MY CONVENIENCE GROCERS - ESTABLISHMENTS Mf' 6yettF�rec1
ftNIVERSAL®
UNV-12110
MADE IN USA
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FORESTRY CCNlENf
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Certified Abar Sowciip POST'CONSUKR
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CITY OF SALEM, MASSACHUSETTS
BOARD OF HE.-,LTH
120 WASHINGTON STREET 4�"FLOOR aPubhcHealth
Prevent Promote.Protect.
TEL. (978)741-1800 Fax(978) 745-0343
KIMBERLEY DRISCOLL Iramdin(a)�s_alem.com
LARRY R;AMDIN,RS/RE _I'tS,CHO,CP-1S
ti
MAYOR HIr.A xii AGENT
February 24, 2014
My Convenience Grocers
111-113 Lafayette Street
Salem, MA 01970
Dear Owner:
On Saturday,January 25,2014 at 2:01 pm personnel from the Tobacco Control Program conducted a
compliance check to determine if your permitted establishment would sell a tobacco product to a minor. A
17 year-old female purchased tobacco from a clerk in your store. Documentation is now on file at the
Board of Health regarding that sale.
My Convenience Grocers is in violation of Section III (A)of the Salem Board of Health Regulation
Affecting the Sales of tobacco to a minor. According to this section,the sale of cigarettes,chewing
tobacco, snuff, or any tobacco in any of its forms to any person under the age of eighteen shall be
punished by a fine of($100.00 Hundred Dollar fine)for the first offense.
FOLLOWING THE THIRD(3RD)OFFENSE,THE BOARD MAY CONSIDER POSSIBLE REVOCATION
OR SUSPENSION OF THE PERMIT.
The North Shore Tobacco Control Program and the Salem Board of Health have worked with you and your
employees to demonstrate methods to ensure compliance with this regulation.
Therefore,you are ordered to pay a fine of$100.00 for the violation stated above. A check or
money order payable to the City of Salem must be at the Board of Health office, 120 Washington
Street,0 floor,within ten days of receipt of this notice.
Should you be aggrieved by this Order,you have the right to request a hearing before the Board of Health.
A request for such a hearing must be received in writing in this office of the Board of Health within seven
(7)days of receipt of this Order. At said hearing,you will be given the opportunity to be heard and to
present witness and documentary evidence as to why this Order should be modified or withdrawn. You
may be represented by an attorney. Please also be informed that you have the right to inspect and obtain
copies of all relevant inspection or investigation reports, orders, and other documentary information in the
possession of this Board, and that any adverse party has the right to be present at the hearing.
If you have any questions regarding this notification please call me at 978-741-1800.
Sincerely
y'yoouuurs,,�,�—c
Larry dfn
Health Agent
LR1hlp
CERTIFIED MAIL: 7012 1640 0002 3312 9809
cc: North Shore Tobacco Control Program
Barbara Poremba, Board of Health Chairperson and Members
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' Violation Notice
cCityffown,��-,/\ 1 %' Y nl Board of Health
Public Health
Prevent. Promote. Protect. -
This notice is to inform you that your establishment violated the Board of Health Sale of Tobacco Products
&Nicotine Delivery Products and/or Environmental Tobacco Smoke(ETS)Regulation.
l A Litr'1yt:)
Name of establi ment
Address
I�a�e viola[io�S T me of violation M, 1,
s age/gender Minor's ID#
Qrdinan`ce,Section Regula`tibAa,
- (Act Constituting Vio ation) .�
Narrative information:
J
I affirm,under the pains and penalties of perjury,that the above report is true to the best of my knowledge
and belief.
K CA
77;�� C
Inspector(nature) �' j ` (Print name)
VENDOR 3T fENJ A—T: acknowledge I received this Violation Notice bn 20-
at �--t• A�TPM ai�d I am being given a carbon copy of this notice.I also acknowledge that 1
have been in medtltal e Peabody Board of Health will provide additional,follow-up information to
this violation notice.
Owner/Manager/Clerk(Signature) (Print name)
If vendor refuses this Notice or if the inspector feels unsafe in delivering it,an explanation must be
written on a note attached hereto.Mailing of this Notice is thus required.
Contact the North Shore/Cape Ann Tobacco Alcohol Policy Program at 781.586.6821 with questions
Establishment-white NSTCP-yellow Board of Health-pink
1-rU.S.,Postal-Service.,
CERTIFIED MAILT. RECEIPT
r (Domestic Mail Only;No Insurance Coverage Provided)
For delivery information visit our website at M.usps.como
r
PS Form 3900,August 2006 See Reverse for Instructions
Certified Mail Provides:
■ Amailing receipt
■ A unique identifier for your mailplece
■ A record of delivery kept by the Postal Service for two years
Anportenf Reminders.
■ Certified Mail may ONLY be combined with First-Class Mall®or Priority Malts.
■ Certified Mail is notavailable for any class of International mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee a Return Receipt may be requested to provide proof of
delivery.To obtain Re{um Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse maiipieos°Return Receipt Requested'.To receive a fee waiver for
a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mallpiece with the
endorsement'Restricted Delivery':
is If a postmark on the Certified Mail receipt is desired,Please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt Is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present It when making an Inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-00Pe047
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete FRece
atAby
item 4 if Restricted Delivery is desired. 0 Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. irated Name) C. D to of Delivery
■ Attach this card to the back of the mailpiece, //
or on the front if space permits. o' g Pl ('
1. Article Addressed to: D. Is delivery address different from tem es
17 0 Y
t� rr If VES,enter delivery address below: 0 No
11-II3LGI'ey+' 5�
114 G)C1 70 3. Service Type
0 Certified Mail 0 Express Mail
0 Registered 0 Return Receipt far Merchandise
0 Insured Mail 0 C.O.D.
L� 4. Restricted Delivery?(Extra Fee) 0 yes
2. Article Number a 7012 -1640 0002 3312--9809
(Tmnsfer from service label) j
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTAL SERVICE First-Class Mail I
Postage&Fees Pald
' USPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box
I
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BOARD OF HEALTH
SALEM, MA 01970
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1384
MY CONVENIENCE GROCERY INC
111-113 LAFAYETTE ST
SALEM,MA 01970
DATE 3 ` 20/ y 53-179-113
PAY ,... .>.
TO THE
ORDER OF pyo, c_.r_/ .D arp
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Commonwealth of Massachusetts
City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
DATE PRINTED: 12/07/2011
ESTABLISHMENT NAME: My Convenience Grocery
File Number:BHF-2011-000015 111-113 Lafayette Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
RETAIL FOOD BHP-2011-0663 Dec 7,2011 Dec 31,2012 $280.00
Total Fees: $280.00
PERMIT EXPIRES
ecember 31 2012
Board of Health
�f
Page 1
Commonwealth of Massachusetts
` City of Salem
Board of Health Kimberley Driscoll
120 Washington Street,4th Floor Mayor
SALEM,MA 01970
DATE PRINTED: 12/07/2011
i
ESTABLISHMENT NAME: My Convenience Grocery
File Nmber:BttF-20114)00015 111-113 Lafayette Street
SALEM MA 01970
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
TOBACCO VENDOR BMP-2011-0664 , Dec 7,2011 Dec 31,2012 $135.00
Total Fees: $135.00
PERMIT EXPIRES. ecember3i, 2012 _
Board of Health
Page 1
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: MtdrP4\/ ENl eA i8ve Date: l2>1- )) Page: ) of
Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,
No. Reference R-Red Item Verified
PLEASE PRINT CLEARLY
Sri f�f� tN C�ii ) i✓S) Yaa i» 1'U
lt� Na 43vt-4 ets t'AvGSt2.
S1-1L\%A LNo%_ �- rn-, C-\L e)' V- , to vt\ rad'O AT —i 4u LetMTi
S�dia S11'�a,
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
3-501.14(C) PHFs Received at Temperatures
{ Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Items 1-22) (Cont.) 41'F145'F Within 4 Hours.
i
PROTECTION FROM CHEMICALS 3.50!.15 Conlin Methods for PHFs
'.. 14 Food or Color Additives 19 PHF Hot and Cold Holding
3 202.12 Additives* _ 3-50116(6) Cod PHFs Maintained at or below
3-302.1.4 Protection from Un p roved.kddioves* 3-501.16( 41014S F
i` 15 Poisonous or Toxic Substances 3-501.l6(A} Hot PHFs Maintained at or above
140°F.
7-101,11 Idemitying Information-Original 3.501.16(A) Roasts Held at at above 130'17. °
'r Containers*
7-102.11, Common Name-WorkingContainers* Mime as a Public Health Control
20
7-201.11 Separation-Storage* 3-501A9 Time as a Public Health Control*
7-202.11 Restriction-Presence and Use* 590.004(13) Variance Re uirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATBONS HSP
7-204.11 Sanitizers,Criteria-Chemicals*
7-204.1.2 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204,14 a encs.Criteria° :Beverages with Warning Labels*
3-801,1IfR) Use of Pasteurized Eggs*
7-205A I incidental Food Contact,Lubricants*
7-206.11 Restricted Use Pesticides;Criteria* - 3-$01..11 @) Raw or Partially Cooked Animal Food and
! 7-206.12 Rodent Bait Stations* Raw Seed Sprains Not Served-
7-206.12 C Unopened F
7-206.13 Tracking Powders, Pest Control and
Ford Package Not Re-served.
Monitoring* CONSUMER ADVISORY
22 3-603.I1 ConsumerAdvisory Posted for Consumption of
71MEITEMPERATURE CONTROLS
" 16 Proper Cooiting Temperatures for Animal Foods That are Raw.Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.1IA(1)(2) Eggs- 155"17 15 Sea
Palling. 'ens
Eggs-immediate Service 145°Fl5sec* 3-30113. Pasteurized Eggs Substitute for Raw Shell
EggsA
3401.11(A)(2) Comminuted Fish.Meats&Game
Animals-155'F 15 sec. *-. SPECIAL REQUIREMENTS
340LII(B)(l)(2) Port:and Beef Roast-I30°F 121 min*
3-401.11(A)(2) Ratites, Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec. * catering,,mobile food,temporary and
{ 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Staffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-.i 65'F 15 sec. " above if related to foodborne illness
3-401.11(C)(3) Whore-muscle,Intact Beef Steaks interventions and risk factors. Other
t 145'F* 590,009 violations relating to good retail
{ 340LI2 Raw Animal Foods Cooked in a practices should be debited under#29-
F Microwave 165"F' Special Requirements.
3-401 A I(A)(1)(b) All Other PHFs-145'F 15 sec,
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.11(A)&(D) Pl Fs 165'F 15 sec. ' (Items 23-30)
3-403.11(B) Microwave 16Y F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk,factors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140°F* 590.000.
ti 3-403.11(E) Remaining Unsliced Portions of Beef - Itenn 1 Good Retail Practices1 FC 590.000
Roasts': j 23., I Management and Personnel , FC-2 .003 I
18 Proper Cooling of PHFs 24. Food and Foal Protection FC-3 .004
1 25, 1 Equipment and Utensils _ FC-4 .005 i
3-501.14(A) Cooling Cooked PHFs from 140'F to 26. Water.Plumbing and Waste _i Fc-5 .tN76
70'F Within 2 Hours and From 70'F 27. ' Physicaf Facility FC-6 .007
to 41'FJ45'F Within 4 Hours. I Poisonous oT Toxic Materials FC-7 .008
t� 3-501.14(6) Cooling PHFs Made From Ambient X29. 1 Special Requirements .009 i
{ Temperature Ingredients to 41°17/45°F 1 Other
_thin 4 Hours* sxvnm�n d za c
"Denotes critical item in the L-dorsi 1099 Foci Cale,or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: tri e�YFN � Date:_ 1)-3d >l • Page: of 2
Rem Code C-Critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date-
No. Reference R—Red Item verified
PLEASE PRINT CLEARLY
c5-
CA
t� e> L L L = S
Sw�G�6S.
> t!IcL 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/
violations before the next inspection, to observe all conditions as described, and to Exclusion
❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twen�te dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. ir�2�� ❑ Voluntary Disposal ❑ Other:
....-y :.-._....^..ti. .,s'ti.y.,. _ .......,-,�. �t �; ;:.-,,.'h../°�°'\•,ati '':-,.vim.'^ ...;.2 .r r-,. r. 1 _: y I.
3-501:14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to
Factors(Items 1-22) (Cont.) 41°F145°F Within4 Hours. *
PROTECTION FROM CHEMICALS3-501.15 CoolingMethods for PHFs
14 Food or Color Additives 19 PHF Not and Cold Holding
3-202.12 Additives* 3-501.16(B) Cold PHFs Maintained at or below
' 590,{)04(F) 41°145°F*
3-302.14 Protection from Unapproved Additives"
15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above
7-101,11 Identifying information-Original 140°F.
Containers* 3-501.16(A) Roasts Held at or above 130°F.
Time as a Public Health
7-102.11, Common Name-Working3-501. Time aa Public Health Con
Containers* 20 Control*
trol
7-201.11 Separation-Stora 590.0044(H) Variance c e Requirementn
7-202.11 .Restriction-Presenceand Use*
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULAT1DN5 HSP
7-204.11 Satdtizers.Criteria-Chemicals*
7-204.12 Chemicals for Washin Produce,Criteria* 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.14 n . tris.Criteria* Beverages with Warning labels*
7-205.11 Incidental Foal Contact,Lubricants* 3-801.11(8) Use of Pasteurized E °s*
7-206.11 -Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served-
7-206.12 Rodent Bait Stations* 3-801.l l(C) Unopened Food Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring* CONSUMER ADVISORY
TIMEtt•EMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption(if
Ib Proper Cooldng Temperatures for Animal Foods That are Raw.Undercooked or
PRFs Not Otherwise Processed to Eliminate
3401.11A(i)(2) Eggs- 155°F 15 Sec. Pio ens,*0q 1. 1112 (
E -immediate Service 145°F15sec* ' 3-302.13 1
EPasteurized Eggs Substitute for Raw Shell
gg
3-401-11(A)(2) Comminuted Fish.Meats&Game
Animals-155°F 15 sec. *
3-401.11(B)(1)(2) Pork and Beef Roast- 1.30°F 121 mm* SPECIAL REQUIREMENTS
3401.11(A)(2) Ratites,Injected Meats--155°F 15 590.009(A)-(D) Violations of Section.590.009(A)-(D)in
Sep.* catering,mobile food, temporary and
3401A UA)Q3 Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness
3401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other
145°F Q` 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165°F* Special Requirements.
3-401s11(A)(1)(6) All Other PHFs-145°F 15 sec.
17 Reheating for tot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403:11(A)&(D) PRFs 165°F 15 sec.* (Itetw 23-30)
3403.11(B) Microwave- 165°F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed abme, can he
3-403.11(0 Commercial ly Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140°F* 590.000.
3403.11(E) - Remaining UnslicedPortiopsofBeef Item I Good Retail Practices J.FC 590.0w
Roasts* 23. 1 Management and Personnel FC-2 .003
18 Proper Cooling of PHFs24. Food and Food_ProtecNat FC-3 004
25. Equipment and Utensils 1 FC-4 .005
3-501.14fA} Coaling Clinked PHFs from 140°F to 26. Water,Plumbin and Waste FC-5 .006 1
70°F Within 2 Hours and From 70°P p7, p cal Facili FC-6 007
to 41°F145°F Within 4 Hours. * 28. Poisonous or Toxic Materials ' FC=7 .008 I
3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009
Temperature logredients to 41OF/45°F 30. Other _ I
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: Maj n/1)Etu f teJ�-lL CAQt Z,9- � Date: 1 I-32,-)1 Page: of_Z
Item Code I C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date.
No. Reference R-Red Item Vermed
PLEASE PRINT CLEARLY
� O ►I�i Q tom\ b(.,) d S � ' Qa '
�0 1 N �
Y�\7 5 8 1 W'ALL
5 2S 1a 1 T1 r7 uJ l� X
Veoc�7Y}, js �G 6�� c g '
1 env Y\e�t) LSI C.1.�1G�N
LL. 1�� fLc>T oU d m r tLt G L\y\ t)
trA v W oL® ;my
S nQLSLr.>ve, , 6! o2ov la Cv�ma�lrl
R \ rc� —' 1 e lam a1Lta 4� o SL 1 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/
violations before the next inspection, to observe all conditions as described, and to Exclusion
❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal Cl Other:
-3-501.14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness.Interventions and Risk; According to law Cooled to.
Factors(ferns 1-22) (Cont.) 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
3-501.16(B) Cold PHFs Maintained at or below
3-202,12 Additives* 590.004(M 41:0/45'F*.
3-302.14 Protection from Unapproved Additives*
15 Poisonous or Toxic Substances 3-501.16(0) Hot PHFs Maintained at or above
7-101.11 Identifying Information-Original 1400F
3-501.16(A) Roasts Held at or above 130°F.
Containers*
7-102.11. Common Name-Workin Containers* Time as a Public Health Control
20
7-201.11 Separation-Storn * 3-501.19 Time as a Public Health Control*
7-202.11 .Restriction-Presenc:eand Use* 590,004(H) Variance Requirement
7-202.12 Conditions of Use*
7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
POPULATIONS HSP
7-204.11 ' Chemicrs.als Criteria i Chemicals* 21 3-801.11(A) Unpasteurized Pte-packaged Juices and
7-204.12 Chemicals for Washing Pmdtice,Criteria*
7-204.14 Drying Agents.Criteria* .Bevera es with Warning Labels*
3-801.11(8 Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact, ,CrieriaLubricants* - 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 PackageNot 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
16 ods Proper Cooking Temperatures for Animal FoThat are Raw,Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-401.I1A(1)(2) Eggs- 155`F 15 Sec. Path° '*Esso° neo
Eggs-immediate Service 145°F15sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell
3-407.11(A)(2) - Comminuted Fish.Meats&Game
E
Animals-155'F 15 sec.
3-401.11(8)(1)(2) Pork and Beef Roast- 130'F 121 titin* SPECIAL REQUIREMENTS _
3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590 Violations of Section 590.009(A)-(D)in
see. * catering,mobile food, temporary and
3-401.11(A)(3) Poultry,Wild date,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165'F 15 sec.* above if related to foodborne illness
3-401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145'F* 590.009 violations relating to good retail
3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165`F* Special Requirements. .
3-401;11(A)(1)(b) Ali Other PHFs-145'F 15 sec. *
17 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.11(A)&(D) PHFs 165F 15 sec.* (Items 23-30)
3.403.11(B) Microwave- 165'F 2 Minute Standing Critical,and non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3-403.11(C) Commercial ly Processed RTE Food- found in the following sectionsof the Food Code mrd 105 CMR
1400F* ` 590.000.,
3-403-11(E) - Remaining Unsliced Portions of Beef - Item j Good Retail Practices .FC 590.Wo
Roasts* 23. 'Manailemerit and Personnel FC-2 .003.1
18 Proper Cooling of PHFs 24. Food and Food Protection - FC-3 .004
3-5014(A)14(0) Cooling Cooked PHFs from 140°F to 25. Equipment and Utensils FC-4 .005 1
26. Water Plumbing and Waste I FC-5 .W6 i
70`F Within 2 Hours and From 70'F 27. Physical Facili i FC-6 .007
to 41°F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials FC=7 .008
3-501.14(13) Cooling PHFs Made From Ambient 29. Special Rego rements ,009
Temperature Ingredients to 41°F/45°F 30' aha
Within 4 Hours* s:sw:r�no-ai<ze:
'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 Rom DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date,
No. Reference R-Rad Item Verified
PLEASE PRINT CLEARLY
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/
violations before the next inspection, to observe all conditions as described, and to Exclusion
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
3-501.14(C) PHFs Received at Temperatures
Viotaflons Related to Foodborne illness.Interventions and Risk According to law Cooled to
Factors Morris 1-22) (Cant.) 41'FJ45'F Within 4 Hollis.
PROTECTION FROM CHEMICALS 3-501..15 Coolie Methods for PHFs
14 Food or CAf Additives 19 PHF Not and Cold Holding
3-202.12 Additives* 3-501.16(11) Cold PIIF*IvIa£ntamed at or below
3-302.14 Protection from Una roved Additives* 3-50 L 16( 4 of P F
g5 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
140°F. *
7-101,11 Identifying Information-Original 3561.16(A) Roasts Held at or above 1300F. °
Containers* 20 Time as a Public Health Control
7-102.11, Common Name-Working Containers* -
3-501.4( Vara as a Public Health Control
7-201.11 Separation-Storage' 5590.004(H) *
7-202.I1 .Restriction-Presence and Use*
- H) arianceR uirement
7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizets.Criteria-Chemicals*
7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
Beverages with Warning Labels*
7-204.14 Agents.Criteria* 3-801.11(B) Use of Pasteurized Eggs*
7-205.11 Incidental Food Contact, ;Criteria* 3-801..11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria*t Raw Seed Sprains Not Served,'
7-205..12
7-206Rodent Bait rs3-801A I C Unopened poral Package Not Re-served.
13 Tracking Powdd ers,, Pest Control and
Monitoring* - CONSUMER ADVISORY
TIMETfE4♦IPERATURE CONTROLS 22 3-603.11 ConsumerAdvisory Posted for Consumption of
Cooking Temperatures far Animal Foods That are Raw,Undercooked or
16 TURF Proper
- Not Otherwise-Processed to Eliminate
P
3-402.11 A(1)(2) Eggs- 155°F 15 Sec. I'atho gens.*e!°"'g'nrrmr
E *s-Immediate Service 145°Fl5sec* 3-302.13 1 Pasteurized Eggs Substitute for Raw,Shell
3-401.11(A)(2) Comminuted Fish.Meats&Game
E
Animals-155°F 15 see. *
3 401.11(B)(I)(2) Pori and Beef Roast- 130°F 221 min* SPECIAL REQUIREMENTS
3-401.11tA)(2) Ratites,Injected Meats-155`F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
Lee.* catering,mobile ford,temporary and
3-401.I1(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 1.5 see. * above if related to ftmdborne illness
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other
145°F* 590.009 violations relating to good retail
3401.12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F Special Requirements.
340LI I(A)(1)(b) All Other PHFs- 145'F 15 sec.°
fl7 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES
3403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30)
3-403.11(B) Microwave- 165"F 2 Minute Standing Crixical,and non-critical violations, which do not relate to the
Time* fitodborne illness intervendanr and risk factors listed above, can be
3-403.11(C) Commercially Processed RTE Food- found in the following sections-qf the Food Code and 105 CMR
1400F* 590.000.
3403.11(E) Remaining Unsliced Portions of Beef item i Good Retail Practices .FC 590.000
Roasts* 23, i Management and Personnel -FC-2 .003
1$ Proper Cooling of PHFs 24. 1 Food and Food Protection FC-3 .004
25. E ui mend and Utensils I FC-4 .005 i
3-501.14(A) Cooling Cooked PHP%from140'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.* L28_� Poisonous or Toxic Materials ! FG-7 .008
3-501.14(6) Cooling PHFs Made From Ambient 29. -Special Requirements
Temperature Ingredients to 41'F/45°F 130 i Other
Within 4 Hours* - s�vcr,ma,:w.ze:_
*Dmotca critical item in the f char 1999 Ford Cale w'105 COIR 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 Verified
PLEASE PRINT CLEARLY
II
i
i
Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes
1
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
-- comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
j
1
3-501.14(C) PHFs Received at Temperatures
Violation Related to Foodborne Illness,Interventions and Risk According to Law Cooled to
Factors(!toms 1-22) (Cont.) 41'F145°F within 4 Houm
PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs
14 Food or Gator Additives 19 PHF toot and Cold Holding
3-501.16(B) Cold PI-1Fs 6iaimained at or below
3-202.12 Additives*' 9
590.404{F) 4l f45'F*
3-302.14 Protection.from Una roved Addiuves* 3-50 L I6(A) Hot PRFs Maintained at or above
15 Poisonous or Tattle Substances 140°F.
7-t 02,11 Identifying Information-Original
3-501.16(A) Roasts Held at or above 130'R
Containers* 20 Time as a Public Health Control
7-102.11. Common!dame-Working Containers'"
- 3-501.19 Time as a Public Health Control*
7_201.11 Separation-Storage* 590.004(H) Variance Requirement
7-202.11 .Restriction-Presenc:eand Use* t
7-202.12 Conditions of Use* REQUIREMENT'S FOR HIGHLY SUSCEPTIBLE
7-20111 'Toric Cattamers-Prohibitions* POPULATIONS HSP
7-204.11 Sanitizers,Criteria-Chemicals*
7-204.12 Chemicals for washing Produce,Criteria* 21 3-801.].l(A) Unpasteurized Pre-packaged Juices and
Beverages with warnin*Labels"
7-204.14 A ents.Criteria% 3-80LIIM Use of PasteurizedE,-as* -
7-205.11 Incidental Food Contact,Lubricants* 3-80.1..11(D) Raw or Partially Cooked Animal Food and
7-206.11 Restricted Use Pesticides;Criteria* Raw Seed S . s;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
TiME1FEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or
Not Otherwise Processed to Elimmate
PHFs txxn,w v+2oer
Po '*
3-401.11A(I)(2) Eggs- 155"1715 See.
Eggs-Immediate Service 145'Fl5sec* 3-302.13, Pasteurized Eggs Substitute for Raw Shell
E
3-401.11(A)(2) Comminuted Fish.Meats&Game
*
Animals-155'F 15 sec. * SPECIAL REQUIREMENTS
3-40LII(B)(1}(2) Pork and Beef Rout- 130'F 121 min*
3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
set% * 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-165'1715 sec, * above if related to t'oodborne illness
3-40I.11(C)(3) Whole-muscle,Intact Beef Steads interventions and risk factors. Other
1450F* 590.009 violations relating to good retail
3-401,12 Raw Animal Faris Cooked in a practices should be debited under#29-
Microwave 165`17* 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
3-403AI(A)&(D) f PHFs 165"F 15 see. * (Ite►nts;2.3.30)
3403.11(B) Microwave 165'F 2 Minute Standing Critical,mid non-critical violations,which do not relate to the
Time* foodborne illness interventions and risk factors listed above, can be
3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR
140°F* 590.000.
340311(E) Remaining Umsticed Portions of Beef F Item { Good Retail Practices FC 540.tNNl
Roasts* i 23. agement and Personnel FC-2 003
18 Proper Cooling of PHFs i 24. I Food and Foal Protection FC-3 004
125. 1 Equipment and Utensils
_. FG-4 X005 j
3-501.14(A) Cooling Cooked PHFs from 140`F to i n, Water.Plumbing and Waste I FC-5 1 006 �
70`F Within 2 Hours and From 70`F 27. Physical Faci' FC-6 1 .007 �
to 41`FI45'F within 4 Hours. * i_28. ' Poisonous or Toxic Materials FC-7 .008
3-501.14(.B) Coiling PHFs Made From Ambient 29. 1 4ecial R uirements I .009
Temperature Ingredients to 41°17/45°F ' 30 i Other ---!
within 4 Hours"
"Drnexex critical teem in rhe£^,doral 7 J99 Fwd Calc ur 103 C$tli 390.000.