. Hasan Zepaj Non-compliance with: PIC: Anti-Choking PASS Inspector: Tobacco PASS John Gehan EMPLOYEE HEALTH Date ICorrect By: Reporting of Diseases by Food Employee and PIC PASS E%O I RED Risk Level: Personnel with Infections Restricted/Excluded PASS Se RED Permit Number: FOOD FROM APPROVED SOURCE 113HP-2006-644 Food and Water from Approved Source PASS FV1 RED Status: Receiving/Condition PASS RED Open #of Critical Violations: Tags/Records/Accuracy of Ingredient Statements PASS RED 5 Conformance with Approved Proredures/HACCP Plans PASS EVI RED Time IN: Time OUT: Urgency Desc(iption(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately orwithin 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 06,2006 ) Page I of 7 Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS Sofl RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED immediate corrective action) Proper Adequate Handwashing PASS RED Y, Good Hygienic Practices PASS RED NA Prevention of Contamination from Hands PASS Sofl RED Handwash Facilities FAIL Critical RI RED ,.�mmants: Hand wash sink has no soap dispensing at time of inspection. Dispenser to be fixed to provide soap. J;fo' nt hand wash sink has no soap. Provide soap. ?--�Front hand wash sink has no paper tovinvels. Provide paertowels. PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS RED Toxic Chemicals PASS RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS RED Cooling PASS RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS FA RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 06,2006 Page 2 of 7 Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE mments: Uncovered foods in"fast foods"refrigerator. All foods in storage must be covered. ,0 ati5eal cmritainer missing half of its cover. Provide cover. ,,�Iafhe�unit mquires proper label. Presently labeled flour. ��more freezer in back room has uncovered foods. All foods in storage to be covered. �machlne has accumulation of grime and mold on inside. Thoroughly clean and sanitize ice machine. ce�Scoop stored directly on cardboard box next to ice machine. Ice scoop to be stored directly in ice with handle exposed or in labeled container stating"ice scoop only". ,,,�more reezer has uncovered meats stored in freezer. All foods in storage must be covered. ��fl�more freezer has opened and spilled peas within. discard any loose peas. All foods in storage must be covered. ,,JM covered breads being stored in back prep area. All foods in storage must be covered. X"�Ious personal items located throughout back area. All personal items to be store in designated employee areas. L_�awing at room temperatures. All thawing foods to be stored correctly and at proper temperatures. Wt-bucket found with accumulation of debris within salt. Discard salt and clean and sanitize bucket thoroughly. Desdd�msects observed resting on tops of several food containers in back food prep area. Have exterminator closely check for insects. c�ebeneath food prep area holding foods not labled. All foods not in original containers need to be labled. L_��dsm refrigerator labeled"fast foods"had uncovered foods. All foods must be covered when in storage. ,Zdm�emlrigerator-ha'cl foods that were in containers not labeled. All foods not in original containers must be tabled. �IlRefriger5torlabkd"coke"had uncovered foods. All foods must be covovered in storage. �,-�alf cooked bacon resting on ready to eat foods. Store potentailly hazardous foods separaetly to prevent cross contamination. L.Jmall refrigeration unit behind counter has uncovered foods. All foods in storage must be covered. �So-ld�nchef refrigerator has uncovered foods. All foods in storage must be covered. "ritiall hazardous foods stored in uncovered pans directly on top of other uncovered foods in unit next to grill. All PHIF must be --stored separately to prevent cross contamination. LMn-c-owred muffins on front line. All foods being stored,must be covered. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSQD 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts Rev. Sep 06,2006 Page 3 of 7 Item Status Violation Critical Urgency rS be',ng stored incorrectly. Soups to be stored in smaller containers.to allow to cool peoperly. utter underneath grill being stored at room temperature. PHF to be stored correctly. Equipment and Utensils FAIL Critical BLUE � Comments: back refrigerator on left requires thorough cleaning. L-Sanig-rafrigerator missing thermometer. Provide visible and accurate thermometer. ZZ-�- Both Back refrigerators have-broken-handles.Repair handles. ��eer chest requires general cleaning. ,jyDxy�eolored freezer requires general cleaning. L_-SaTne-freezer missing thermometer. Provide visible and accurate thermometer. L>m1rore freezer in back room has no visible thermometer. Provide visible and accurate thermometer. .What ap LIZZj-peared to be a used mousetrap was being stored directly on food containers. If traps are not being used properly,discard orein correct areas. jce�achine has broken inside panel. Repair panel. M�Pped stored incorrectly. Mop to be stored so it is hung and allowed to air dry. Dishwash machine external theremometer not reading. Thermometer to be serviced. ,-O'tensil stored in back hand wash sink. Hand wash sink for hand washing only. L,4%�nmore freezer requires thorough cleaning. Kenmore feezer missing thermometer. Provide visible and accurate thermometer. L.M felving in back food prep areas require thorough cleaning. uATc-,owa,e requires thorough cleaning. j_r.arr�pener has accumulation of grime. thoroughly clean and sanitize opener. Knives in knife rack found with accumulation of grime on them. Thoroughly clean and sanitize knives. ,Kmf,rack requires general cleaning. Cmp"'tic-e-rrequires thorough cleaning. —Stove top irrb ack food prep area requires thorough cleaning. a-refrigerator in back food prep area requires thorough cleaning. 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 06,2006) Page 4 of 7 Item Status Violation Critical Urgency Same unit missing vent cover at bottom. Provide cover. Shelving that holds apple juice has accumulation of grime on them. Thoroughly clean shelves. three bay holder(green,orange,blue)that has flour etc in them has broken tops. Provide new tops or repair. Same container is unlabled. All foods not in original container in storage must be labeled. Daily sanitizing log not being filled out. Log to be maintained daily. i.-Nors'anitizing�test strips available at time of inspection. Provide test strips. L_.��gjastic gloves at time of inspection. Provide gloves to prevent cross contamination. Salad unit requires thorough cleaning. light cover over salad area missing cover. Provide cover. L��s Of front counter require thorough cleaning. Knives in front area stored incorrectly. All utensils must be stored in designated areas or containers. Lr!O�hef unit requires general cleaning I front area stored incorrectly. Ice scoop to be stored in ice with handle outside of ice or ina desinated and labled ice scoop only container. LMafious utensils on front food line not being stored correctly. Utensils to be stored in proper designated containers. Vtap'eus utensils on front line appear not being washed and sanitized between each use. Utensils to be washed rinsed and �sanitized between each use. �elvs beneath grill require thorough cleaning. , g boards not being washed correctly. Stored on floor then placed on in food prep area. cutting boards to be washed rinsed and sanitized properly and stored correctly. Water, Plumbing and Waste PASS BLUE Physical Facility FAIL Critical BLUE Comments: Back room screen door has ripped and torn screen. Repair screen to prevent entrance of rodent and or insects. Same door requires door sweep.Visible air gap. Seal gap. ,-A'ccumulation of food,grime and debris visible throughout establishment. Entire establisments floors,walls and windows require thorough cleaning. .--.-Back room has exposed insulation on ceiling. Floors walls and ceilings in food prep or storage areas have to be made impervious and easily cleanable. 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 06,2006 Page 5 of 7 Item Status Violation Critical Urgency 0�ac<room floor has molding vegetables beneath refrigerators. Thoroughly clean floor. - W16" V ath shelving in back room, requires thorough cleaning. ,--mffi'ng foods beneath and next to ice machine. Thoroughly clean and sanitize floor. .� Electrical box behind dish wash machine in disrepair. Secure box. ,.'�®r 1 n back food prep area has accumulation of grime. Thoroughly clean floor. —ffe—ciricai outlet covers in disrepair in back food prep area. Repair or replace covers. LXaftglover back food prep area require thorough cleaning. Hole in ceiling tile above back food prep area. Repair or replace tile. Behind juice glasses in front area has exposed wires. Repair wires. Screen door on side has torn screen. Repair screen. Ceiling tile above juice glass area in disrepair. Repair or replace tile. L.Fmntlfo—�r behind counter requires thorough cleaning. Water stained ceiling tiles observed throughout establishment. Find source of leak and repair. Replace tiles. Broken Ight cover over front food prep area. Repair cover or replace. L-Hore—iri floor next to back refrigerators needs to be corrected. Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes FAIL BLUE LScjm�en&:An alcoholic beer observed in kitchen refrigerator at time of inspection. Establishment not to have alcoholic beverages on premises. GENERAL COMMENTS: 734: 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 06,2006 Page 6 of 7 Item Status Violation Critical Urgency 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 06,2006 Page 7 of 7 oxnrr v�'� '�' j � y� CITY OF SALEM, MASSACHUSETTS � LICENSING BOARD ��Bqnur� 120 WASHINGTON STREET 978-745-9595 ext.421 NOTIFICATION FORM IF YOUR APPLICATION INCLUDES THE SERVING OF FOOD YOU MUST HAVE THIS FORM SIGNED BY THE HEALTH DEPARTMENT PRIOR TO SUBMITTING YOUR APPLICATION TO THE LICENSING BOARD. (this form MUST be signed and returned with your application). NAME OF BUSINESS N A �� II Corporate name: � d/b/a: � LOCATION: � � TELE. # TYPE OF LICENSE APPLICANTS INFORMATION Name: Mur eit�/�'�� Z�',�'<,� Home address: City: State: Zip: Home tele. # HEALTH AGENT/INSPECTOR'S COMMENTS: M�• Z�,�i� i 1�a7 �,c� ��-l-l: �-(z_ � I�r-�� E �pi / � � a c� � �"-1��-�-- �- '2.��i alth Agent � notification form 0010 Jefferson Avenue Maria's Place City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-7817 Handwash Facilities FAIL Critical RED Owner: I —Co-m-'m"'ent: Front vhandwash sink has cloth towel in it. Sink to be used for hand washing only. Hasan Zepaj I PIC: --5-a—m'esink has no soap hung up or paper towels hung up. Provide soap and paper towels. Marenglen Zepaj I Inspector: John Gehan Date Inspected:Correct By: 11/22/2006 Risk Level: Permit Number: BHP-2006-0144 Status: Open #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)7411-11800 GeoTMSO 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 22,2006 Page I of 3 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 C ent: Personal items being stored on shelves where food products are stored. Personal items to be stored in proper and Risk Factors (Require immediate corrective action) designated-areas. �wes found with accumulation of food debris. Knives to be thoroughly cleaned and sanitized after each use. ,,.-�e are labeled containers that were unmarked. Any food outside of its original container must be tabled. Labled at time of inspection. BAck-To orn requires light shields or cover. Provide protection. stored incorrectly in front. Scoop to be stored in designated tabled container or with handle exposed. �-J�Oop�i Lk��Ous f" s-6n-iiront line uncovered. Foods to be covered at all times. =anitizer reading too weak in back prep area. Adjusted at inspection to proper concentration. Sanitizer reading to strong in front line. Adjusted at time of inspection to proper concentration. Equipment and Utensils FAIL BLUE II.-Xomment:3-Bay container requites relableing. I.P"eral cleaning of coke refrigerator required. ��s cid refrigerator requires general cleaning. --K'nife rack requires general cleaning. �icllwave equ-ires general cleaning. v w, c r r �atslicer requires general cleaning. ..4ce machine requires general cleaning. '.�n mr ore freezer requires general cleaning. �M ,�efreeer in back room requires general cleaning. _,Pa,'k left refrigerator has broken thermometer. Replaced at inspection. ,�Sanitizing log being kept in advance. Log to be maintained daily. Physical Facility FAIL BLUE ,',�men�tBack food prep area ceiling tiles are water damaged or physically damaged in various areas. Repair or replace tiles. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 22,2006 Page 2 of 3 Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS0 2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts Rev. Nov 22,2006 Page 3 of 3 i �'�aL `} ��. � � 1 �Massachusetts Department of� 'Public�Health Salem Board of Health �` 120 Washington Street,4'"Floor Division of Food and Drugs f Salem, MA 01970-3523;�-�-----"""" FOOD ESTABLISHMENT INSPECTION REPORT ,° Tel. (978) 741-1804�Fax (978) 745-0343 1_ Name , , Date T f 0 eretion s Tvoe of Insoection -a�� Food Service aRautine Address � O^ � � Risk ❑ Retail b Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone �J� ` �' ❑ Mobile Date: Owner HACCP YM � Temporary ❑ Pre-operation � „ �,� � � �-1 ❑ Caterer ❑Suspect Illness Person in Charge(PI �J � /� Time ❑ Bed 8 Breakfast ❑ General Complaint � P.I�1G. ' G--c.(!I�Y' In:l Z� ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an explanatio; op thw arrative page(s) and a ci3ation of specific provlsion(s) violated. vNon-compllance wlth: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking, robacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ��9o.00s(� �., action as determined by the Board of Health. ��/I � (� ��- C'Ci /, FOOD PROT_ECTION MANAGEMENT�'��{��"-�,"] ❑ 12. Prevention of Contamination from Hands ��V �1 PIC Assigned/Knowledgeable/Duties NU �I ___ �� ❑ 13. Handwash Facilities EMPLOYEE HEALTH _ - - - PROTECTION FHOM CHEMICALS � _ _-- ----_ - ❑ 2. Reporting of Diseases by Food Empioyee and PIC " - '� �� s � ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections RestrictedlExcluded ❑ 15.Toxic Chemicals � �FOODPROMAPPROVEDSOURCE� - --��----" �- TIMEREMPERATURECONTROLS - ❑ 4. Food and Water from Approved Source a_ �(Potentieny tiazardoue Pooda) , � . �_ .� -__ - ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17• Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTEC710N FROM CON7AMINA710N� �, r a., r = . . ❑ 19. Hot and Cold Holding ❑ 8. Separation/SegregatioN Protection , ❑20.Time As a Public Health Control ----- __ �.._a. ❑ 9. Food Contact Surfaces Cleaning and Sanitizing � " �� `REOUIREMENTS FOR HIGHLY SU.SCEPTIBLE POPULATIONS.(HSPj�; - , 0 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing -��_❑ 11.GOod HygieniC P�aCtiCeS �ONSUMER_ADVISORY�.- � �.: _ � a �•� ,�:. ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related � Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions ❑ immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.00Offederal Food Code. This report, when signed below c x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations d 24. Food and Food Protection (Fc-a)(5so.00a) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-a)(sso.00s) the food esfablishment permit and cessation of food �1 � 26. Water,Plumbing and Waste �FG5��5so.00s� establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-s)(5so.00�) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fca)(sso.00e) and submitted to the Board of Health at the above address 29. Special Requirements (sso.00s) within 10 days of receipt of this order. ' 30. Other DA7E OF RE•INSPEC710N: �,a�_' � ' sssomspecr�o.�ia.eo� � �tkQ.. U\��a�'1 r�v�S ��-e-r� �x c �- �1��1 .� , Inspector's SignaWre: PrinL• �� .\_ � � / r� PIC's Signature: � `� , Print: ' Page�of 2-Peges i i't,�v v��cXJv'�1 �� , � �� Violations Related to Foodborne Iilness Intervenfions and Risk Facfors(ltems 1-22f PROTECTION FROM CONTAMINA710N $ Cross-contamination FOOD.PROTECTION MANAGEMENT 3-3Q2.11(Al(t) Raw Animal Foods Separated hom 1 590.003(A) Assia iment of Res onsibilirv' Cooked anct RT'E Fcxds* � � 590.003(B) Demonsteation of KnoH�led e* Contamine6ort from Raw Ingredlents 2-103.11. Person in charge�-dnties 3-302.1.1{A)(2) Raw Auunal Poocis Separated from Each Other" EMPLOYEE HEALYH ContaminaBon from the Envtronment 2 590.603(C) Responsibility of the person iu chuge to 3302.11(A) � Fcwcl Protection" reqave�epoitiug by fockl am�loyees and 33Q2.La" Washin Fruits:md Ve*etables a licacits* 3-304.11 Food Contact�vith Eyiripmenr and 59QOt)3(F) Responsibility Of A Fc�d Employea Or An � . � ApplicantTo Report To The Person In Utensils , Coniamination from the Consume� - C6ar �'" 3-3Q6.14{A)(H) Rahuned F�md and Rcservice of Food* 590,003 G) ke occin b Petson in Char e* 3 590.003(D) �ixclusinns aud ResL�ictions"� Dispasitbn of Adulferated or Contaminatetl Food 590.(H)3(B) 12emoval of Exclusions and Restrictions 3-707_11 Discarding oi Rewndi5aning tinsafe FOOD FROM APPROVED SOURGE r�� 4 Food and Water From Regulated Sources 9 Food Contact Surtaces � 596.Q(k}(A-B) Com�lianc�c with Food Law* � 4-561_ll 1 blanuai Wazewashiug-Hot Water � � 3-201.12 Foai in a HenneCieall•Seated Container� Sanitizalion Te eratives* 3-201.'I 3 P7�i,d Milk and�blilk A�oducts* 4-501.112 Mechanical Warewashin�-Hot Warec , 3-202.73 SheIIE s* SanidzationTem cr�tures*� � � 3-202.14 E s and Milk RuduUs,Pasteurized* A-501.114 � Chemical Sanitization-temp.,pH, '3-202.16 Ice Made Ftom Putable Ihinkin�Water" concentrarion aud.hazdne,ss. * 5-'L6,1.'t 1 Drinkin Water fmm an A roced S tena'" 4-G011 Y(A) Fa.1uipment Food Contac[Surfaces and� 590.006(A} Bottled Drinkin Water� L7tensils Clean* 590.006(B) Water Mezts SGmdards in 310 CMR 22.0" 4-602.i 1 Cleaning Freguency af Equipment Fc�d- Coutact Surfaces and Utensils* SheY�sh and Fish From an Approved Souroe 4-702.t 1. Frequency of Sanidzation of Utensils and � 3-20114 Pish ancl Recreatiemally Caug.Irt Molluscan Pewei Conract Surfaees of E ui�meut" ShellSish"` 4-703.11 Methcxis of Sanitizafion-Aor Wa[er and- 3-20115 Molluscan Shellfish from NSSP I.isted Chemicat* Sources* Game and Wi7d Mushrooms Approvetl by 10 Proper,Atlequate Handwashing Re Wato Author'd 2301.1.L Clean Cundition-Hands and Attns* 3-20218 Shellsrock IdenGficaYion f're�sent�* 2-301.12 Cleanin Pra:edure* 590.OQ4(C) 14i1d Mushrooms* 2-301.14 When ro R'ash* 3-207.17 Gamc Animals* 1.] Good Hygienic Practices g � ReceivinglCondition 2-�401..11 Eatin ,Drinkin or Usin Tobacco* 3-202.11 PHFs Received at Pra r Tei1i ecatures" 'AD1.12 Disch�rges Prom the Eyes,Nose and 3-20215 Packane inte rit�` Mouth* 3-IOL11 Food Safe and Onadulcerated* 3-301.12 Pieventin Contamination When Tastin "' � Tags/Records:Sheiistock .12 Prevention of Contamination from Hands 3-202.I8 �Shells[ock Identification" �yO.a�(F,) Preventing Contamination from � 3-203.12 ShellsCoek Identifiwtion T'LainYained* Em lo eea* Tags/iiecords:�Fish Prad�cis 1-� Handwash Facilities � � . Gonveniently Lxafed and Accesslble 3�tQ2.1 I Yazasite Bescraction - 5-203.11 Nwiibers and Ca aeities� 3-d02.12 Recoxds,Creation and Reten4on* � � 590.004O} Labeiing ot Ingredients' S-20411 Location and Placemen[* . 7 Conformance wlth Approved Procedures 5-20�.L 1 Accessibili ,0 eration and Maintenance tHACCF Plnns Supplied w'dh Soap and Hattd Drying 3-502.11. S ectialized Processin Meihc�s" Devices 3-502.12 Redaredbx oen acka"n�,criteiia" �-��>�•il Handwashin Cteanser,�Availabilit� 8-103.12 Conformance with� ;oved Procedures* 6-307.t2 Hand Dr 'n•Pro�ision °llenotes edtical i[em iu the federal 1999 F<wd C.odc ur I Oi CMR 590.00Q. � �� ' CITY OF SALEM BOARD OF HEALTH Estabiishment Name:'V�ti n i .� i i� �.1 Date: .��,l 1>—1� Page: c�- of �- nem code c-criacai nem DESCRIPTIO O VI ATION%PLAN OF CORRECTION Dete No. RMerence R-Raditem � (J � —��^ Verltled mEASEPRINT CLEAR�Y � � O Jn 1 �' C'n �r`L�� 1��' L'"11'6�� ,�II I /'�. /O O � � �� #-� n k� `c� i n o � I� r�:L UK-. � � Y�'vv"� �,., � �v / � � 1.��. (�� _ ^ 1� � V ( % r T1� fl itP �� ' ", � D. �- � ��-�4�j�� .� � �,n r: /� C `/ / l �J �^. - �� ! A/,� + OMn ✓) .�� .Nl. nA • � �---( T j� _ . � (�Y A U S..rJ.. i` I I�'�.a �-„ l`��V�_ . �Ol �/�1 / /�f.li.�fl— � ' �� n:��S .�C U I. `�,��r�r,,, � � . In�- ,4r 4!�' �- C �'S � . , .,��( I�-, , , �1'�' �l � �..o.-,� � �.� " 5 ' �� 7� � �) /�� /� Y�/" :��, � a n n/�P V� - C�,(�.w V �. ` ��/I`•-r/'`— r �- � U � i \ YICPI�'j1 n,r 1� a f B .�.P „„ � _. � , , �� ., ,, — •on � �Le11: -� � �l � . . .Dnn �o;� ( � ' � � - - (� n /�� n.NiD4,f.r o a 1 �0 8 , ( `�-'-6L �/1.�_JSL lX�-Ct/I.c . g /1 .R_� � ��.. /1 � j_r _ t '�:J +�� c � 7 -� tlnn�-� ' � � i � . v1 :1 /1. .p � � ) i.-,Pn o V C�n . � ' b ' C1�.�, _' -1(1 f, .� ,� � a ^. � � . . .� I �,�. N r r� o , - � �tP, � (' : ,.�. -� , n c ° , _ , � v .� � — ,� � , � � � ,� -P � a ,-� � �� Discussion With Person in Charge: -� Corrective Action Required: ❑ No ��les , I have read this report, have had the opportunity to ask questions and agree to correct all �/'Voluntary Compliance ❑ Empioyee aesviccion i Exclusion violations before the next inspection, to observe all conditions as described, a�d t0 �e-inspection Scheduled ❑ Emergency Suspension , comply with all mandates of the Mass/Federal Food Code. I understand that ��,� _. (�_t_ � � noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of o embargo ❑ emergency Closure , � your food permit. � r' , ❑ Voluntary Disposal ❑ Other: . - � . . � 3->�I,ld(C? PI3Fs Received at Tempernture�: . Viotaflons AelaCe�i to Fardb»nre Alness Intervt»tions an�t AisR According to$�w Caoled W Faciors(ltems P-22} {Cont.) di'Fl�kS°F Witiri¢4 Haiits.* PR�i'�C'TIOFI FRt3M CNEMtCALS 3-SOL.IS Cwlin Methods far PHEs 1¢ . � . . Footl ar Cntor ABditives � � . �9 .� S'F1P}iot and Cotd Hatding 3,202.12 Adrlitives" � 3-SOL16(B) Cold YI�Ps:�iaintained at ar b�ow _..._. S90A(kt{� 411�5 F* . 3-362.i�t Psotection�fromiJnap�roved:�.dcliti.es" 3-5011b(A} Ho[PHFsM�iintainedaYarabove - 15 Poisanausor�ToxlcSubsesnces . � 1��. * . 7-101,11 Identif}5ng7nfonnation-Oripnal 3SOI.ifi(A) Rc�r�Heldataabuvct30'F. * Conminers* � ZQ Time as s Putiic Hea�th Cantrol 7-102.11. Crnnuron 2dame-Wcrr�n Contai�r,±* . 7-201.t 1 Se 'on-St�ra x' 3-SD1:19 "Cime as a Pubtic FIealth Connol' 7-202.11 .Resn'icticm-Ptesenc:eend�Use° � 590.(nM(H� VarianceRe uiremeffi � 7-202.12 Catditians of lise+ p�qU1REME8VT^..^ FOR NIGNIY$USGEPYIBi.E 7-2U3.t 3 T�ic Casvriner�-Prohibitions* PQPULA710NS HSF 7-2Q4.11 Saniriurs.Criuria-Chemicais" 7-204.12 ChemicaSs for Washin Produue,Ctiteria" 21 3-801.i7(A) Unpastsuii2ed Pte-pttckaged Iuices aud 7-2U4.14 �n encs.Criteria° .Bevsa�aeec with W':uiuna Labe7s* � 7-205.11 fncidenW Food Contacrt.Luhiicnnts* 3-�Oi.11(E) Use of Pasteisized 8 as* 7-2U6.31 �Restricted Use Pestiaides;Cziteria� � J'g�� w ar Partially Cook.ed Aninull Foad and Raa Seed S s Nar Served. � 7-?06.12 � . Radent Bait Stakion.4�` 3-$Ol.tl C Uno ned Ftwd packa Nue I2e-sere'ed. " 7-206.13 Tracking Powdeas, Pest Contral and Monitcsrin " CONSUMER ADViSORY TIMEIFEMPERATtiRE CON7ROlS 22 3-603.21 Consumer:adi�isory Poated for Cansumprian erf 16 Proper Cooking Tempera4ures far .4nimst Fcwds ltiat xre Raw,Undetcooked or PNFs � � Not Otherwise�F'rcx.�essed to Bliminate 3-AOi.11A�ij(2} Eg�es- 155�l5 S�. paw�*�*�'��n�zxrr E �s-Fmmeeiiate Service 145°FtSse:.^ 3-302.13 Pasteurized Eg�.s Subs[imte for Raw SheF1 E ,� 3LL4Q1.12{A)(2) � � Cesmminuted Fish.Meats&Gatne , Ac3imals-U5°F 15 se�;. " 3-�i01.I1(SHl)f21 Pori;and Bee£Rmst- I30°F 121 mio' SPECIAL EdEflUiREMEPtT$ 3-401.1 i/A}(2} Ratites,3njeaed D4eats-15i°F 15 ��•��A}-{D) Vioiarions af Section 59@.(1Q9{A)-(D}in ��,� catezing,mobile food,temparan and 3-4(31.1 i(A)(3) Pauiny,t�'91d Game.Stuffea!PHHs, residentiat kitchen operations shautd be Shcffing Containing F'uk,R4eat; debiteci under the appropriaCe sectiffns Paal or Ratites-765'F t5 sec,* above if relatul to frwdtwrne iltness 3-401.11(C)(3) VJhole-muscle,Ihtact Beaf Seeal:s 3nterventious and risk factors. Ocher 145°F* 59tD.049 violations relxting to gocxl zetail 3-401.12 Raw Animat FarJs Cwked in a practices should be debited ander#I39- Micmwave 165"F x Speeiat Requiremenis. 3-�301:11(A}(1}(b) A2l Ot6er PI1Fs- 245°F 15 sec.� ;� Reheatiog€rn Hat Hold§ng VJOLAT/ONS RELA7ED TO GpOD RFfAPL PRACTICES 3-103:41{A}&{I>) PF�,1b5"F 15 sec. � (Items 23-30) 3-4fY3.Ii($) . Microwave-�IbS`F 2 Minute Stanc3ing Crilicat,m�d nors-critical veolations,whirh do nnt relnte to ihe - - Titne* � � foodbnrne rl7ness interventions and rislc factors tisre�3 above,enn�be 3�03.(I(C'� Cmnvtterciatiy Processed R'f'E Fo�i- faund in ihc follnndxg sectionS.of the Pood Cvde urrd 105 CMR l�°� S�.QU�. � 3-�tM3.11(E) Remaining linsliced Pcmlcros of I3eef . � ltem i Good Ratait Practtces fC 63AOt?D � Raasts': j 23_ i i�9an�pemsnt aad Personnei ��F��C-2 .003 � i lg Proper Coaling of PNFs V 2A.. ��ood and Focd Pro[ection FC-3 .OQ4 ;.. I 25. E ui menfandUtensiis FG-4 .W5 i 3-501.t4{A) Cooling Ccmked PHFs from I�10`F ro ; z6. Waeer.Piumtrin and Wasie �� FC-5 006 ; - 7D`F tiGirhin 2 Haus and Fron�70°F 27. � Pti ical Faci' : FC-8- .067 . ta 41`F!4$'F Within 4 Houts.* 28. Pasonovs w Taxic Materiais ! FC-7 .Q48 . 3-501.34{S) Couling PHFs kiade Fcom Ambient 2g. �S ecial R viremeMs � _009 Temperanare3agreciientsto4l°F/45°F ' � I Othflr __i _ - V✓ithin$HoutS* s:sror,:,m�::.uc_ "Drnoees aitieat i�.nx in the L^.der�i 1999 Fr.r,�l Code W�lU�G'N(t�90.O�p. � , �r � , � .. � .. �'r--*..._.:a F.+..,. .M._ . ., e Mass��husetts Department of Public Health Salem Board of Health � 120 Washington Street,4�" Floor Division of Food and Drugs Salem, MA ois7o-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name,,/� _ Date T e'of O eretion s T e }Ins ectlon I1 \7�R(`I��S ' ( FoodService outine Addre'ss � } � /��(� ^Sr ,� Risk ❑ Retail ❑ Re-inspection �F'� Level ❑ Residential Kitchen Previous Inspection Telephone (�� n� t� ( " ❑ Mobile Date: Owner HACCP YM ❑ Temporary ; ❑ Pre-operation Caterer -e.-f�� e .c/ ❑ Sus ect Illness 1-�t� � �_ ❑ P Person in Charge(PIC)M p /�\ Tim ❑ Bed&Breakfast ❑General ComplaiM � I � �(1.�C' .�v1�I c,� HA P Ins ector ��'�� Permlt No. � CC P ��G �P � �-..� Out: ❑ Other Each violation checked requires an�€x lanation on the narrative page(s) and a citation of specific provision(s)violated. -�� Non-complience 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),Q' sso.009(� 0� action as determined by'the Board of Health. C�^,,,,,� � � v �000 PROTECTION MANAGEMENT = � � ��.a ❑ 12. Prevention of Contamination from H�ds ...��.� �. .� ❑ 1 PIC Assigned/Knowledgeable/Duties �___ ❑ 13. Handwash Facilities 4EMPLOYEE HEALTH � �� _ _ _ -- 'PROTECTION FROM CHEMICALS, . ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Addftives ❑ 3. Personnel with Infections Restricted/Excluded _ ___ ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE TIME/TEMPERATURE CONTROLS(PWeMially Nazerdoue�Fooda) � ❑ 4. Food and Water from Approved Source _ —�-- - ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ,.�;- �❑ 6. Tags/Records/Accuracy of Ingredient Stetements ❑ 17. Reheating �7• Conformance with Approved Procedures/HACCP Plans ❑ �8�Cooling PROTECTION FROM CON7AMINA710N °�� •� ° - �� ❑ 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 HIGNLY SUSCEPTIBLE.POPULATIONS_(HSP); ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ONSUMER.ADVISORY — _ '• _ _ _ Q�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 of Healthely or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR c x 590.000/federal Food Code. This repoR, when signedbelow 23. Management and Personnel (Faz)(5so.00a) by a Board-of Health member or its agent constitutes an a(� order of tlie Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-a)(sso.00a) cited in this report may result in suspension or revocation of I (,� ' 25. Equipment and Utensils (Fc-a)(eso.00s) the food establishment permit and cessation of food 26. Water,.Plumbing and Waste �Fc-s��sso.00s� establishment operations. If aggrieved by this order, you 27. Physical Facility �FC-s��sso.om) have a right to a'hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fca)(s'so.00e) / and submitted to�the�Board of Health at the above address 29. Special Requirements _(s'so.00s)_.� _��, within 1.0 days of receipt of this order. �� ` ---- 30. Other r,,^ •"`?��" -J �DATE OF RE-INSP..ECTION: r'' CJ.--! D S:ssarrla�rec�ormsia.dx�.._..� � � Q �� //,�� \ . . } � �_ �i� v`^� V�U� l.C�(/�^✓�uQ� Li(JL�-"� ..,!. Inspector'sSignature:•-1 Prink i ' � PIC's Si�ature: ''7 PrLrt: Page 1 ot �ages i��, .� _ ,-�� , G, ��>> r�t ?�� ., � � o _ � � Violations Related fo Foodborne llfiess � lnterventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION $ Grass-contamination FOOD PROTECTION MANAGEMENT _ 3-3Q2.11(A)(t) Raw Animal Poods Separated f'r�m 1 590.003(A) Assi;�tmentofResponsibility` _� Ca�ked and R7'E Faxls* 590.003(B) DemonStration of Knowled�e°` Contamirtatlon from Raw ingiedients r 2-103.11. Person in charga�-ciuties 3-302.11(A)(2) Raw Aninv�l Foals Sepurated frcmi Eac6 Other* � EMPLOYEE HEALTH _ Confamirtation Irom the Environment 2 590.003(C) . Res�ponsibility aFthe p�;rson iq chuse to 3-302.,11(A) Fow3 Protectian" require rcpartiug by Y'ood emptoyees an�t 3-3Q2.15 W'ashin Fru3ts and Ve*etables � liamts* 3_;p4.1�, F�{��ntactwithEquipmentand 590903(� Responsibility Qf A F�xi Employee br rin Utensils* t�plicant Tu Report To The Person In � � � Contamination Irom the Consumer Cha�t e" 3-306.14{A)(;B) Returned Food and Rescrvi,ce of Food* 590.O03G) Reortinab PersoninChar�e* DisposftionoiAdWterafedorContaminated 3 590.D03(D) Exclusinns and Restrictione* Food 590.003(E) Removal of Exclusi,ons and Restrietions 3-70LI't Discardin�+�oe Reconditioning linsafe FOOD FROM APPROVED SOURCE ��* 4 Food and Water From Regulated Sources 9 Pood Contact Su�faces � � 59�.004(A-B) Com�liance with Food Iaa-'k 4-501.11 L Manual Wazewashing-Hot Water , � 3-201.12 I+"crod in a Hermeti,cally Sealcd ConYaioer* Sanirir.etion Te ratures* 3-2Q1.13 Fluid Milk and'Milk Pr�doccs* 4-5Qt 1 t2 Mechanical Warewashing-Hot Watec . 3-20�.13 Sheli E s* Szinitization Tem eraNres" � � 3-2U2.14 E s:md R9ilk R�oducis,Pasteuriud* 4-561.114 Che�mical Sanitizarion-temp.,pH; 3-202.16 ice Made Fcom Potahle I7dnkino 4Yater' concen�atiou and hazdness. �" 4-GOI..I](r�) Equipmen[N�ci ConCact Sarfac�s and� 5-101.1.1 Drinkin Water fmm an A roved S stem" . 540.006(A) BotUed Ihinkin*Water* L7tensils Clean° 5�70.066(B} Water Meets Stanciards in 310 CMR 22.0° 4-602.R Cleaning Frequency af F.quipment Foi�d- Contact Surf�aces and Utansils' Shel!lish and Frsh Fron,.an Approved Source q_��2 t� F�equen�y of'Sanitiz2tion of Uteasiis an�l . 3-20714 Fish and Reereali�nally Cau�t Ivlolluscan Foai Contac[Surfaces nf E ui mentrt Shellfish* 4-703.11 Methocls of Sani[izati�n-Hot Water and� 3-20I.]5 Molluscan Shellfisls from NSSP Listed Chemical* Sources'� 10 Proper,�AdequateHandwasliing � Game and Wi;G Mushrooms Approved 6y Z_;�� . � Clean Cundition-Hands and Mns'" Ae ufafo Authord 3-202.1 A Shellstnck IdenNfieatian Present* 2-3q112 Cleanin Prucedure* 540A04(C) 14%ild Mushrooms* 2-30L14 When to Wash" 3-201.19 Gam�;Animals* � ll Good Hygienie Practices � g ReceivinglCoodition 2-401.11 Eatin ,Drinkin�or Usin 'Cubacco* 3-202.11. PHPg Received at Pro er Tem eratutes* �4�,1z Discharges Fcom�the Eyes,Nos�and 3-202.15 Packa�e Ltte it " Mouth* 3-SOI.,F 1 Pood Safe and tJnadult�eratetl* 3-3pL l2 Preventin ContuninnCion When Tastin �' ( TagstHewrds:SAeIlstock 12 Prevention of Contamination from Hands � 3-20218 Shellstuck[der.uficNtioc' S90.0(W(E) YLeventing Cantaminaaon from � � 3-20312 Shetlstock Identific�tion Maintainecl� Em lo ees* � � - TagalRerords:�Fish Produa#5 13 Handwash Facilities � � � 3-402.11 - PazasiieDestruccion' Co�venienttyLocatedandAccessible - �-402.12 Recusds,Creaticm xnd Retentitm� 5-203.11 . Numbers and Ca acities� 590.00.M1(n Labeling ot ingredients' S-204.11 T�.ication and Placement* 7 Gonformance wiih Approved Procedures 5-205.1,1 �Accessibilit•,0 e�ation and Maintenance /HACCP Plans Suppfied with Soap and Hand Drying 3-502.1]. S ecialiud Processin lvtethods* Dev�es� 3-502.12 Reduced Os Qan ucka 'nQ,critaria` 6-301.]L F�L�ndwashin Cleanser,Avxilabilit� 8-103.t2 Confacmance wieh A xoved Yrocedures* � 6-301.12 Hand�Dr �n Provision *Denotes c�¢ical item in tlie federal 1999 Pa�Caic or 1 Oi CMIi 590A(Ifi. LA-) CV 9f.- CITY OF SALEM BOARD OF HEALTH Establishment Name—AN\CtAAZ(,4, Date: S-to Page: of it Cc e C-Critical item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date et R f rence R-Red Item PLEASE PRINT CLEARLY verified 0(4— lfl�(cor -z -e4— eePA ��,A-,,,�(C-I Y(0) 2,L, N6 - , . ( �� T 14� r Coo a 10 MO —VA OAAA Plp 0 00,1,4m k 011__e�" _6 0 IU �-4"A CPJ2AA� PA P PZn, C, 60 A SULUP- ()-4M4 U14 �Al AJJIAO ,�Ip'� Qt�'-�Ja ot 0100� k 0'4" "9Z 11 U_/K 1A'XA, cltA� 0� + V_��j Fk �A W()J�0� CIVI, &,?OA A_'� e-) (/h ,�__vp A ol" UAP19(�� Discussion With Person in Charge: Corrective Action iie—quired: o No J�A Yes I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance E) Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to inspection Scheduled 0 Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that _13C noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of 13 Embargo U Emergency Closure your food permit. 0 Voluntary Disposal U Other: , . _. 3501.L4(C) PHFs Received at Temperaturzs Violatians Refated to Faodbame/lines&7nterventlons snd Risk Accordino t�Iaw Cooled to Factors{$ems�t-22) (Cont.J � dt°F/45°F�thin4Hoiixs. * PROTECTiON FRQM CHEMICAI.S 3-501.15 C�lin Methods for PHFs I4 . � Pootl or Calor Additives 19 � PHF Hot and Cold Hoiding ' 3-501.16(B? Cold PHFs hiainfained at or beluw 3 202.12 A�dirives' S90.00�3(h� 41°/45°F* ' 3-302.1�1 Protection fram Una rrned Addiiives" 15 - Polsonoas or Toxic Subsiances 3-50116(A} Ho[PHFs Maintained at�or above 140°F. " 7J 01.11 Idemifying Infozmation-Original 3.501_I6(A) Roaste Held at oc above 13Q°F. '� �Contniners* � Time es a Pubiic F}ealth Controi �-702.11. Cummon ATame-Workin Containeis* 7-201.11 Se ara6on-Stora " � 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-Presenteand�U'se° � SJO.W4(A) VarianceR uirement 7-202.12 Conditions of 17se• . 7-20311 ToucCattainers-Prohibiflons"' REQUIREMENTSFORHIGHLYSUSCEPT18lE PQPULATIONS H5P 7-241.11. Sanitiurs.Crite�ia-Chemicals'* i 7-2(k.12 Chemicals for 9✓ashin Prcduee,L'ritexia° 21 3-801.11(A) Unp:�steurized Pre-packaged luices and � 7-204.14 in ents.Criteria" .Bevera es with Waznina Labeis*� � 3-ROi.I l(B) Use of Pasteurized E �` 7-2U5.11 Incidentai Food ConTact,Lubricants* 3-801.11(D) Raw or Partiall Cooked rinimal Food and 7-2Q6.11 �Restricted Use Pesllcides,Criteria�' Raw Seed S uts Nar Served* 7-30612 . Rodent Bait Staaons* 3-ROI.LI C) Uno r�ed Food Packa Not Re-servrd. " 7-2D6.13 Tcackin�Powders,Pe..ct Convol and . Monitcrrin * CONSUMER ADVISORY TIME(1'EMPERATUAE CONTflOIS 22 3-603.i t Consumer Advisary Posted for Consumptian of 16 Proper Cooidng Temperaturea fw An�mal Poods'Ihat are Raw.Undexcooked or PHFs Not Q[hera+ise�YProce�s�ed to Eliuuna[e 3-401.11A{I)(2) Eg�s- 155°F IS Sec. Patho ens.* E �s-Immedia[e Servic�e 145°FlSsec+ 3-302.l3 Pasteurized Eggs Substinrte for Raw Shell 3-441.1 t{A)(2) Commiuuted Fish.Meats&Game E � Animals-1�5°F IS sec. " 3-401.11(B)(1)(2) Pork and$eef Roast-130°F 121 min* SPECIAL REQUIREME►VT'S 3-401.11(A)(2) Ralites,Injected Meats-155`F 15 590.Q09(A}-(D� Violarions of Secuon 590.009(A}(D)in �� , catezing,mobile food,temporary and 3�0].11(A)(3) Poultry,Niid Game,Stuffed PHFs, rasidential ki[chen operallons should be StufSng Conteining Fish,A4eat, debited under the appropriate secfions Poui or Radces-165°F 15 sec. * abwe if related to foodborne illness 3-401.11(C}(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F� 540.�04 violations relaring tn good teTail 3-401.12 Raw Anima]Fmds Cooicec!in a practices should be debited under#29- Microwave i65°F* Speci2l ReqUirCments. 3-d01all(A)(1)(b) Atl Ot6er PHFs- 145°F 15 sec. � 1'7 Reheating tor tbi Ho�d7ng VlOLATIONS RELATED TO GOOD RETAIL PAACTfCES 3-003:t((A)&(D) PHFs t65�F IS sec.* (Item523-30) 3-403.11(B) Miccowave-�l65`F 2 Minute Standing Critrcul..med norz-critical violations,which da rsot relaie to the � Time'" foodtrorne illness internentions muf risk facto�s listed q6ove, can'be 3-503.t i(C) Commucially Processed RTE Foa!- fouad in the fallawing sections�of the Food Code and 105 CMR � 140°F'x 590.Q00. � . 3-403.11(E) � Remaining linsliced Porticros of Beef i item Good Refail Pmctices .FC 5� �R�a: � � 23. Man � ntandPersannel �FC-2 _003 � .I 18 Proper Cooiing ot PNPs - � 24.. Food and Food Proteciion �FC-3 .004 i 25. E ui ment and Utensils FC-4 _005 7 3-5d t.14(A) Cooling Ccroked PHFs from 140°F to �, W ater.PlUmbin and W aste FC-5 006 ' 70'F Within 2 Hcrurs and From 70°P � 27, � pti sical Faci6 > PG-6 .007 . to 41`F/45'F Within 4 Hcnvs. '^ 28. Pasonous w Toxic Materials ' FC-7 .008 3-501.148} Cooling PF[Fs Made From Ambient �. �S ecial R uirements ; .009 Temperemre Ingrcdients to 41°F/4.5°E �� tt'� - _-� Within 4 Hours" . s:sw,i�m,urt.zm� 'Unores criticai i�m in the federai i)99 Foai Code or lU5 G7NR 59U.000. - „ ' ti. tr .. - ,..r..i � .-y.,'w,�4'� i. , . ,a�fi `'. i�..". R, .. � , . �_ .. :n.,...!'4 -Mo.r�rr.�,s9�,�.�t�!�ro��" �JFM"y�.I•'.. A �^ l� ��.. �}_. �" � . M2�SS��chusetts Department of Public Health sa�em eoe�a or Hea�tn 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 Nam Date e of 0 eration s of Ins ection �d.�S �a E� �i t��0� FoodService Routine Address Risk ❑ Retail ❑ Re-inspection � � �P �-'� 'Level ❑ Residential Kitchen Previous Inspection Telephone � � ❑ Mobile Date: Owner �,\ HACCP Y/N � Temporary ❑ Pre-operation Yi, � c� K'x�lU. ❑ Caterer ❑ Suspect Illness Person in Charge(PIC)/'�� J Time ❑ Bed&Breakfast ❑ General Complaint l � Z"�'d2"n,1G� � P In: � ',GU��_ ❑ HACCP Inspector �� t � V `-i p��: ;� Permit No. ❑Other Each violation checked requires an expl�ation on the narrative page('s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Iliness Interventions and Risk Factors nnti-Cnokin� ronacco � Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) sso.00s(� action as determined by the Board of Health. ;�FOOD PROTECTION MANAGEMENT,'��, �`"��' �' ` e,,_„ „„„„, F„a F.. ,. ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties a ry p ❑ 13 Handwash Faalities �EMPLOYEE HEALTH � � �� ` � a � '� i"PROTECTION FROM CHEMICA�S "^" " "' "'° ' �' � ��'j ❑ 2.� Reporting of Diseases by Food��Employee and PIC � '�� .�„ s, �°�,.,��. � b�� .� �-� -�-- � .�� .��t � ❑ 14.Approved Food orCobr Addftives ❑ 3. Personnel with Infections Restricted/Exduded ' � d.� , m ❑ 15.Toxic Chemicals � F4�4. F Od APPROVED&�URCE„�,,,,,;,� :'� 16 " °`"�"� '. � T(MEfTEMPERATURE CONTROLS ctenUaH Hazardous FOodsj '�' �g ❑ and Water from Approved Source "F» �w � R' y �/ � ,=F. = � �,. a a ,e�,s, z.,_..�,a i�i.-, .� .. �a. a! /"`v1--t14 5. Receiving/Condition ❑ 16. Cookmg Temperatures `��, lJ' " ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ »• Reheating : '., ❑ 7. Conformance with Approyed Procedures/HACCP Plans ❑ 18. Cooling e' ' �g�^�� ° r°-- ^, ❑ 19. Hot and Cold Holding �PROTECTION fROM CONTAMINATION ' �:� � ' � � � • = ; �..� � wK .,z.;_,..b. .�w�x �,z �� :. ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control �vi �fl 9. Food Contact Surfaces Cleaning and Sanitizing � �;REQUIREMENTS FOk HIGHLY SUSCEPTIBLf POpULAT10NS(HSP)�� ❑21. Food and Food Preparation for HSP � ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices 3��CONSUMEH ADUISORY, e "` ,�_`� °,� ,�,�,,,�,._ _ n�"��,r�„ ,�,-„�� ❑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 Ilinesses 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 pfficial 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 � ' � ' ^ by a Board of Health member or its agent constitutes an 23. Management and Personnel �FC-z��sso.00s� ' order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-s)(sso.00a) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(sso.00a) the food establishment permit and cessation of food 26. Water, Plumbing and Waste �Fc-s>�sso.00s� establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-s)(sso.00�) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FCa)(sso.00s) and submitted to the Board of Health at the above address 29. Special Requirements (eso.00s) within 10 days of receipt of this order. 30. Other DATEOFRE-INSPECTION: C�_�`-�� ss��,o��o,�,<ea j , ��_ Ca_p� � � � �i�� . .� Inspector's SignaWre: ��, ( � Print: ��- 1.�� A PIC's Signature: �� ' /'7� � �.) Print: ^+ ��1' Page1 of�Pages +./'O� ,.r _ GiiL! / Ts2 1�'Y� .� v - - � �% ,,.. � , � A Violations Re/ated to Fopd4orne tllness ' ' • Interventipns and Risk Faciors(Rems 1-22) PROTECTlON FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Crpss-contamirration . 1 590.003(A) rlssi� imenEoFRea imsibilit * 3-362.11(A}(1} Raw An3ma1 Foods Separatedfrom - � 590.003(B) Demonstration of Knowled e* � Cooked and R7'E Fa�ds* � � 2-103.11. Penon in char e-duties . Cantamination trom Raw ingredients . � � 3-302.11(.4)(2) Raw Anirz�n]F�wcis Separated from Each EMPLOYEE HEA�TH Other* 2 540.003(C) Responsibility of the person in chuge to Canfamfnation Irom the Envlronment cequire reporting by food employees and 3302.11tA - Food Protection* a lic�uus* . 3-302.15 Washin Fruits and Ve ztables 590903(F) Responsibility Of A Fcx�Employee Or An 3-304.1 t Food Confaa wiW Rquipment and , . � . Applicant To Report To The Person In Utensils* Char e" � Contaminafbn from tha Consumer 590.OQ3(G) Ke ottin b Person io Char�e" 3306.14(A)(B Returned Focd and Rescrvice of Food* 3 590.003(D) ExclusinnsandRc.�strictions* � � DtspositlonotAdufie�atedorGontaminated � 590.003(E) Removal of Exclusions and Restriclions - Food - . 3 707.11 Discerding or Rewnditioning linsafe FQOD FRQM APPROVED SOURCE Food" q Food and Water F�om Aegutated Sources 9 Food Contact Surfaces � 590.OQ4{A-B) Com�liance wi[h Food�Law'k 4-501.11 t b4annal Wuewashing-Hot R'ater � 3-20]12 Food in a Hermeticalt�Se:iled Container* Saniti•ration Tem ratures* � - 3-20113 Fluid M�Ik and M'ilk ftodacts* 4-SQI.I t2 Mechanical R'arewashing-IIot Watec 3-202.13 Shell En s* SanitizaYionTem eratuces* - 3-202.1a E s:md Milk Pralucts.Pasteurized* 4-501.11.4 Cheancal Sanitization-temp.,pH, - cuncentration:md hardness. " 3-20216 Ice Made Fxorn Potable Brinkina VJater* q�01.11(A) &luipment Food Contact Surf'acx:s and � 5-101..1.1 Drinkin Water from an A roved S stem' � 540.006(A} Bottled Drinkin Water* Ukensils Clean� - 590.0(K�(S3) Water Meets Standards in 310 CMR 22.0" 4-60211 Cleaniug Frequency of Equipment Pood- - � Contact S�rfaces and Utensils`k ShelHrsh and Fish From an Approved Source ¢_7p2 1 L Frequenc.y of Sanitizauon of Utensils and 3-201.14 Fish and Reerea[ionally Caught Molluscan Foocl Cemtact Surfaces at E ui ment* Shellfish* 4-703.11 Methocls of$anitization-flot VJaYer and� 3-201.15 Molluscan Shellfish from NSSP Listed Chemical�' Sources� 10 Proper,Adequate Handwashing Game and Wiid Mushrooms Approved by 2-30111 � Clean Conditian-Hands and Arms* Re uiato Authorit 3-20218 Shellstock Idenrification Prescnt* 2-301.12 Cleanin Prcxedure* �590.004(C) Wild Mushrooms° . 2-301.Id When to Wash` � 3-201.17 Game Mimals* 1.1 Good Hygienic Practices �j ReceivinglCondition 2-AOI.11 Eatin ,Drinkin or Usin Tobacco* � 3-202.11. - PHFs Received at Pro er Tem eratures* z'4��.�2 Discharges From the Eyes,Nose and . 3-202.15 Packa e Inte it * MouthM 3-I Ol.11 Fcwc1 Safe and Unadulierated* 3-30L l2 Preventin Contamination When Tastin * b � . Tags/Records:Sheilstock 12 - Prevention of ContaminatVon from Hands 3-202.18 Shellstuek Identification M � 540.004(E) Pceventing Contamination from � 3-203.12 Shellstock Iden[ification Maintained* EIlt �O �� TagsiRecords:Fisb Products i3 Handwash Facilities � � Convenientty Located and Accessble 3-402.11 Parasite Destmcaon* � 3-A02.12 Rernrds,Creation and Retention* 5-203.11. Numbers and Ca acities* 590.004(1) � Labeling of Ingretlients' S-204.11 I.ocallon and Placement* � Conformaace with Approved Procedures 5-205.11 �Accessibilit .0 eration and R�laintenance � lHACCP Plans � Supptied wfth Soap and Hattd Drying -3-502.11 S ecialized Yrocessin Meilu�ds* Devices � 3-502.12 Reduced ox en acka h�.criteiia� 6-301.11 Handwashin Cleanser,Avaitabilit� 8-103.12 Conformance witl�A roced Proceduresx b-301..12 Hand�D 'nR&ovision � °Denotrs crivad item in the fe+feiel 1999 Food Catc or 105 Ci4lR 590.W0. � . - � ov �_ gO44� Kal-4 e, ry CITY.OFSALEM BOARD OF HEALTH _-M&A 1..0,46) P6.e,9_ Page: of Establishment Name- Date:9�- 2kco—r)C) Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY __T:�Dww ;L\- 1 JJ0 Ly,/V) X,0,�h"A�_A _ (�� Qe .CL+P -oo "bwf G ff"+A +6 C),V-,V110'"I A 4A ��e, Aj A. lot rt V'o n4 0 on 19 Yk--- Z_ —0m 113 c 1�'q A N ell 1 10 ('A '-Z)h A,1 7+1�,A e--M 1 0 _a, I I LU V F)a,,4-74 (VA/vi �IVUI A 1-0 4 �n lk A� ou �$Lwif 43�1 _4�t A,'- F��XA ,�A i�i,x-) 0 �_V It-It e. 1AK'Xic &A,�w 0)? 4.- nV (A� I- Y-At, �A -vl /'A 1 1,/9 A P A0 �aA V, �Kl/l /_X k'�"o O/A 47)V�o 0 U 0_"' G-7) A 0�O >1 AO 0 - ��C -kV �-t4kOA A/1A(-AAA1 ph,91 �'/\A J2�,, tA A�2_ Z�r inAf ea�_ A Jl"�_ _AA001-"(di^1 Discussion With Person in Charge: Corrective Action Required: Li No les I have read this report, have had the opportunity to ask questions and agree to correct all R2i, Voluntary Compliance 0 Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to �6 Re-inspection Scheduled Ll Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that 0 ne- wee� 1�noficompliance may result in daily fines of twenty-five dollars or suspension/revocation of 0 Embargo 0 Emergency Closure -your food permit. Ej Voluntary Disposal LI Other: I ' ' , r... ... � 3-)Otl4lC7} PHF'sReceivedat'femEseratures Vtolations Hetated to Foodbarne tl7rtess lnterventions end R1sk .4ccY�rding ro I,aa Ccwlul ta factors(lteMs 1-12} (ConG) �51°7'145"P WiCliin 4�Hnurs z . PROTECTION FROM CHEMICALS 3-50t.15 Cc�lin�>Mcthods fcu PHFs � :IN ' PHP Not and P,oid Nolding iq Pood or Color Additives 3.SQ?.1bB) Cotd PHFs Mnintuinecl at oc b�iow 3-202.12 Additives* � 54tLO(bl(F; 41`I45°P" 3-302.L4 Protectiou trom Uua4�Dn'�recl Additives"`� 3_j�j j,�6tA) }�.{nt PH£-s Maintaioed ut rn'ab<rve � I.S Pasonous or Toxic Substances i ";-IUt.11 Ickm�t rn�!afo�matun-Ou<� 14U'F * . ❑a� �nntau i�"� �:(ti I��(\) � Rc�,cisFicld;�torabo�el3U°F.'"_, --- �— I —r T�me as a Pu6lic Heatth Controi �f 7-102 1( Ccmn c n ti+7ie ti x�i.•,( z�ocim�r,' . .-.� .. — ' --I — -v-. . —�-- ` �z� � � ,U� 1� 1 i im,as i Pobix I-i<�alt6 Cbntrul* 7201.11 ��a��t�i�n Sr� � -i � --- _.�_ 1 — � 7-2O2.11 �kc,t 4t on F'r �„n �� wd i t � ._.��:`��`H�� Var:antrP�nirenr�s�t �_� 7-202 12 Condiuon,of US �� 7 303.1i ' 12axt�femt tine� Proh�bi��on. REQIJ[REMENFS POR WiGHIY SU5CEPTi�l,E -�— P4PUlRTIONS{HSP) � 2W.1'I ! S:utnneiw Cntrrin Ch�cuc IS �� —' " - 7 'P1.72 Cliinu ��tnt� ihu.,i.,w�«e C.nte.iin" � �F � ;-S)t i((;i) lhifr.teuii<edPcepu�raged7uicts a�d� 1 �� f3��e�s e. ��it6 1i3� ui 1.at 1s�" ' � 7��U�l id� Ur irt� lz rc Gc._C nt� i 3�� - � 4G' i i(13j tk of Vuc,e.u:�7ed k � � � �(—�{15.11 ln�td ntalt Nx;C�,n[�<t �Ietiv� aN�" q�1 li(ll} �Rn �» P�nisL ��fAutt7� 1 [a�Jami ? � '/ °��.�� fZ' ��i � �t �i.7�C fiLtt�f.. ( 12P1 i` �� {T� `�< d ��Ln¢lt Vc t SIP�t x ( � 7 n(r.1� � R�nG[ B + ��u��nt � r � - � — — — - � ---� .. R`i 7 [( �t;s�ctc�r.z+,�it'a � t . '�` � lf �ar�� I � �r� {76.! i I : k� s,E . . x. E �Cs,ntr � ar,.i - ._. -----. .._ ___._.._�.---- -- �..�..�....__�l._��U�i Y[I7i�.� __...��.. ___._� .__ C�N5UMER ADYISORY t !2< 'fii_' (� T t or,�u n�r �i + �n:4 3'u�� 7 i�u< n� eurote-a�t 1 � �-s[��,��aTu��car�7Ra�s ; I �. ___ _ � � .__ F ' m t 1) +r�l 1.0 u kx� lai+ tn�t,d � j( Proper Coaking Tero�eraiures for ! � � � �nt f}t�u n n� Pr<etss {�n L:tu i�n is. P}'Fs � � � i I . � ..:};Ji.li.l(I i.<`_j l �. 153 r 15 y - _ i_ _..�. '_ � ''4`_'�.. � ` �_ � . . _._. __ i _ _ ..� .._ �._, . �p --��v� i rtriz ct �tt 5.� ��i ( 5 1 �Ssec'."' � _�J3 � � i i�ary �1 7 _� 4 h� �iE. 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'_"' .'3 ._ _._ ._...___..A„..__.... .. ! q7 � � hch Ysrg9Qtii�att(o3�tte9 f YlG+lI}7;Utu Irt:L�tT�-L1r'Y (aL3C1L7d"sET6tFLrn+i ,tfCF."-.�— _ __. _ -. _ _ � � iili \)..t13� � S ttl �c�_` ' `c ... . ..�,.� (l�eiz�4�3-i�13 . . � . tU3.it(Sj .�� 4it�3nw rc ifs E � �im� St�¢din� f,17 �r�:�.rr.r� �� rrtrctl � itr +i�.��lrrh�'r .�nt <F<u� + �:,, ��11( i�OC�f[1'fie. ]� > > t'9< if l +n��i't �J 7(t�rP)tti!<tl[4t[ ', tiirt{��' �5 3i3.iliCj i t 56m�i:ial: I'�v,.,��cE'.(} }-��:xi- futna.rr,i,rr i i,.,,s„ .nrn ��i �%�c:r�ucf��>Jce�21�n ( �L,`� � dt� Y � 40(JOr� ..�._...� .__ _.._ .__.�. - ._ __ _ . . 3-0{i�.it(C) 2u�uaing;L�,sut��P<:r,ro.�ofl�?eeF i tt m � Gao�Reta�iPrarUccs 1 FC 580AOG � � � it,a5t.` � '�t, � Vi�na rin�ri�to Per onr�� rC � �(.3 _ 5 __ ': r—j- �. _. _.� - -.� -y � oa i F,� nd ihra P o,c tior FC s 6c4 � tg , , Proper Cooling of PHFs �- -. ..- -... � �— "t—:-- .-�-�_ — .— '1 � "� �_qu n c,nt and tne+s�1s � P�` A SC5 '. i s-Z('l.f�iCA} � {ixrl�nzCtxik c:PH1=c E�nm i+(t'f�to � �25 Vlate� P� ,ainq erd J ,te ' �G ° � .OG6 � ( � � f Rutin (iou : �,;dCr�un �i}"I' . ��7 cFy< fz �it� , '-Ff. b � OC,_ ' u3iF �.5'Ptttlind �-iu � i 8 y � ns� ioc ,x Mltrz�s i C 7 OQ3 � �S�t.tdtb� ��f�<hu,�YF[E. ?vi3tic Fecml.lmb.ent j i � S�a. +�k ,,,rtm�i+ _ � fX,� � � � Fern� �ramtc9� t�c at;ts tc vd�Fid-3_�, � ;_ � �Gfra _.—,, ---_.-- " I,__ ' �..... . .,i � ltrtn��-713.nir�' '' �--------._..._._. . .- �-- --�._._, `F - ,:I��cat �� ,i,.�di:l;: ... c -, n.rc ..:c..: .��.t 11< .;f_j6. .. CITYOFSALEM BOARD OF HEALTH Establishment Date: 2;— rc-�(O-(-)j C-) Page: Item Code C-Critical item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Dete No. Reference R-Red Item Verified PIXASE PRINT CLFARI Y "ID rrAJA\l A (1A�L 00 PA IPA AbJYA-Al 0))j U� Y r--Y�o Y-�:? A-0-4 pmc)-A/kA, �4/\ AA W-4;k7 I�OCA�, — —He')C'4 K?A�� A�) �Oez�:� \J A) 1/ 0 k)'0A1)- V\ 0 sc;� I �JWA ?AA,I) �IJVA�, D A A i A L4 , Discussion With Person in Charge: Corrective Actiori—Required: Ei No K9, Yes tt�- Voluntary Con-plian I have read this report, have had the opportunity to ask questions and agree to correct all ce 0 Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to inspection Scheduled Lj Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that y result in daily fin ft t f Jollars; or suspension/revocation of cj Embargo 0 Emergency Closure ,noqcompliance ma es o we,,n y- we c your food permit. /6tl 7 . El Voluntary Disposal U Other: • �- . ' . �_° , � 3-5i!1.14(C) .. PHFs Rec:eived aCPemperaWres � 1 � V7olatio�re Related to fbodborne 1llness lnterventions and Aisk Ac:cY>rding to Lxw Ccwled tu Fadors(lteMa 1-22) �Cont) . �I'=C74.S'l�Witk�in d Hows. * � � PROTECTION FyOM CH@MICALS 3-St)1.]5 Cailin��Methods ftx PHFs 14 Food or Color Additives 19 � RHf Hot and F,old Holding -- 4-5(�?.]bB} CotdPH}+Muint:�inectatorbel��w � 3-202.12 .4ddiuves" 540.IN}�(F) il`l45°T� 3-302.14 Prot�tlionPromlinappro�edrldduiae4^' - 15 �Poisonoue or Toxic Substances � �} -�'��t'{��1 llnt PFii� btxint�ined cit nr above I ; IU(.11 � Ideutdymgloti� mahon- On<ms! � I I40I�� S 5(`1 95[A) R� �tti Heid at or:;boce 190°G '� � tancauien` - �� — -_i � i 2U � T�rne as i Pu6iro Nsatth Contro! i i O2 11 -�--tI-Cu�m�c i1 ti jme til �r6� t,C m�nn�� - — - ---� 7 20t l l t �a�3ti<n SPniaa�: . ._-' ��_ !�_ �Fim� sti e Pnbla H<alt0 CanU•ot* ! .' 2SS2.1.1 Ite_aitiu;cm-Crcacau-imd t��e" �----� i �U fl¢7rH�_.. . V n i :re T� e��cnStaC ..-.� ._ .�___._.._.�.---`---..._.�3 7-2t)?.12 C'o idit�rn�.of L�s�- 7-'_03 t 1 Toxiv f u��t une.t F'rol�h'r ;uos* � �EQUIREMHNTS FOR NQGMLY SUSCEPTi�LB 3 20�4.t 1 Samivee, Ceitcrra C�u.mi� I+' _�QP�LATIONS{HSP�___ _ _ 7�'_04J Z ('h nu��IS fr�r th i�hu� t��uce C ntc,ia" " j �f ( i SQi I 1�A� lh�p+veuri�ed f a pa�d�.gcd Jtnces and�� 7�7U=V.i4 D��m�, �crntc.Cntc�ir. .. � I l_ ��_. �.. Buer� c.��uhi�7tnii�lab�i ` �bGl �'ffi� ' 1��. olPu:teanzcdt sf �� i �05.1� i In.it' n alt xu7CiN�ct �I��6ii�a� 5� �j ` . 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'bdi{ I4 I 4�) F � u�O(1J f�i � � � T Good Ret�1 Prac"tces �- rFC 590.00G � 3-0r13Jt t) ; 32�. inmri;Cn i��JP�� aonst+ lirrl ��ttan� ; I� a t ° � �2 �9an�yrmt l� �CPrr ��r i .. � EC 1 18 � �Prctper Caoftng of PN�s �� ..'! k-��a �d�a�d P otcrio _ { FS, i GG�. . 2h c�ut�men� ao8 Uten ils f r) a }n�''- �s � ) � f<n�l n taik:,ti PH7's fram I�iN�, te , . -- - � ; � j ` �h Wahr ''� rt bin�uid lJ ..E� ' fC 5 � .CK i 0 .t�lrti i � � , � ttithin � Licwr, end (r��m "i'?- ``� -- - --�� - -� - i � � �_7 Phi F�t ittp_ _ � FC � �I ; i 71 S-;5�P 44 tl�n ^ N ui ' �,cd 'as t>> �� zx M Pr ilt C � ' 6vi _�.-�-' - �- — -- �3..JOi1+?{S) � t rY ur PtT( 19 �e From 1mPizut � ' 3 � S,pr� i n � v�,e��vi - ',};`,_ - -- ' � � .-... __ , . .._ � : 'It,n�,crauire ti�r�c.;curs u .!"'FIdS`} � ;-+u �ttiE _..,_ _..._ _ �..__. ._ . _i i � nPith�nsA�n�r.: I ...,.r�.m. , , L__..__._..�._._1.�.-�-------��------' `lan � �. .: .,. .__. . .,)r.":w�C� ..¢�iu;t iRJ)i(ir(i. � . . ! . . ..!e�v'ti.Y^r..., . .. �� Jt��{, � p ( � )} .�.......+I'. R�w. ,?+lJ.,p+r�Fsy.,' ,R,,�� . '.' ".t'��°Fhr�rw...sf�:,.>'Mn+•Tt6T"4Wfi1S?a.�'i�`i I� ,..�� }1/'�w� " .. Mw`.Mi..�. . � '�T'�T� �3"�ia��q�'y'��"1 *� � � Massaci�usetts De.partment of Public Health sa�em eoa�d or Hea�tn Division of Food and Dru s ` 120 Washington Street,4�"Floor 9 Salem, MA 019703523 ' FOOD ESTABLISHMENT INSPECTION REPORT� TeL (978) 741-1800 Fax (978) 745-0343 Name n (` rJ �, - Date e of 0 eration s Tvoe of Inspection � ,/,�� ')G�X�(.rQ� �� Food Service ��Routine Address /J Risk ❑ Retail ❑Re-inspection �� *�` � �� t � �'�'"�" Level ❑ Residential Kitchen Previous Inspection Telephone � �'j ;� ' � '� ❑ Mobile Date: Tem ora Pre-o eration Owner � HACCP YM � p ry � P ��,� ��(_,S„ ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) � � � Time ❑ Bed&Breakfast � HACCP Complaint �n: t( � Inspector �� Out: ra Fermit No. ❑ Other Each violation checked requires.a�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 Tonacco Violations marked may pose an imminent health hazard and require immediate corrective seo.009(e)�sso.00s(F),0' action as determined by the Board of Health. �'FOQDPRO7ECTaON M,4HRGEMENT„1"�; _ � :��,4, a� �, „'„� ❑ 12• Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties �]'�3 Handwash Facilities f �--.w• -i � x m a ,�i� �`,r� � � EMF+LOYEE HEALTH ' - ,� � �r E, � ' �„ . � ��a,m,..�.-� ,. ��,u�s�tl,' �;.�.m a i e: ` .� 4°�PROTEC110N FAOM CHEMICAlS'""��''�`� y ;: i"`e�' r i �`�;P �❑ �2. Reporting of Diseases by Food Employee and PIC � � _�_��-.-a��"--� �•• � a�� « �� -�=w�.�M• ��»�»"��-�»ti: ❑ 14.Approved Food or Color Additives � 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals ��'FOOD FHOM APPROVEp SOUiiCE y„,P.�,;.'„„,�,„„„�,„,;:'„ s;'.��w,�,..�.� +...`a ('.,TIMEITEMPERATURE CON7ROLS(Potenilallq Hazardous Foods) `��'� � � ❑ 4. Food and Waterfrom Approved Source r� ro,�.�.w��,��.�o..,�.�a.,!�.,.,ea �,'n ,�,m=.tn�»_�,..§.�c.,�� ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17• Feheating �❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling t PRbTECTION FA6M COMTdMINA710N � �" " ; ❑ 19. Hot and Cold Holding � . � �' ' - .v..A.d:.n�tw,.o t 4u,«�,...a..�h..' � 8. Separation/Segregapon/Protection � ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing � ."RE�UIREMENTS FOR HIGHLY SUSGEPTIBLE POPULATt6N5(HSP);�.`�! � ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 19. Good Hygienic Practices � �CONSUMEFt ADVIS6RY;' � y m�,',°��. "�`;1 �,„,�,„��.„„�;,�,„,„,ws,,,,„� � ❑22. Posting of Consumer Advisories� � :t � Violations Related to Good Retail Practices � Number of Violated Provisions Related ❑ Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions a 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 pfficial 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 '� ' � ' by a Board of Health member or its agent constitutes an 23. Management and Personnel �FC-z)(sso.00a) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-s)(sso.00a) cited in this repoR may result in suspension or revocation of 25. Equipment and Utensils (Fc-a)(5so.00s) the food establishment permit and cessation of food 26. Water, Plumbing and Waste ' �Fc-s��sso.00s� establishment operations. If aggrieved by this order, you 27. Physical Facility (Fc-s��eso.00» have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FCa)(sso.00a� and submitted to the Board of Health at the above address 29. Special Requirements (sso.00s) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTIONi'� �y,,,��3," / �u s ssnm:o��Fo.mc-ia.aa �I�s� �� G��w��titp'� V t�l��' �x ��,�.��,`�' . - .. Inspector's Signature: �� ,,,.� Print: � �� '� � � / PIC's Signature: r . ,t�`'� �p .1� � Print: L�� N 1)/ T�I �� Page��of�L.Pages j � � � nww. . �-�'• Y' Vialations ReJated to Foad4orne tliness . lnterventions and Risk Factors(ttems 1-22) PRpTECT10N FROM CONTAMINATION FOOD PROTECTION MANACaEMENT $ Cross-co�tamination 1 590.003(A} rLssiaumentofReseons�bilrro"__� 3-302.t1(A�{1) RawAniinalFaatsSeparatedfram � 590.003(B) Demonsfratioo of Knowledge" � _ C��ked anci R'I`E Faxis* �2-103.1 t Person zn charge--duties Contaminailon from Raw[ngredients 3-362ll(A){2) Kaw Anin�l Foals Separated from Each EMP�OYEE HEAI.TH Qther* 2 540.Q03(C) Responsibility oP the person in c6ai�ge to Contamination from fhe Env7ronment cequire iEpating by foat employees and 3-302.11.(A) Fcwd Protution* � a �I'rcanGa" 3-302.15 W'ashin Fruits and Vefl�etables � 59Q003(F) Responsibilit}Of A F��Bmployee Or An 33(M.I t Food Con(aa�with Eyoipment ancl , A{�plicant To Report To The Person In {7tensi'Is* Char e' Corttamrnefron from the Consumer 590.003(G) Re artin b �Person in Char e* 3..3{}6.14(A)(B} Returned Foal and Resen=ice�zf Fuod* 3 590.003(D) ExclusionS.indRestricYions* � Dlsposit(onofAduRe�atedorContaminated � � 590.003(F) Removal of'Exclusions anci Restrictions Food I 3-70111 Discai-dino or fteeonditioning L;nsafe FOOD FROM APPROVED SOURCE Fcwd�` 4 Food and Water From Regulated Soerces 9 Food Contact Surtaces � 590.0(kl(A-B) Com7liancewithFoodC,aw* 4-50t.111 MantlalWarewaehing-HotWafer 3-2U1.12 Bood in a Hennetieal� �Scaled Container" Sanitiratian Tem eratures" � 3-201.13 Fluid Milk and Milk Praincts* �t-5011 t2 Mechanieal Warewashinb I�iot Water 3-202.I3 Shcll Eo�as* Saniazation Tem eratures* � 3-2O214 E >s and Milk Products.Pasceuriudw 4-501.114 Cheutical Sanid�aCion-temp.,pH, 3-202.16 ice Made Frorn P�table Drinkin��Water" concentration and hardness.'k ' S-1.61.1.1 Dcinkin Water fkom nn A roved S stem" 4-6QLll{Aj Fsquipment I'^'oocl Conract Surf`aces und 590.006(,�1) Aonled Drinkin Wau:r° UYsnsils Clean" � 590.0(}6Bj Water Meets Stanciards in 3 t0 CMR 22.Q^' �-602J t 4leanin�Frequency of Equipment Nood- ' Contact Sud�accs and Utensils'p SheiNish and Fish From an Approved Souroe 4J02.11. Fceguency of Sanidzation of Ufensils und 3-201.14 F'ish and Receeationsl'ly Caught Molluscan Foal Contuct Surfaces oP ui menC" � St�ellfist�" 4-703.11 Methods of Sanitization-Hot Water and 3-201.75 IvIollnscan Shellfish from NSSP Lisred Chemical* Sources' 10 Proper,Adequate Handwashing Game and Wrid Mushrooms Approved by 2-301.1 L Clean CundiEion-Hands and Aans"' Re ulato Autharit 3-202.18 Shellstock IdentificaHon Prescnt* 2-301.12 Claanin Pr�xedurc* � 590.004(C) Wild Mushrooms� 2-301.74 When to R�ash* 3-201.17 Game Animals* 11 Gootl Hygienic Practices 5 Receiving/Condition 2-'a�� Eattn ,Drinkin�or Usin Tobacco* 3-202.11. � PHFs Received at Pro er Tcm eratures* 2-401.12 D�sshargos Fxom the Eyes,Nose and � 3-202.15 Packa e lii[e it ' Mouth* 3-1011 L Fcad Safe and Lnadulterated' 3-301.L2 PrevenCin>Conta�nination When Tastin " ( . Tags/Records:Shellstock �2 Prevention of Contamination from Hends 3=202.18 Shellstock Identilication " SzJ0.0(W(�) Fceventing Contamination from � 3-203.12 9hetlstock Identitcation M�untaineci* ' Em lo ees* � TagslRecords:Fish Products 13 Handwash Faciifties � ' Convenientt Located and Accessible 3-4Q2.11 Parasite Destruction* - Y � 5-203.11 Nwnbers and Ca aeiries�' � 3-402.12 Records,C7eation�nd ffe�ention"' S-2ik}11 I.�carion andPlacement* 590.0(k4(J) � Labeiiog of Ingredients` . 7 Conformance with Approved Proeedures 5-205.11 Accessibilit ,O�erution and ivlaintenance � /HACCP Pians Supplied with Soap and Hand Drying 3-502.11 S ecia6zed Processin Mefl�als* Devices � � 3-50212 Rednced ox • en acku 'n�,ccitec-ia* �-301.11 Handwashin Cleanser,Avaitabilit� '� b-301.12 Hand D 'n�Prov}sion ' 8-103.12 Conformance wit,l�� toved Ptocedures* '� -*�enotts caitia�l item in the feiferal 1999 Foa1 Cate or 1i�5 C:vIR S9QOQQ. � � CITY OF SALEM BOARD OF HEALTH Establishment Nam—e-�(W)AtA �_5 Date: q�A�V(a Page: Pj-,\of Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF ORRECTION Date No. Reference R-Red Item PLEASE PRINT CLEARLY Verified kD AAt��A _'9A1) X-t-PA AAA-t AA 0 'R I.Z) �'CW A A Xj Z10,11 �Lnkbz/ V) 4")0 QA _/hj�fT0 cliaw)— NO LM '04't-> �'p I" j P P '�r) (N I t �A^ --,/I OVA '<�7) VY nV 33 n CA 1) '01VI CJA(�A CA 1) Q.1A4 �,110 _ao lipa) 4rA191 -re _U�No Discussion W!.th Person in Charge: Corrective Action Re�quire I have read this report, have had the opportunity to ask questions and agree to correct all oluntary Compliance 0 Employee Restriction KV Exclusion violations before the next inspection, to observe all conditions as described, and to 0 Re-inspection Scheduled La Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily f ines of twenty-f ive dollars or suspension/revocation of 0 Embargo L] Emergency Closure your food permit. Ll Vojuntary Disposal U Other: . . . . . . .. � . t-$;}I.}4tt:} � � Pli�'s Recei�ed ui�Tempi,r�aLuse.S •� . Vtotatiorts Helafe#fo faodborae ftfness.tnterveniion��nd Ri,sk. . . . . �fi.coidi[ig to ia��Cooiad Y�s � fe# � Factors(1te�s Y•22} {ConG} . . . i��..F14S F WiYhin d�How's. # t ' SC,1 15 - _ C�xrlin��1�fethcxis£or PiiFs � ��r��-��y�F�� - . . � , ��S . ._..e._..._._..� PNF NM and Eold Hoiding �4 ' Faod or Calor lAdda�ves � � . , � _._�� ,5{)t lfi[,S� Cotd Pkif.INanttau3ect at rn'beiaw � 3-2f�2 32 I x.de�tnc�s��- � 590.Oti-1(t^) 4t°I45°F* ....._� - 3-3ti2!4 � YEvtect�n fr�zn t �a��prtr�ed �.ddiEi4ea-�� _ ._.. , 1S � Poisonaus ot Tax�c 5ubstances - 3-S�(.t hfA) 1-Sait['FIF g Mav�t�Enetl ai or abovc -�- --j I d{j'F." -{� 7-((51.11 , kkntifq�n�Inf�itnatrr>n �ti3E'ioin:�l � 3-�i;l.l"{A) R�xists Re{ti ss[��r abovc 130°}`_�' ( i f'Otif2tnCP5� ..._._ . #---�-�---- Zp 7+me as a R¢.rbi'rc Nea!?h ControE r 7-1�2_!( Curo�ttanNxc�� Rr�r(.in�t aiztu7ers� � � � . � 1-2(�t.l l S: n euc n-St��_ � 3-S6i f 9 � Trmt,as a PuWic Heai h Control'� 7-2t}2_ll Restf�ct:on-Presenec anzt t,>c'� "�6.9(k}fR) _._._ �Vdritwee Re mn°menE ______�..f.._.T ?-202.12 � Cnzi�iF�iune«f Usc� � RHG1U113�MENTS FO�HIGNLY SUSCEF7l'lC3LE 7-303.i 1 '1'axt�. t'fl��taiau��-T'rohibitiont*` pt,RUC.ATipN${NSP� . r 2Jd.1'i , Sanrti�ris C'ritrc�a Chusxica�ti. � -... .._.. -_ i-30� 1_____2 Ch..nu�+tcfrn« i�h[uef'�-arJs�c.o Cdtesia�, 2t� ,-8(}t.il(hj Cn�a.reo�izeti5'rc gzcF:agedJaiti;rsau�l �-r-2t1<t.l� T)r 3ny As,c.n�e.Crtcct�a�� ..�_... �.�.�..._..__........� S3etie �tare�with ti�aimo .l,abals* . � r-205.11 tnctd �rt�l Fa,x!t L�t ct l.ubzicm� s�" �-KGl 1 rtt�t [.se�f Faz�i�w�xcd k t�. ( 7-'LOG.[I Re.�¢r�iied`'ae Na ractde+.C fEetl+-�`� �3-f3Ut.i 9 tl)? k aiv or Paril;�ll C�x7k .d 4n�tnttl Fc�wd��id � !--«_._.. ____ .. _ �f2cn Sted S�xntris Ivot Srivcd �� 3 7 ,.U5.12 �t2�rclEn l3a t Ssat�,ns�� . �w$Q7 1!(C, t�rE t ened T�a.�i PatY�gr iVoi Rc ser�eci. �� 7�'6613 IraikiagPcevtEs i P�.siCantxotand � - -'--'-�'--�-'-" � �.�� 4Toaztotu�� . C�NSUM�Fi ADVISOFtY �� 1 t':onsiEm�x hd4attres P�s��d for t'rufsienp4iun�f� TdMEt'TEAAPERATURE CC?NTE�C3L� � ( �� Rraper Coakiog Temperateras tor riniai�l t x�d Chac irc Itaw,l�rzdarar�ked c,r PMFs ( tiot(3illcrki54!'ro�ctiied;oH�tt�u3�ain � 3-IFOl.t t RtL(2} T�F,s i�5 i� I 5 5�u. Pu[ht�uns� "'"' 'p6 Y�� 7mrut�iz ztc Str t�,e- k45'l�-t Ss«;c�. 3=36' 11 t' etekm� U 1 g�;Subatwteue£or Raw She!d � . 3-4(�I.It(r1)F2) �C��m�ninutcc F«h 'utesst4 k Game . t r�a.r. �._... _______.._.._..__ ____� �Anrm tis- t�5 C 1� eet SPEGIAl.REQI31REN9�NTS '� 40'l.I I(f3}{i}(2} Ptrt! i�_d Bxct{Zuist -176 f !'�� cuin�� ----- �-------� ¢.401.11(A)C�� K mrt�,tajcc= d �4�ets 175 F IS 590.0(J9tA) ii7)�VialeTi471�,ol'Settitrn 7i�)t7.Of}4(A)-C�3}an � « , � caiertnfx n�okrllt icxxl te��tpi�ri�iyand � �-4C�1.li{,A}{5} Pa�AittY,tL-il�lC;iit�e StutfedYl{t:s, � rc5idcnt,.�lkitchcnopezati4»s,l�c�aldbe � Su�flmeC'untarr�m�,��sb hfe�< <'IeEn�Gu`tiader i�7c a{�Propriate sec�mus � P,ultef ar Etarscs.x i6S�T �5 Scc�` � abc,4�it rcla[etl ic�tuodbornu 741i�es�s � 3-d0i.li.{C}r3j �9�olc.-ma �Eulnci��[3uC5te�ks interroec�tions:uadrf4k�facYors. C)tlaer � (4� t��' S4fi tM39 aloiatiaev relacing to g�mc#r�:tai2 � I�-a0l.12 � It�u ��imat�axi;Ckwkcd 9ir a � p�ac hces slioul�I be debited undcr 1129- 1 �� liicrowave �bfi 1:* Special Requisaments. � ?-401 fl{A)(1}tb} 4i!Ctiet�['F3I�s � 3�s5"#� i5,ec.� � �� v ___...__ Reheating fiar Nn4 Hoidmg `__ Vlt)LA7/ONS AELATED TO G4qD RETAtt PRACTIG�S ____�� . ,�ItA?&{l)} Pi{��>3fi5`=F ! x�, �" {Stems 23 l�}) �- i r#(}3.1 i('E2) kfi�towave !65' F 2 t�iinuta Standin;; C�itu�a]rznd nnn rritical e•rottrttor�,r, xHich r'lo n��» iclate ao tF:e 7�ntr"' �� -fov�horne itt�zc,ss aiirervent�oi+s::rrid riakfirctvrs t�ste�f nh<rvc_ e�+n Lc �. "t-d03.1 kfC) t m��n�rciallv Pru;.acued R'FL'.Fi�ad- (cn:nd zn rlre fa!!>xur� sutions ol�th�,tnorl(ade mid i�n C 12K {-i(} N� �<3�)OOQ � 3-4{73.if{(�} Retz2��vagLncp��fPurtronsafBecf ttem �oottt�eta�tPr�Cttces �fiC i 5900(10 i � I�.�ast�� 23 �'�Aansgemeni a�d Per an�Ei� �FC ? � 643 , I 24 l Fend antl F�i PrpteciE�o ' Ft, 9 604 ! - �g � Praper Goaling ot PNFs -�. - .-- -�- � }-- < ------ �— � 25 �Eqn�nmentandUteiuifa � PC �l � .605 � :�-SOi.ld(A) � Cu��i[ne C�wk�,d PHTts fraar t#7`f�ti� 26 _J�Water Fiombingand Nasta ,�PC 6 `-.006 ' ( � . , � . . � �.. �. ..', � ''4'i=Wittr n 21x�urs n�vd bram 7J`I�` 27 ( Phys��at�acdit ; �C�6 �_.(}tF7 i � to�1"FtAS b t4 tiii�i 4 Hous .�� Porsonous or�c Matertais. .. ��G 7 I .400 � ...�_ � "� 29 S �.ial fi uireme�iis .. . r— 1 IX39 � -; ._ _._ 3-50i.fdfBj Cfmtt�gfl{Ps�vSatEeFe��oti.lsnbieut � �� . ' �_. fi __m� ETampecatz�reYufreciient;tz,41°Ff�15`k� - �. �0 ,_Oihar.,. ._....._...�. ._...._.�. ,._- i_.__ ..� �.,._.�. J lkSfhitt�4Ftewrs� � c ,�;e-z.a. � . '9Denores cntical iEe�a hf�hr l��.ier�! 1>99 Fond C i�eeor 105 C'141{�gi1 iY0{). � CITY OF SALEM BOARD OF HEALTH Establishment Name- _�o PiliaffR Date: Page: Of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OFtORRECTION Date No. Reference R-Red Item PLIA11 11111 IL11111 Verified (�b J-KC� jj)OM� rAXT WI I 1zzA-'QJ1) AA O-AP r"APZ�t- r��-AA -4 eZIA1 10 'L — P �' (AA ��/A/11� (t/)0 V-Q'd r-fue'n (71v) <�)"A-V' —�M1AeX1)MAiVO4 I OAFA-0 AA OPJ-A-,,Q �4nr)r--Y�OPZ71 R)PAIVJAA.�- L -CA(� (aa./VA k.)( 0 A4 aT P A Akio a , Discussion With Person—inCharge: ---- Corrective Action Recturs—re I d: D No t<5,'Yes I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance U Employee Restriction Exclusion vi.olations before the next inspection, to observe all conditions as described, and to led Lj Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that rioncompliance may result in daily fines of twenty-f ive dollars or suspension/revocation of 0 Embargo L3 Emergency Closure Ll Voluntary Disposal LI Other: yo u r food permit. �3-Sirl�1=t{L:) ..._._ Pi{Fs Recr_ived at Temperatur�s � Vtolatian�Rei�i Fo Faodbarne lttness tnferveni3ans aod Rlsk � l�ueordinb to Caw G`ouiad ta � Factore{l#ems J•,Y2) {ConL} � 8 i �145 ['WEY�irn��ticrurs.* � � -�-t_.___ _.__ _ �� I PE30TECTlON�ROhf CSiEMIC{4LS - s 5-5tt] l 5____ C��lia�Llethoci^tcar PftFs y4 Faod or Calar Addit'rves �� i �'�F��and f,ald No#d�rtg � � 3-SOI.j6(S} Co7cE PfII s Mniuuinetl at or beiz,u� 3 2�i2.i2 s.d�tr�es'k 590.0(i4lF} 11°!45°I-. 3 . 3 302.i�k Prot�U on€romlk�appn�;��i �ddeu�es*__j - , - --� 15 ` Paisonous orTaxfc Substences � � �-�� lfi€Aj lini k 112'�Maima'tiaod ut ar above 14D,F * ± 7-�lt�t.lk E�3n lof�i�rtation-£�ii o�i �� '_ .�.____.__. -----{ j �,Q �n`F�� 3 "it`rt_Ifi�A} RcustsHeldatotnba�al34"F_ '��1 7-1€�2.E t � C'u�nmc�n 4�ro� 41 ur',.in�f un�i3ners*� � _.____ T�me as a Pudlic H�atth Control � ?-2011I �Sr. c�aucrn Sa�i r�� „_,�,,,-,7�t 19 � Timt,as a Public Healdt C oateoI*�� 7-262.Ii Xest.icG:c�n-Pr.senceaodLse� �9t).t)tkitF�U_...__._. LertanecRs,.�iremev�t ��__� _.� .._.__.._, � 7 202.12 Cnnd�tions af U�t REOU[R�MENTS FOR HlGHF.Y�SUSC�PTi�LE �7_'�3.i1 T�3x��Cuutat�net ProlzEb"stiou� PC4PU�.kT(ONS(HSP} 2(kt.i l SnnF �zeis Ctfter�i Ctie2�5ic,ts -� 264.12 Cl�imita(s f�r'tA�a�hii =1 srw�aa C�n��era� 21 3-�Ot 1 iCA;� Cn ivteur7�t Prs 3a�}a*ed 7t�iceF auc! � w �� P t b 7�OA.i� L�r��r�2'�cott.f ri[e� � F3e�er�tvitl� W�u nu�lab�h° �� 7-2QS.l 1 L�cidentat t��uxl i�ni��.t Is�h�i�an s� � '�-A61 I1(B} Lst oi Pe�teunrcd b�;��s"` ?-206.(t Retiiv�u� d i 5s,Pe nc ide�s C z Eeita (�1 I i{£)} R iw or 1'aii�,ili 1 G+�l.ed Autmal E cxx!and �7-�Ob.(2 , I�a(eni Bmt St:�uoni. . . �� R n SGe�l 4prz�a[s �,'ot Se�rtzd � , ,� a a �3-&;GI I�ICi C,n�r e.nedFcxdPtic.Fa�t hvtRr�terced_ '� �7�1Q6 1� 7'raickart�1�nvders,1_si C�iv�troi anc9 ' - � Moni�orir}rsi"_.__. � _____�� CG4NSEIMEit A4VISORY ----�--r----- , - --� 4it�fiEREPAPERATt3R�COPt�ROLS � a� 3&4 1 i Conswnu ��7so�v 3�nttd i��c Civuttmgtiun of 16 � Proper Coaking Yemperatares tor � �nim�l 2 �ad�`i'hat arc R iu Undarco�ked i=r � PH�s �ot f�f3zr�a�i�, Pras svrd t�1l:dumzt�ie � ('�uhc� s n s "�`�°` 'i ea 3-4�OLllAtk)(2} � s.s,. t5` � i4 5.�.� � � -�.. . . �_t't„�e-Ii2truc.clrtU..Ssrviut4��i�t5sec'� 3-36� 13 Ya>tear�riF�g::S.�bstiYaiefs�rRawShell � 3-d01.ti{�}t2� ' Com}n+_nair,d 4�sh 'Meis�s t�.Gunu -� ��;i�'�."_. _....._� _ ,! r1s��m tls- 1�5 t t7 e c SPECIAL REQ131REMEWTB �,..461.13.1Hif2�si2} Pt��k anG.l3ce.P kui�.t � I (} t i21 ruin' .-.. .-..-, _t� - - - 590.OQ�3t�t)-{�7)�Vic�lai�7��s of Sc�tian �9�.6tT�(A}-{i7)7n ( �-4iJ`l.Ii(��)f2� 1ta�2re-,tr7j�ct a b4cnts I 5�F IS � � ti�� caterin�,, mobilc tc�d, [enzpurary aitd x-4(si.i I tA)t3t � Paulvr,bYild Ciame>Statteo Y11Fs, � resiGe t�ti�t kitchea opr.rati,Qns SLioii(d be � I 4t3�1�3��g ik�a aii,u�g Fist,ht�at, � � debiied midcr the appcu0detu vectiE�n�; � � � Poi�ttrc o��RunttiS l55°E 1 S 4Wa. * � atw�t �f i cltttad tti fcsaltrornc i(Iness � 3-401.11(C)(3j 'Vh le-�au Ir i�2�,acz73�tf Sr�aks . inte�ventrozv5 an�i eisk facT�rs <}Yher � i45 1 '- 590�)fl9 l�tplati�ine relaein�ta;o�� cctatt � �� at�t.12 i2,� �nn),naEY�;.�ds Cc�okecl ur a � gaa�ticcs stro�ld }�debiNed wxder, �{?9- [ � - � R�truovuve IC�S�F* Spccial Rec�uircm�nt�. , � 3-40t.i7[A}(1)(t�j A(SCktt�sYllF �1�t5°F' 1Sscc. ' � � � i 4_____.____,_. ._._. �7 Fieheat3ng#ar Nat Hatding VlOGA71pNS RELATEp 70 GOQp RETAJ!PR�4CTlCE� 3-403,f tfA)&fl�} PH}"; 345"E ! ticc �' {1[nms 23 i0} � 3-d0?.11(L;j Yt�caowtvc 165 �2Ht�ntzt 4ta¢d€ng� Crit(cm'andni,nrri7ir,al �r< nttotts,asf;rchdoiar'�reeFuteant7s� l3me�- foadborr�v e9ra�>> n�tctvEnt�wts eaud rnA fitctt�rs tr �<d aI ove. cau fie 3-�1Q3.i t(C) t.im,n rciak4v Pi�ies.e;;#ft T'E.Funct � fvtsnu iri iJv)olFnk m�,vu nacx qf�hc Fi+u�T{"qde mid!/�'s f�tt{ � d{} j�� Nf�(lttt! �...._._ � � ..__.....__� ._. _.._ .._ _. � > � ttem �Gaod Retaft Practtces � 7 fC �59(!0l10 ; 3-4f�3.I({I:) R ia iunu Urasticed I a�reions of Buxf � ._... . - -- �.. -- , � � 3 ! Mattagnmr t and Per anrr I TFC 2 I t54)3 r ._ � _ - - -'- -- ; � �24. � Fo�d�nd Foat Prqtectron �FC 3 � .p0�i ' '� �g Praper Cooting of PHFs ,�- _ ._...._ _..�... ,...--- _ � 26 �Et�u�pment and lltei�.stls , FC 4 065 ° ..� ____...� � � 3�-SOt.Ld�(Aj Cc�dine�xked FHT"s fscvn tdtl"P fc� ` 2b i Water Pii rr � �--- --'.A --- �-� � ib'nganU'f7ast� FG 5 � 646 ' �� 7�°E Withan 2 Hours aE�d Frorn'10`l' � �27 � F':�ys� a�Fz dit� � �FC 6 � W7 I � 3..SQt.l4{li} �nRfiuer�ure 6�ncccii�ait;lu�i�b3'J4i5`F C�29 ��ec�al Fir-qui emenMit-r�ais .. . ��C T ^I .�� ? . s � �� - 30 Other !�i w,thin 4 Hwn�` , �. s,�t .za. ._ ._ � L_______�...� _ .� . . . '�I)anotrs ceiGicat i{oir,i�t ih�I•tera! 7949 Fo�xl C+uiC ar 965 C,?+4i2 596 f}g{y. . CITY OF SALEM BOARD OF HEALTH Establishment Name-��ii n Date: 0) Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY (k� 7�4A U 0 K)4 12 A ubno'n ' W, A Z� 0-<- -WA-P A" 19 A.,, r"DOA 4--(A A t,�J.4�X 10-6- rp-1 rI An �o 0o L;, aA- aclC� A )n I I Jq-� )J, r �/y W0A1, /VV\ Emscussion With Person in Charge: Corrective Action Required: u No Yes Voluntary Compliance U Employee Restriction I have read this report, have had the opportunity to ask questions and agree to correct all K, Exclusion violations before the next inspection, to observe all conditions as described, and to ?f�_'Re-inspection Scheduled L:I Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that aw�� 0 Emergency Closure noncompliance may result in daily f ines of twenty-f ive dollars or suspension/revocation of El Embargo yo ur food permit. Ll Voluntary Disposal LI Other: ti � i ♦ . . ;( ��{}l.i4(Ci} � Pf€Ps Received at Tem{reratures Viofateans A�tat�d ta Foadborna Ittness laterurmtkms end RisR Flccordiug to C.aw Ccalad tu Factars{UeYtts f-22) {"CanG} � � 4 t'.1�f45°F W[thin��4 3iou�. ' � ��-Si11.7'� � Cixflia�s�fethc�di#'cx PFiFs PROTECT90�FRCkM CHECutlGAi.S �4 � �" PNF Hot and£a!d Haiding (�-�Fo�d or Colar ABddRves � �- -- ��Stl� 16(S} ColEi PHHs�Yiaint�iinec!at oz bz3c�w .Y2.{).�,�2 �t�(jJtiA tix .�4�.{}{k�E� '��1�$°}��` � 3 ;{t}2.2& I'rotu.t yn frosuG,iapPrf,.-ed Ad�titives" � � �g ' Poisonaus nr Toxic Subsksncss '� 3501.(b{�j 1 t'r>t PH,Fs ivtaintaiued af or atXrv� _. 74G'i=." 7-F(11.11 �fdenlifyingdnfc�matinn-C3rioin�cS . . i 3-Sl7t.l6(A) ftu3sfs Hstd at or at�ve t30°F. * � ° Cnntam..rs" - ---�------------- ----- '� T�me as a FubE�e Heatth Control�� 7 102.t�1 .�' Common Name YL�skina C oiit�aaers� ------ 7-20t.7 S � Se u�.ccr�n-..St��a c�� s�..-�. .�� 3S6i.79�� Time us a Put7lii Naalth Cott[mI� 7-202.}S Re�tii�ct�on�-Ps s¢ncc.and t €c* 540.�ti�1�A7� 4'�r,anz:e Rey.e�remeut 7-202 I2 C��nditirn3s c�f tts�M �� pgq�pqENTS FOFt HIGHLY SUBCEF�TiBLE 730'3.11 2i�xtc-f,ui�tainei� Profi�l+ri.roav � �SOPULAT30N9 HS�_ 204.11 SamtireA, Ctitu ia th Eix Is y� ;-gpl.tt(A) Ln i,teu izr,�lPre acFa edluices��d� �7 2t}�._!2 Chu�atf +l4 forti «hu�q i'iodAet�c <utc:iaa: � P P " � _ __- . Bi�eri e.wtthYtafi�❑ i,ab�,t�� .�7-2.0d.7d t7rt7n A�es�te.t r�t�. �3� ..._.. 4 � y-801 11� Lu�f Pa�nurize�l Y '� .____.� ! 7 Z{}5.I 1 Lx:id..,aFal F�xl C t��st�.c�.l.z�b�icants" � 7 2UG.t I T�v�rri�i d 'se Ye nudes.C iE iir�� -$�t I 1{D} 12 iu oe Vuif 3llv(�xr},cd Avimal Eaid�nd �7-20b.12 Ralum l�mt Statif,n� _ t2 iu S�ed S�aruuts hot Se�vc.d '� �� , 7306.13 17.aikmg Pnwciurs,Y�s�t_'untrat a�id� 3-Y{U i ll[C� L-nv �ned F�a� Pacl�age h��.Re a�erce�. _� f :�onitac3n�_ C{3NStDN#EFi AQV130RY TIMFJTEMPE6#�4TUFt�CONTR{}LS ' 2��!>0� I 1 Consu�7icr.4dvisoc5 Pusted f��r<:rnteasFpt�on o, � ��iiT�71 T.x��a'fhuc ere Raw.Lndaea'�ked c�' � 16 � �roper Coe�kmg T�mpecafures#or . not f?tlxerH ise. !'rc,ztiti d to 2ifiminate S�HFs ex.�n��« i:ro� � � 3-40i 11 AQ t{2} F�y.a�_ !5` � S 5 5 �._.. ____�._.._ Pathu„tim ` � 7�,�,s-6i�nxd�xt�Sertiri� I�5'2'ISseoa� I 3-30 r !3 P�.stem�i d 1 gg�Sul�a�itute frn-Raw Shei3 �� 3-4�L71(�.)C21 Cornm9nutiai i izh,�te�u f� Gamn -�-.. �°'�s - Anunats�� 1» I ig cec SPECIA�RE4lI1REMENTS � . _�.. ;-4011 k(B)tik2) Pa�f;and 13zet Ri�st-1 >O F 127 nxir�� - � 3-40t.7t(A}[2} � Kai�rc.e,Tn�cci d �vlczEs t 5 F 15� 59t1{}(74tAj-ft7} Vialatitatsol�5ec6�op 7�3Qf1O9(A}{E}lin ti�� ( eaterm� m�bik iar� teznporary and � 3-40LIi{A1C3j Poaltry,Gt`tldC„n5�; $ruttcc!YHFs, c�.�idfut,al kifchca ogeratian�shoitld t�e � S�uff�i�C,+nt ur�znt Fish. hfeae � deb�tcd un<ler t6e apprapri�te seccions j rovlrry osJtantt� 16S'I �5 sec. �' n1wGe if related w L��bornc i!I!zr.ss � �-AOI.11.(C)i3j tiVhole-me �2�„Intaci[3e�.f 5tc�}:s inCerv�ntions:uzd eiS,k faetors. t)thet � ' I (�5°t^`- 590009 vio3ations reladng 1a�o;�retail 3 40L12� � Rau rin9nia!1 iax(v C'a,k�^d iiz n � prtacnccs should 1+e debitecf under It29- , 4i�cro�e�;�v� 165 b'" ( Spectti K�gGsirc�m4xtts_ 3�dC1112(A)(lllb} ektlCht;er!'tEF, 145`S� l�sec ' � (� �eNeating far Hnt Hn4di�sg V� YfQGATIONS AELA7EA TD GOOD RETAK.PRACTIC�$ 3-t03.1li.4}8c(D) Pt�!'s]5rk��5sec..= {ltems2,3-3t1) . �-403.11(Bj Yhuou�aec 765 P`"A2EnatsStanditt�� C;+iticair�rrdnon �n[ir.altio?nt+urrs. xlrrchdormf ��bat t��tt�e . � leme�' � f�andGornesltrznssmterv�et�Gnesurrdri+kjactorsLsttc�ah�>>e.c<'rn&t. 3-d03.I ItC} C,�mrnerciti�[iv P» ssc 3 R1I:Fa?c2- (c u»d a�th�fol7�w a�zg �ernons �{zA� Fi>od Cade mn�l lt» CkIX ` Xt Otl� ��y„t,.> ,� _ __. _ . 1- _ z � rtem Goad Reter7 PracOces � � Fc 590 000 � 3-a6__I t{E) Rtmmii�im�Lrxtizced Fa�rcions ofHeef' ._ .. _ . I�uas!:�* � � 23. Man��ameni antl Per onnel� � FC 2 �603 � i ""- 24 �Frnd tnd Foaf Protec4ion ' FC '� .004 i _._ 18 Praper Coollhg of i+HF� � - -... ..-� --}---.. t.. . . -- - -- 25 En�uipmeni and Ut�vis+is FC 9 005 � �}-S0t.1.d{A} G�w�iin�.Cook�d PAI s frima IAD`F tt: . - -' , �. j � 2& �Wat�.r RiimbincLnanci Naste �FC 5 r.DUU . i 7s�°F Wittttn 2 T1cw.rs �E2�7 Frorn 1C�I' { 27 � Fhps al Faci4hL i �£' 6 � 6{?I I � tu 43 Ft�S F��xtksn 4 Hou4 ti � 3 ?8 �paso�ous or Towc M ater��ls .� 7 �.Oq'� � { .___._._._ - . .. �_ � �3-Si71.3§tTi) F oet�sre,PHF�al,�ie FE�om Arribient -� � �9 ��euiai R��.uemen�s � .009 ; Temp�ratttte 3�i},zediente to 41°E144`F �30 Other , __�_� �� ! � _ .v..�..._..__._._. .._... _..� 1Lithtn�Fk�u[ti* ��...._._.._ + v� .,�a��zs, *llenotis�r�uuat lten,i+s�he Gvdew�� t999 Po�xi Ca�!e or i QS CNt(2 5�i1 OfHi. r ,� Commonwealth af Massachusetts � �. City of Salem Board of Health IGmbe�ley Driscoli 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DA1'E PRINTED: 12/30/2008 ESTABLISHMENT NAME: Maria's Place File Number:BHF-2004-000068 10 JeFferson Avenue Salem MA 01970 LOCATED AT: 0010 JEFFERSON AVENUE 201 ' SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2oo9-03t9 Dec 3Q 2008 Dec 31,2009 $280.00 ESTABLISHMENT Total Fees: $280.00 PERMIT EXPIRES December 31, 2009 , Board of Health This Permit is not transferable and must be reissued upon change of ownership or bcaHoa The permit must be posted in a prominent location in the EstabGshment. In accardance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 I � ' � � • � CIT'Y OF SALEM, MASSACHUSETTS � � B0�1RD OF H&�1LTH I2.0 WdSHINGTON$TREET,4"�'FLOOR TEL. (978) 741-1800 - KIMBERLEY DRISCOLL F:1Z(978)745-0343 MAYOR JDIONNE(q�S,qL�iM11.COD4 � J�1NET DIONNE, ACT[NG HF,�ILTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAMEOFESTABLISHMENT Mi�l�ll'�iS 'PL,fTI�. TEL# I -�0�� 7��/�� ADDRESSOFESTABLISHMENT IC� �tTri'CCSD�V /IV� FAX# MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'SNAME }��SA'N �A�T TEL# ��I��S�o��y' ADDRESS�(ZrJ►�1 lSV" S� P�� P�— �Jq 6 0 STREET CITY STATE � ZIP CERTIFIED FOOD MANAGER'S NAME(S)M��IJ l]�lv LCl�� CERTIFICATE#(S) � (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON M�.�I VGL�J V �/ 17 HOME TEL# �7g�l��O 363 DAY,S OF OPERATION � .Monda Tuestla i . -Wetlnesda :..: 7hursda " � '<Frida Saturda Suntla HOURS OF OPERATION ;6,�,_3 PM ; �,�v,�3Fm : � m' Please write in lime of day. ; i � ��3PM; f�A�'►-3PM; �6n�m 3� . 6� �-3Pr�' �� —c1 (Forexamplellam-11pm) ; ; TYPE OF ESTABLISHMENT FEE (check onlv) RETAIL STORE YES NO less than 1000sq.ft. _$ 70 1000-10,OOOsq.ft. =$280 morethan 10,OOOsq.ft.. =$420 ------------------------------------------------- ------- -----------------------------------------------------------------------------------------_---------- RESTAURANT ES NO less than 25 seats - 140 (Outdoor Stationary Food CaR$210 25-99 seats $2 more than 99 seats 0 I -------------------------------------------- ----------- ---- - ---------- ------ --------------------------�----------------�------------------------ BEDIBREAKFAST/ YES O� $100 CHILDCARE SERVICES �� -----------------------------------------------------------------------------------------------------------------..----------------------------------------- ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES �� $25 ' TOBACCO VENDOR YES (TJ1 $135 ALL NON-PROFIT(such as church kitchens) YES `� $25 *Please pay total with one check payable to the City of Salem. ' This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62G 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 state taxes required under the law. - 41 0 I 3� 0 Signat � �. � Date Social Security or Federal Identification Number ------ ------- - -- - -------------- ----------------------- ----- I - �,p --------- ------------------ Revised 424/07 FOODAP2008.adm heck# e �A " r�. " �� $ .�-�p�0 � �7/ � ��' _ ' � . vy