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ALEXANDRAS LIQUORS - ESTABLISHMENTS Alexandra's Liquors 126-North Street a 4 �t I o Commonwealth of Massachusetts a + City of Salem Board of Health Kimberley Driscoll120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2008 ESTABLISHMENT NAME: Alexandra Beverage Corp. File Number:BHF-2004-000116 128 North Street Salem MA 01470 LOCATED AT: 0128 NORTH STREET SALEM, MA 01470 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0015 Jan 3,2008 Dec 31,2008 $70.00 TOBACCO VENDOR BHP-2008-0042 Jan 3,2008 Dec 31,2008 $135.00 Total Fees: $205.00 PERMIT EXPIRES jDecember31,2008 Board of Health i This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 4 of 28 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4'"FLOOR TEL.(978) 741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR iSCOTTO SALEM.COM JOANNE SCOTT, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT C� ( /gyp UPY P C'oej� TEL# q78- 7&-/ .. ADDRESS OF ESTABLISHMENT FAX# MAILING ADDRESS(if different) EMAIL-Business': n rr Website: OWNER'S NAME A�«DSL! (JbQ IIDLI TEL# 97f 777'-/7S� ADDRESS ZF,&k 1�E 1P(UE /17////EL'S N� ,4 01 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYS OF OPERATION 1 Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION Please write in Gme of day. (For example 11 am-11 pm) TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 - --------------------------YES O---....-.N- d---- ........ ...l.ess--- .than--"--. .. - ---- -----=-$_1_4-0----. RESTAURANT .. 25.. seats-e "-- - (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 -�--- 4E -- ------- - Y ---.....*K �----------------------------------------------------------------------------- 1 ...... BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES----_-.---., --------- ..--------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO 2 TOBACCO VENDOR E NO 135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax r ums nd paid all/ //4 state taxes required under the law. x t�/YZ�"� /D !7r/3(IJ�l�d-;,- Xign ture bate Social Security or Federal Identification Number ------------------------------------------'---'--q— ---------- _ Revised 4/24/07 FOODAP2008.adm Check#&Date ?373 $ b 0128 North Street Alexandra Beverage Corp. City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 744-1480 PIC Assigned/Knowledgeable/Duties PASS ❑J RED Owner: Non-compliance with: Argeros &Linda Hiou Anti-Choking PASS PIC: Argeros Hiou Tobacco PASS Inspector: EMPLOYEE HEALTH Elizabeth Salandrea Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 1/28/2008 Personnel with Infections Restricted/Excluded PASS I0 RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS (] RED BHP-2008-0015 Receiving/Condition PASS D RED Status: SIGNED OFF Tags/Records/Accurecyof Ingredient Statements PASS ❑d RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS RED 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 29,2008 ) Page 1 of Item Status Violation Critical Urgency RED; PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS RED Foodborne Illness Interventions and Risk Factors(Require - Food Contact Surfaces Cleaning and Sanitizing PASS 0 RED immediate corrective action) Proper Adequate Handwashing PASS ❑d RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS ❑d RED Handwash Facilities PASS 0 RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS 0 RED Toxic Chemicals PASS RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS 0 RED Reheating PASS 0 RED Cooling PASS 0 RED Hot and Cold Holding PASS Q RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS 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®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 29,2008 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Management and Personnel PASS BLUE Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Physical Facility PASS BLUE Water, Plumbing and Waste PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: Establishment sells a limited quantity of pre-packaged candy, chips and snacks. No health code violations cited at this time. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 29,2008 ) Page 3 of CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH RECEIVED 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 DEC -4 TEL. 978-741.1800 2Q06 FAx 978-745-0343 CITY OF SALEM Kimberley Driscoll WWW.SALEM.COM 130ARD OF,F-IEALTH Mayor .JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT WO" UP.v C 64,D, TEL# Q7?- 7W-- j�Q� ADDRESS OF ESTABLISHMENT �D�/ PY fe [ T� FAX# ?7o"-' 7Y1,4 --1e darJ MAILING ADDRESS (if different) EMAIL.--Business': ��}} p� Owner's: OWNER'S NAME_ �//YTL OS 9` /^r�y�/Q /7 /D N TEL#.- 978- 7'7—/x!-r-S - ADDRESSNiOIMd✓G /J{�/L/C A/7/2YS STREET CITY ' STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) ✓/J CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) EMERGENCY RESPONSE PERSON HOME TEL# DAYSOFOPERATION Monday Tuesday Wednesday _ Thutsday Friday Saturday Sunday HOURS OFOPERATION 44 PleasewriteIntime ofday. 14 f�m �, / v ✓ la /I�ry7 tfOrexamPleftamltdml INT TYPE OF ESTABLISHMENT check on RETAIL STORE <I-YE9 NO less than 1000sq.ft. 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ------.--- ...-.................... ..--------------- -- --- - ------I ....._ - -....-- -... -----------=' . ....... RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 - --- - -----.....-.....__._........... - .... ....._.......-------.._..... ._._._........ .......... _.. BED/BREAKFAST YES NO $100 ------- ------- -------.__---__---..___-------- ---- ---- - ------ _. ...... __ .- . -------- __.-._---- ----- ------- ------ ADDITIONAL PERMITS. MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR NO 50 ALL NON-PROFIT(such as church kitchens} S 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 620 Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge arid belief, h ve d all state Tei rns and paid a(I state taxes e aired under the taw. Ap 8"06 Signature Date Social Security or Federal Identification Number Revised 11113106 FOODAP2007.atlm Check#&Date_`!Z�1�2 / yr�j� s Jod.m t My^%�'�5 � ! �x}.Rex�ta,..4 =w �+Fi`41�;;� i � i♦ ,nom *a"`�nV� qu,,.� n+yA,�n� aY ".x.'{��t .`;PSE', Co mo i'i v. t Commonwealth of Massachusetts) �e, its S t �� a'�;eo4*f 5' • } ;� • �.� ��^:� x' �''t�y� Board of Health ,�� `� ,"rl�Y s .ro .�° ; ,...�''�. . ...' .a, ..x .. sw.� "".'C::'A;?`✓'T'STnxY'it`4r. ^'�,"�,,.r"i°tx�sP�id�t"l'v ;'�J"�!T'u"'�N,^r��l.."'�',. '�x�(.s, '"�+}�.MiiyQr p'F...�„=i” Y a ,. .. SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/19/2006 ESTABLISHMENT NAME: Alexandra Beverage Corp. File Number:BHF-2004-000116 128 North Street - - Salem MA 01970 LOCATED AT: 0128 NORTH STREET SALEM MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2007-0059 Dec 19,2006 Dec 31,2007 $50.00 TOBACCO VENDOR BHP-2007-0082 Dec 19,2006 Dec 31,2007 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 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 3 of 24 0128 North Street Alexandra Beverage Corp. City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 744-1480 PIC Assigned/Knowledgeable/Duties PASS RED Owner: Non-compliance with: Argeros & Linda Hiou Anti-Choking PASS PIC: Argeros Hiou _ Tobacco PASS Inspector: David Greenbaum EMPLOYEE HEALTH Date Inspected:Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑ RED 11/21/2006 Personnel with Infections Restricted/Excluded PASS RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS 0 RED BHP-2006-0002_ Receiving/Condition - PASS 0 RED Status: SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS ] RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS 0 RED 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 22,2006 ) Page 1 of • Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS 0 RED immediate corrective action) Proper Adequate Handwashing PASS ❑d RED Good Hygienic Practices PASS RED Prevention of Contamination from Hands PASS RED Handwash Facilities PASS 0 RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS RED Toxic Chemicals PASS 0 RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑J RED Reheating PASS ❑J 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 RED CONSUMER ADVISORY Posting of Consumer Advisories PASS V 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. Nov 22,2006 ) Page 2 of ;t Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: 1002:Establishment sells a limited quantity of pre-packaged candy, chips and snacks. No health code violations cited at this time. 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 3 of `4 g f f�n y� 4 In��": h A ✓ moi R� N+'^M�f'""]1'✓1fW'�('?i%h"�M6.i`AF ��S'ffi'l d�. ` �- .1�'F[ BF: ik{e `,L'�',>A� .ne.T +x9F3?[. ?'�«tr.,,,,' ,^-g'-a'c't..,,."'7.��'..^"^.��"'„'R7 T, ws,.ts.:*�;^.�+h:T'ita4<' a v'P°`,. „'.i�f`P�!"'ry. ;tPs[x"'iC+3"{'�ar r•i.` �?Pi^}�cyef2'e;G c Commonwealth of Massachusetts City of Salem ,. • - " Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/05/2006 WHO'S PLACE OF BUSINESS IS: Alexandra Beverage Corp. File Number:BHF-2004-0116 128 North Street Salem MA 01970 LOCATED AT: 0128 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0002 Jan 1,2006 Dec 31,2006 $50.00 TOBACCO VENDOR BHP-2006-0004 Jan 1,2006 Dec 31,2006 $50.00 Total Fees: $100.00 1 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. 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 3 of 18 � CITY OF SALEM, MASSACHUSETTS ;,. BOARD OF HEALTH D �� 120 WASHINGTON STREET, 4TH FLOOR �CQ SALEM, MA 01970 L, C'7 & 0 � TEL. 978-741-1800 j0of 4p"a STANLEY J. USOVICZ, JR. FAX 978-745-0343 7O OP MAYOR WWW.SALEM.COM JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2006 APPLICATION//FJJOR PERMIT TO OPERATE / A FOOD ESTABLISHMENT NAME OF ESTABLISHMENTAO (O/A7`'4 �2i7/4t" 0440 TEL ADDRESS OF ESTABLISHMENT IRR A)4t# JJZz'r - MAILING ADDRESS (if different) OWNER'S NAME S fr�brLdcL f �i TEL# '�X-- 75;OV�IIO ADDRESS /34-34 CITY 2V7v STATE ZIPA1976 CERTIFIED FOOD MAN GER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON HOME TEL# HOURS OF OPERATION: Mon.9:�ue._,� Wed. Thu. - Fri. Sat.LSun./e7 - U� TYPE-0F_ESTABLISHM ELM FEE (check only) t---RETAIL STORE YE NO less than 1000sq.ft. a-O 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 ........... YES------- -N - O--------------- ----------------------------l.ess... -t--han--25----.s.ea....ts...--------- -$"-1'0"0'............ RESTAURANT 25-99 seats =$150 more than 99 seats =$200 ........ ......-- BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS ------------------------------------------------------------.....--------------------------------------------------------- MAKE (notjust_serve) ICE CREAM, YOGURT, SOFT S jRVE YES NO $5 EJOBACCO VENDOR a�-Q(/j E NO 50 ALL NON-PROFIT(such as church kitchens) � NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best know ge and bel f, have filed all state tax returns and paid all state taxes required under the law. i ature Date Social Security or Federal Identification Number --- --------------------------------------- ¢ < --- --------------------------------------- Revised 11/03105 FOODAP2.adm Check#&DateT 0128 North Street Alexandra Beverage Corp. City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 744-1480 PIC Assigned/Knowledgeable/Duties PASS 0 RED Owner Non-compliance with: Argeros & Linda Hiou Anti-Choking PASS PIC: Argeros Hiou Tobacco PASS Inspector: EMPLOYEE HEALTH David Greenbaum Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS RED 1/18/2006 Personnel with Infections Restricted/Excluded PASS Q RED Risk Level: FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS RED BHP-2006-0002 Receiving/Condition PASS 0 RED Status: SIGNED OFF Tags/Records/Accuracy of Ingredient Statements PASS 0 RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASS 0 RED 0 Time IN: Time OUT: Urgency Description(s): BLUE:' '- Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jan 18,2006 ) Page I of Item Status Violation Critical Urgency RED: PROTECTION FROM CONTAMINATION Violations Related to Separation/Segregation/Protection PASS 0 RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED immediate corrective action) Proper Adequate Handwashing PASS 0 RED Good Hygienic Practices PASS ❑d RED Prevention of Contamination from Hands PASS Q RED Handwash Facilities PASS ❑ RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS RED Toxic Chemicals PASS ❑d RED TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS RED Reheating PASS RED Cooling PASS 0 RED Hot and Cold Holding PASS ❑J RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS ❑d RED CONSUMER ADVISORY Posting of Consumer Advisories PASS 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. Jan 18,2006 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection PASS BLUE Equipment and Utensils PASS BLUE Water, Plumbing and Waste PASS BLUE Physical Facility PASS BLUE Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: 437:Establishment sells a limited amount of pre-packaged nuts candy and gum. No health code violations cited at this time. 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. Jan 18,2006 ) Page 3 of ..r -f5nr�`#`x � t -� :�. �, � +'s., a r u � :w,r F x•+,y„r i. K �� t� "�� s� CITY OF SALEM MASSACHUSETTS o ^ 120 WASHINGTO�i..^wTREET;4TH FLOOR q SALEM, Iv1A 01970 .� TEL. 978-741.1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Liquor Store Name of Establishment: Alexandra Beverage Corp. Address of Establishment: 128 North Street Owner's Name: Argeros & Linda Hiou Restrictions: Application Date: 12/2/2004 Permit for Food Establishment 139-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 33-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. qEALTH AGENT r IMASSACHu 0V - CITY OF SALEM, AQ BOARD. OF HEALTH ®", # (�U� y, 120 WASHINGTON S' P„EET, 4TH FLOOR Y V U f SALEM, MA 01970 TEL. 978-741-1800 CITY OF SALEM FAX 978-745-0343 BOARD OF HEALTH STANLEY J. UISOVICZ, JR. .JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT /TTO OPERATE FOOD ESTABLISHMENT NAME OF ESTABLISHMENT Z(Lp/J/�/ -pL�4PyQ%P Ae'a TEL#?r/9- ADDRESS OF ESTABLISHMENT Ike rW- S�eC r MAILING ADDRESS (ifdifferent) // / OWNER'S NAME f7a?xoS `./.,7a2, ///D Ll TEL# ADDRESS /3 Aa/r�7z Ovo-- CITY_ ST,4TE/}'J/.'} ZIP CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON S,/,yne 4rs alDv G HOME TEL# HOURS OF OPERATION: Mon. /, ue. '� Wed. ✓Thu. ✓ Fri. ✓ Sat. Sun./A TYPE OF ESTABLISHMENTFEE check only RETAIL STORE ES NO less than 1000sq.ft. 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 G,p RESTAURANT YES NO 3 / less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVEY S NO �5 TOBACCO VENDOR 72—� XNO ALL NON-FROFii(such as church kitchens) Jl 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. Purs t to MGL Ch ter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my be owled a elief, have filed all s to x returns and paid all state taxes required under the law. Aeco D Z_ , nature Dae Social Security or Federal Identifiratinn dumber ----------------------------------------------------------- --------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Dal `Y 1 l _ r : f � Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name 1F Date Tvpe of 0 eration(s) Tvpe of Inspection N,- AM7/�6f/)1�1� r] Food Service R utine Address /'Z� F Risk U, Netail ❑ Re-inspection rr Telephone Level El Residential Kitchen Previous Inspection y -1Ao *ItL ❑ Mobile Date: Owner HACCP Y/N ❑ Temporary ❑ Pre-operation r L NY9rt 1016110,r ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time El Bed& Breakfast El General Complaint r�'T In: ❑ HACCP Inspector ;4_V.,) Q-"&tri Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑:' ` action as determined by the Board of Health. .FOOD PROTECTION MANAGEMENT [112. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El- .. 13. Handwash Facilities EMPLOYEE HEALTH - - - ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS ( El 3. Personnel with Infections Restricted/Excluded El 14. Approved Food or Color Additives FOOD FROM APPROVED SOURCE El 15.Toxic Chemicals ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices 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 ofCHeaN_ 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (Fc-9)(990.009) 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: S:590MclFo 14.doc r Inspector's Signatureoi,,,,,) Print: PIC's Signature: "f Print: Page of Z..Pages v-� Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination I 590.003(A) Assignment of Responsibility" 3-302.11(A)(1) Raw Animal Foods Separated from 590.003( 3) Demonstration of Knowledge* Cooked and R I F Foc s" 2 103 11 Person in chitrge--duties Contamination from Raw Ingredients 3=302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other` 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302A HA) I Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590-003(17) Responsibility Of A Ford Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Repots To The Person In Utensils* Change* Contamination from the Consumer 590.003(G) Reporting by Person in Charge" 3-306.14(A)(B) Returned Food and Reservice of Food* 31 590.003(1)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal.of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with FUvd law* 4-501.111 Manual Warewashing-Hot Water 3-201.1.2 Food in a hermetically Sealed Container* Sanitization Tem eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eo-s* Sanitization Tem eratures* 3-202.14 Eggs and Milk Pralnets.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pFf, 3?02.]6 Ice Made From Potable Drinking g Water* concentration and hardness 4-fi01.'11(A) Equipment Food Contact Surfaczs and 5-101.11 DrinkingWater from an Approved System" Utensils Clean* 590.006(A) 'Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Flxxl Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of S nnization Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical" Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulato Author' 2-301.11 CleanConditSon-Hands and Anns* 3-202.15 Shellstock Identification Present* 2-301-12 Cleaning Procedure* 590-004(0) Wild Mushrooms* 2-301.14 When to Wash'` 3-201.17 Game AnintakI2 ilGood Hygienic Practices 5 Receiving/Condition 2-401.11 Eatin , Drinkin or Using Tobacco* 3-202.11 PRFs Received at Proper Temperatures" 2-401.12 Discharges From the Eyes.Nose and 3-202-15 Package Integrity* Month" 3-101.11 Food Safe and Unadulterated* 3-301.12 Prevenihtg Cnntaminafion When Tasting" 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.1$ Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained" Em L ees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite,Destruction* Conveniently Located and Accessible 3-402.12 Records,Creationand Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.11. Location mid PlacwmemP' 7 Conformance with Approved Procedures �-205.11 Accessibi hty,O eration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502-12 Reduced oxygen packaging,criteria* 6-301-11 liandwashin Cleanser.Availability 9-103.12 Conformance with A xoved Procedures* 6-301,12 Hand Drvine Provision t *Denotes critical item in the federal 1999 Food Code or 105 CMR 59(11)00. i CITY OF SALEM BOARD OF HEALTH Establishment Name: &l_I1AW4A-4 1S&(AF41-ss C,,�g Date: / ��u� Page: 2 of 2- Item Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION Date Verified No. Reference R—Red Item r PLEASE PRINT CLEARLY r R r �IfiTh-�i"'tA' r Ih N C7 rC. Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines oftwenty-five dollars o suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �� C�r ❑ Voluntary Disposal ❑ Other: 3-501.14(C:)� PRFs Received at Temperamres Violations Related to Foodborne Illness Interventions and Risk Aa crding to IXiw Cooled to Factors(items 1-22) (Cont) 41`F/45°F Within 4 Hours, PROTECTION FROM CHEMICALS 3-501.15 Coaling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41"'145°F* 3-302.14 Protection,from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. * 7-101.11 Identifying.information-Original 3-501.16(A) Roasts Held at or above 130,F. Containers"` 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Stora c�' 3-501.19 Time as a Public Health Contnol* 7-202.11 Restriction-Presence and Ilse* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.1.1 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULATIONS(HSP) _ 7-204.12 Chemicals for Washing Produce,Criteria°` 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels- 7-205.11 Use of Pasteurized Eggs- 3-801,11(l)) g s- 7-205.L1 Incidental Food Contact, Lubricants* 7-206.1 1 Restricted Use Pesticides. Criteria* 3-801,i 1Q>} Raw or Partially Calked Aminal Food and Raw Seed Sprout's Not Served. rf 7-206.12 Rodent Bait Stations* 3-801..11(C) Unopened Food Packs=e Not Re-served, 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME[TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 15 Proper Cooking Temperatures for Animal Foods'lliat are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.I1A(1)(2) Eggs- 155°C 15 Sec. Patho ons*E0"c'rmoat E &s-Immediate Service 145'Fl5sec* 3-302.13 Pasteurimd Fhge Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game B p, Animals- 155'F 15 sec. * 3-401.11(B)(1)(2) Pok and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.1 l(A)(2) Ratites, Igjected Meats- 155°F 1.5 590.009(A)-(D) Violations of Section .590.009(A)-(D)in sec.* catering, mobile food, temporary and 3-401_11(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165"F 15 sec. 4= above if related to foodborne illness 3-40,1-11(C)(3) Whole-muscle,Intact Beet Steaks interventions and risk factors. Other 1450F* 590.009 violafions relating to good retail 3-401.12 Raw Animal Foals Cooked in a practices should be debited under-/729-- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(I)) PHFs 165'F 15 sec. A (Items 23-30) 3-403.11(B) Microwave- 165"F 2 Minute Standing Ciitical and non-critical violations, which do not relate to the Time* fttodborne illness interventions and risk factors listed above. can be 3-403.1 1(C) Commercially Processed RTE Food- f nand in the following sections of the Food Code and 105 CHK 140"F* 590.000. 3-403.11(6) Remaining Unsliced Portions of Beef item Good Retail Practices FC 590.000 Roasts* 23. Management and Personnel FC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection FC-3 .004 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PFIFs from 140"F to - -"-"- - - ---- - 26-. Water,Plumbing and Waste FC --5 .006 70°F Within 2 Hours and From 70"F 27` Ph slcal Facili _FC- .007 it)41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(13) Cooling PEIFs Made From Ambient 29. S ecial Re uiremants 009 Temperature Ingredients to 41`F/45"17 30,___ Other Within 4 Hours* uuoqu„rn,:kez.a"� .k Denotes critical item in the iMeral 1999 Food Code or 105 CMR 590,000. i r CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH i + e 120 WASHINGTON STREET, 4TH FLOOR '7o SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: Liquor Store Name of Establishment: Alexandra Beverage Corp. Address of Establishment: 128 North Street Owner's Name: Argeros & Linda Hiou Restrictions: Application Date: 12/4/2003 Permit for Food Establishment 141-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 33-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, orequipment chan es are made all plans for such must be P � 9 � submitted to and approved by the Salem Board of Health. HEALTH AGENT ti r' CITY OF SALEM, MASSACHUSETTS +� BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 DEC 3 -2003 TEL. 978-741-1800 FAX 978-745-0343 CRY /. F SALEM STANLEY USOVICZ, JR. pyI�/ l! JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT ' 2004 APPLICATION FOR PERMIT TO OPERATE AFOOD ESTABLISHMENT NAME OF ESTABLISHMENT l4leYdlk1Ga &!Vo AP aTEL# 7f«L—/V 4L '��C/ ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME TEL# 9,7 ,777 115e ADDRESS /ykJe� /U1> CITY '?/7U 77P5 STATE S ZIP D/9ag '3 CERTIFIED F60D MANAGER'S NAME(S) Le CERTIFICATE#(s) (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON .S,99,o C18 ✓t HOME TEL# e HOURS OF OPERATION: Mon. ue. � Wed. --Thu. �— Fri.!Sat.— Sun.—C-,&—&d TYPE OF ESTABLISHME FEE check only RETAIL STOREES NO less than 1000sq.ft. 1000-10,000sq.ft. =$100 more than I0,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFTERVE YES NO $5 TOBACCO VENDOR 33.97' <:PP NO ALL NON-PROFIT(such as church kitchens) YES NO $25 Please pay total with one check City payable to the C ty 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. Pursqgnt to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my e owledge d belief, have filed all stale tax returns and paid all state taxes required under the law. ;IZ ; n S/-3os5J'P/ Signature V ' ate Social Security or ederal Identification Number ------------------------------------------------------------------------------------------------------------------------------------- Revised 11/03/03 FOODAP2.adm Check#&Date THE COMMONWEALTH OF MASSACHUSETTS " CITY OF SALEM BOARD OF HEALTH Address: 120 Washington Street, 4th Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name A n Date Type of Ooeration(sl TTvoe of Inspection .4/ i'A'/GiWIGI,c ��F' p Lo /_/,5- 0V NFoodService ®'Routine Address / ' Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone �"{y' /1lxw ❑ Mobile Date: OwnerHACCP Y/N ElTemporary ElPre-operation 6L'lolgr 69/A /i A/ q '4/m rd ❑ Caterer ❑ Suspect Illness Person In h rge(PIC) ,. -m Time El Bed 8 Breakfast El General Complaint In: ❑ HACCP Inspector �. Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco , Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/ Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/ HACCP Plans El 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation/Protection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related r❑ Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions l 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 Si n'atu- . Print: 'F•.-'�g`-� 1J1J�4'se� U �J;'�.ree_�r.��_ PIC's Sign Jra L Print: Pae of�Pa es STON FORM 734A HOBBS&WARREN - 80 Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION a Cross contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from V 1;!: 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) I Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants 3.304.11 Food Contact with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in 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.;i 590.003(D) I Exclusions and Restrictions* Food 590.003(E) I Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H, 3-202.14 Eggs and Milk Products, Pasteurized* Hardness* p gg Concentration and 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10..: Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 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 Animals* 2-401.11 Eating, Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* . 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 3-402.1 I Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(7) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7 Conformance with Approved Procedures Supplied with Soap and Hand Drying HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* *Denotes critical item In the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: iT/ x�nr/rnsy��iryPn�� e.o Dater Page: of 6;2 < Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - Verified PLEASE PRINT CLEARLY 4 l' s! Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ S Exclusion vio)ations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understari�f that . noneampliance may result in daily fines o twe ty-five dollars or sUs nsion/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: � 4 3-501.14((.',) PHFs[deceived at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cowled to l,. Factors(Items 1-22) (Cont.) 41.°F1450F Within 4 Hours. * PROTECTION_FROM_ CHEMICALS3-501.15 Cooling Methods for PHFs14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501-16(B) Cold Pfff s Maintained at or below 3-202.12 Additives" 590.004(F) 41°145°F' 3-302.14 Protection front Una roved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F-* 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Heid at str above 130°F. Containers` 20 Time as a Public Health 7-102.11 Curmmon Narne--Working Containers'" 3=501-19 Time as a Public Health Control lfh ControP 7-201.11 Separation-StraPress age* 5!J0.004(Hj Variance Requirement 7-202.11 Restriction-Presence and Use* 7-202.12 Conditions of Use. 7-203.'11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.1.1(A) Unpasteurized Pre-packaged.Juices and Beverages with Warning Labels* 7-204.14 Drvinn Agents,Criteria* 3-801.11(B) Use of Pasteurized Enos* 7-2(15.1.1 IncidentalFood Contact,Lubricants" 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1.1(D) Raw or Partially Cooked Animal Food and Raw Seed S tout's Not Served 7-206.12 Rodent Bait'Stations* 3-801.1.1(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders, Pest Control and Monitoring' CONSUMER ADVISORY TIME)TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 1.6 Proper Cooking Temperatures for Animal Foods That are Raw, Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.IIA(1)(2) Eggs 1557 15 Sec Pathogens * Enos ,Immediate Service 145°F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3401,11(A)(2) Comminuted Fish.Meats&Game Animals- 155'F It sec. * 3-401.11(6)(1)(2) Pork and Beef Roast,- '1.30°F 121 min)R SPECIAL REQUIREMENTS 3401.11(A)(2) Ratites,Injected Meats- 155"F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec catering,mobile food, temporary and 3-401.11(A)(3) Poultrv,Wild Game.Stuffed PHFs, residential kitchen operations should be n ' I ueJiiBii uadet the a ,rt,,n6;ai' ScdJ Glib tuffiq_l:bnlaininn Fish,Meat, _pf r- Poultry or Ratites-165°F 15 sec. * above if i elated to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145".F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited wader#29-- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145nF 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(6) Microwave-165°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Time* ,foodborne illness interventions and riskfaciors listed abore, can be 3-403.11(C) Commercially Processed RTE Food- ,faun/in the,fnllmving sections of the Food Code and 105 6141? 140°F* 590.000. 3403,11(E) Remaining Unsliced Portions ofBeef Item Good Retail Practices FC 590,000 Roasts* _23. Manaemenl and Personnel FC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection IFC_3 . .004 -- 25_ Egwpment and Utansds __ _FC 4 .- -5 i 3-501.14(A) Cooling Cooked PHFs from 74(1°F to 26. Water Plumbin and Waste i FC-5 .006 ' 70`F Within 2 Hours and From 70°F 27. Ph sical-FacilityFC-6 .007 to 41.°F145°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.,14(B) Cooling PHFs Made'Fiom Ambient 29. Spemal Requirements 009 Temperature Ingredients to 41".F145°F 30. Other Within 4 Hours* A:iJ9 I nbA112a«. "Denote,.,Critical item in the federal 1999 PurrJ Cale or 105 C51R 590.000.