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NEW YORK FOOD MARKET - ESTABLISHMENTSUse Only Nhrnb -r: 2014 - I10 r� Date Filed: i Expirat'in Date:AoLr'-1 a��', j� u i Y FEE: $25.00 (includes 1 certified copy) Type: ✓New Renewal, no change Renewal, with change BUSINESS CERTIFICATE In conformity with the provisions of Chapter 110, Section 5 of the Massachusetts General Laws, as amended, the r undersigned hereby requests the filing of the following business certificate in the City of Salem. Furthermore the undersigned fully understands that the filing of this business certificate does not constitute a license or permit to conduct said business within the City of Salem. This Certificate expires four (4) years from the date of issue. If you cease conducting business before that time, the law requires that you withdraw this certificate with the Office of the City Clerk. Name of Business: N Qlhl ( (S{t— Conducted At: r a �rZ vvt eat , Phone No.: (P.Q. Box Not Permitted) Type of Business:�tinr"Qn� , �eQiQ Sfis�e By the following named person(s) or corporation Print Full Name & Title `Rlhmad �tazi State Tax T.D. No.: n9 '7 9 " b (if avaitable) Corporation / Residential Address & Phone Number 1 Sa`Qwr Satlzw. Gly , (fat W'^ - -1 , Driver License or State ID No.: S]00`179s- Signatures X X on APR 2 8 21014 20� the above named person(s) personally appeared before me and made an oa that the foregoing, statement is true. Signature: City Clerk - "'"' "' Notary Public \ Seat or Nora y Seat SuarrF Commission Expires: 1 8 ' e7 1995 and anoath business certificates al to eiiect.for fou(4yeisfroru be date of issue and shallberenewed each four arsher thereafter. Section statement der must be filed ththe wn clerk upon discontinwng,rennng, or withdrawing from such business or partnership. CopIca of "such certificates shall be available at the address at which such business is conducted and shall be furnished on request during regular business hours to any person who has purchased goods or services from such business Violations are subject to a fine of not more than three hundred dollars ($300.00) for each month during which such violation continues. MASSACHUSETTS DEPT. OF REVENUE PO BOX 7010 BOSTON, MA 02204 AMY A. PITTER, COMMISSIONER MICHAEL J. LIVIDOTI, DEPUTY COMMISSIONER 402C a AHMAD HIJAZI ,. 21 SALEM ST SALEM MA 01970-5013 Dear Taxpayer: Notice 80615 T/P ID 189 376 709 Date 05/12/14 Bureau CSB THREE �S�aCNUg�, v fI� ✓ Y rE%vf 4��ti The Massachusetts Department of Revenue (DOR) has some important information regarding your business tax filings. Per Technical Information Release (TIR) 04-30 and 05-22, new businesses and existing businesses applying for an additional registration that collect any of the following taxes must file and pay them electronically regardless of the dollar amount of their annual tax liability: withholding on wages or retirement distributions, sales and/or use tax on goods, telecommunications services, meals and/or beverages, and room occupancy excise. Because all of the .tax types listed above must be filed and paid electronically, you will not be receiving any tax booklets or coupons through the mail. If you have not done so already, please visit DOR's website at www.mass.gov/dor, click on "WebFile for Business" and register to use this application at your earliest convenience. Through WebFile for Business, you will be able to submit. tax returns and payments, and manage your tax account online. If you have further questions after touring WebFile, please contact our Customer Service Bureau at (617) 887-MDOR or toll-free in Massachusetts at (800) 392-6089... Sincerely, The Massachusetts Department of Revenue l 1111 �I��G�i��'��wll III COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF REVENUE PO BOX 7010 BOSTON, MA 02204 403C AHMAD HIJAZI 21 SALEM ST. SALEM MA 01970-5013 Dear Taxpayer, Notice Date: 05/16/14 Taxpayer ID Number: 189 376 709 Below please find your Sales and Use Registration Certificate (Form ST -1). Please cut along the dotted line and display at your place of business. Sincerely, Massachusetts Dept. of R v nue �l\ The vendor herein named is registered to sell tangible personal property at retail or for resale, pursuant to the General Laws, Chapters 62C, 64H and 641. This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct ST -1 can be issued. Massachusetts Department of Revenue ST -1 AHMAD HLIAZI Customer Service Bureau NEW YORK FOOD MARKET PO Boz 7010 21SALEM ST Boston, MA 02204 The vendor herein named is registered to sell tangible personal property at retail or for resale, pursuant to the General Laws, Chapters 62C, 64H and 641. This registration is effective only for the registrant at the location specified herein. Any change of name or address must be reported to the Department of Revenue so that a correct ST -1 can be issued. This registration must be displayed for customers to see and is not assignable or transferable. COMMISSIONER OF REVENUE IDENTIFICATION AHMAD HLIAZI NUMBER NEW YORK FOOD MARKET 189-376-709 21SALEM ST SALEM MA 01970 ISSUE DATE 05/01/14 This registration must be displayed for customers to see and is not assignable or transferable. COMMISSIONER OF REVENUE Z compose Inbox (21) - brats Sent Spam (29) Trash > Folders > Recent 4A <+ + 1 @ Delete a Move � 9 Not Spam ® More = C011apseW Tax -ID -Number -Online Order Receipt f Tax-ID-Number-Orillmopm Support. i;r l <T=.i,:33 Pt,'. To Me This message contains Wadded images. Shoal Images Change this setting Tax-m-Number-Online.mm Order Complete Your order for a Tax ID / EIN from the IRS has been placed. Your transaction ID i5 8058297946.' Your Tax ID Number / EIN from the IRS Will be emailed to you along with a PDF copy of'your 55.4 form within i business day - You can check your queer status or contact us. Please be sure to yduslist our email address to assure that your EIN / Tax ID is sent to you properly. CONFIDENTIALITY NOTICE: This email and any attachments are for the axcnsive and confidential use of the Intended raiment 11 you are not the mended redlent please do not mad, dstnt w or take mm in rater, upon this message. If you have received this in a.,,, please nobly us immed6tely by rata. email and promptly delete this message and its attachments from your computer system. We do not waive atmmey-client ormm product proffege by the transrobaw of this message TAY ADVICE / LEGAL ADVICE NOTICE: Tax advice, 9 say, contained in this e -mad does, not conntMe a'relience opinion" 0 defined in IRS Circular 230 and may not be used to enabtish reasonable reliance on the opinion of counsel for the purpose of "trading the penalty imposed by section 6652A of the Mental Ravenna Cade. Ilia fico, promfoo reliance opJrm4 only n fom al opinion letters Containing the sgn rsne of a macer. As pre.4oudy Rated on the da or wbmissmn and footer of all related agency file processing websies we are not the IRS or any other govemment agency am are a prate State and recent fdmg agency specializing in busmen; trust and estate firings. 79x5 Woods or Beammmek OH 454321937-69r,9616 1 unonosvto, Reply, Reply All or Poniard ( More , /d Pt r INITIAL SERVICE REGULAR SERVICE TERM/N/X EXTRA SERVICE COMMERCIAL REPORT BRANCH ACCOUNT RT. TELEPHONE I OHIO 1 S. DAV F T PRODUCTION I TIME IN 11 TIME OUT 051 SERMICE PROPERTY AT BRANCH t1/fc� �o� nn�PJcsz'T G , /i L21 f -?" Tjos7�ar Z39�' G+�O/jL / r�^ \ oi3- 6/:t 00 43 OPERATOR NAME & CERTIFICATION NUMBER N SUPERVISOR NAME & CERTIFICATION NUMBER Ti ) 3 Target O German Cockroaches ❑Pavement Ants ❑Rats O Pests ❑American Cockroaches ❑Argentine Ants Mice El 11 Oriental Cockroaches �O Fire Ants ❑Silverfish C1 O Other Cockroaches El Other Ants Cl Flies L1 Occasional Invaders Stared Product Pests Other Other Materials #used #used 450 Insiders 620 WIND-UPTRAPS WO Insect Monitors 610TIN CATS 410 PheromoneTimps 60.5 Rat Bait Stations Pest Control Materials Used EPA Reg. # Tic Etc Amount 600 4dTimp 640 Mouse Bait Stations 630 Snap Traps 1 655 Liquid Bait Stations 293 Advance Granular Ant Bait(Abamectin 8110.011% 499-370 Areas Inspected and/orTreated Pest cannot maf#deh u#adinrlkatadby cases from#atatbR 295 Advance Dual Choice Ant Bad(Abamectin B1)0.011% 499-496 315 Ascend Fire Ant Balt (Abameclin 8110.011 % 499-370 MFod Areas [1 Dining Areas 0 Offices CN.B,,u�bllcAreas C VJ r5 a r.Vst/Locker Rooms ! Nispfay Areas 11 Laundry/Boiler Room / .3 torWageNtiliry L' I WarellouseAreA' 1y£ - f - It -. - - - L1 Processing Areas Patient Rooms 11 Guest Rooms asement T [ 0 R06f O Exterior Perimeter O Landscaped Areas O Loading Dock/Dumpster ❑ Other 309 Avert Roach Bat Stations (Abamectin) 0.05% 499467 365 Advance 3888 Ant Gel Bait (Borax) 5.4% 499_#92 100 Bond Dust (Orthoboric acid) 99% � 9444-129 15 Demand CS(Lambda-cyhalothrin) 00.015% 00.03% 00.06% 100-1066 210 DeltaGard G (Deltamethfin) 0.1 % 432-836 158 TriDie Bulk Dust (Silica Gel) 40% (Pyrethrins) 1.0% 499-429 41 Genital IGR EC (Hytlroprene) 0.06% � 2724-351 SW Generation Mini Blocks Bait (Difethialone) 0.0025% 7173-218 541 - Generation Blue Max Blocks 8iL(DBelNalone);0.0025% 7173-236 542\ First Strike Soft Bait (Difethialone) OA025% 7173-258 KckerEC(Pyrethrins) 00.05% 00.1% 00.2% 432-1145. SW LiquRox It But (Disodium Salt of Diphacinone) 0.106% 12455-61❑ 352 Madorce FC Roach Bait Stations(Fipronil) 0.05% 432-1257 351 Maxforce FC Ant Bait Stations (Fipronil) 0.01 % 432-1256 357 Maxfome FC Ant Gel Bait (Fipronil) 0,001 % 432-1264 354 Maxforoe FC Magnum Roach Bait Gel (Fipronil) 0.05% 432-1460 355 Maxforce Complete Granular Bat( Hydramethlynon) 1% 432-1255 151 PTO/ -Kick Aerosol(CyOuthrin) 0.1% 499-470 70 PTO/ -Kick CS(Wluthrin) 00.0075% 00025% 00.05% 00.1% 499-304 W PT 565 Plus XLO Aerosol (Pyrethrins) 0.5% 499-290 159 PTTriDie Aerosol(Silica Aerogel) 4.8%(Pyrethrins)0.6% 499-385 81 Tempo Ultra WP(b-Cylluthrin) 00.025% 210.05% 432-1304 Precautions vocu83 thropn and pet s. May cause aye, nose, thirst, or skin tsH ion. MWaaof e, rose, Avoid breaming vaprs omists, or dusts. Harmful it swallowed. Dampen granulest..1vite. Do not tamper with rodentiade placements. Do not mWm to room until agar ventilation. Do not touch treated areas until dry. For flea treatments, remain o6 treated area for a minimum of four hours or until dry Tempo SC Ultm(b-CyOuthrin ❑0.025% 00.05% 432-1363 1-12V81 ULD BP 1001-12V (Pyrethdns) 1.0% 499-452/11540-9 92 ULD BP 300 ULV(Pyrethrins) 3.0% 499-450/11540-1 591 Weatherblok XT BaO(Brod6acoum) 0.005% 100-1055 38 Mother Earth Scatter Bait (Boric Acid) 5% 499-515 Treatment Code r/CI:C= Crack &Crevice V=Vold O=common 5=Spot ST=Bait OC= Directed! Contact B=TBand SP=Space IN =1 -pectin ' Equipment Code(E/C): C=Comp.Air Sprayer T=Tap BS=Beit Station D Hand Duster A=Aerosol BO=Bak Gun T= rTreanent F=ULV Posting Service Sticker? Yes 101 No Supervisor's Comm �er�t v 0 UNRESOLVED PROBLEMS? CALL 1-800-TERMINIX (1-800-837-6464) SPECIAL SERVICE INSTRUCTIONS. C ER'S G_pATWRE` t 'TE AMO TPAID SERV SIGNATURE DTE GASH CHECK 051 To: For: LMC Disposal Services LLC PO Box 8293 Lynn, MA 01904 781-913-3977 Contacts Mark Wescott 617-794-8005 K' Louis Coiro 781-913-3977 1V f I T: -The Cit, of Salem oard of Health egulatibn PubUcHdalth Prevent. Promote. Protect. Effective February 41 2013 "No retailer, retail establishinentq or other individual or entity shall ell or distribute or cause to be sold or;distributed a cigar unless the cigar is, contained in an original package of at least four (4) cigars and is sold at a retail price of more than two dollars _and fifty Cents ($2.50). e packaged as i cig&r = �$2.go or more 0 PadCaged aS.2cilgars = $5.00 or more * Packaged as 3cigars = $7.50 or more * Pa4aged as 4 or"jmore = market price M 1 CERTIFICATE OF ATTANDANCE t,. December 2, 2413 Massachusetts Health Officers Assoc: Tobacco Control Program Lynn Health Department Lynn Regional Tobacco Control Collaborative CJI@I<In I IOIII IGD lot uumill hill lilll dill jill nmanumt 11111 line III ]III U.S. Citizenship and Immigration Services This card is not evidence of U.S. citizenship or permanent residence. This document Is void If altered, and may be revoked by the U.S. Government. The person identified is authorized to work in the U.S. for the validity of this card. RM l ->se xev. nzzo,ts ]t IIImnO.WW In eM Ue NMNm. USPS WYIO USCIS.ISNm WMmS4wI, 81+bm, VrOSr]PW]I IAUSA2058962725EAC1490030978<< 8603131M1411144PAK<<<<<<<<<<<9 HIJAZI<<AHMAD««««««««< i I� S card belongs to the Social Security Adminisfiat[on and you must Lm it if we ask for it. - Pu find a card that isn't yours, please retum it to:: _ .Social Security Administration P.O. Boz 33008, Baltimore, MD 21290-3008 " MY other Social Sec unty business/itiformadon, contact your local al Security office. Ifyou write t- the above address tor any business r[han returning a fou nd card you will not receive a response. d SecuntyAdmmi8o-80on7]a , SSA -3000 (08 2011) tpF� � jYi yssacnusQtts Learner's Permit 03-13-86 01-V-16 fly:: 509" 1) , S160497,95','+ ISa6e df firth t:itPiresSex Height Classhlumber 6� 427.14 Issued HIJAZI AHMAD 1 21 SALEM ST I SALEM, MA 01970 Class - D: Small vehicle less than 26,001 lbs, except schoolbus. NOT VALID FOR IDENTIFICATION. Ia n . . ,, 1-30-9924-864 Registrar You did not register to vote today 01-27-2014 A14617 68 3 �� J Yq aGKao*�diZS zi 9- �, C1 �- I 9- d I � � f{� a ANS/ ACCREDITED PROGRAM Gn,6 an Natonal Standards Institute an&Ihe Conference far Fund Protection L) fA i EXAM FORM NO. 4937 CERTIFICATE NO. 10973358 ServSafe CERTIFICATION TO AHMAD HIJAZI for successfully completing the standards set forth for the ServSafe° Food Protection Manager Certification Examination, which is accredited by the American National Standards Institute (ANSI) -Conference for Food Protection (CFP). DATE O 04/24/2C DATE OF EX Local laws apply. Chi )r recertification requirements. of the NRAEF, used under license by National Restaurant Association Solutions, I.I.C. 6/9/2014 Berkshire AHEC -Secure Online Registration Confirmationof r- « r t! Thank you for registering online! You have completed the process successfully! You should receive a confirmation of your registration via email shortly. Please close your browser window at this time or return to our home page. Confirmation of Order Print Confirmation Ahmad Hijazi MA Food Allergen On-line Training Financial Option Food Allergen Fee Quantity Amount 1 $10.00 Program Subtotal: $10.00 Subtotal for Ahmad: $10.00 Grand Total: $10.00 Amount Paid:($10.00) Balance Remaining: $0.00 https://thriva.actiwnety orkcoMReg4/(S(4jc4sg45gzuOg 35515q g mg br))/Form.asp:Oreg keY RpYOYP)E37%2bZM UE%2bXBZ%2ru8U sGjWVD4JJ7WY2Zjs7mN IP/o3d 1/2 6/9/2014 Berlahi re AHEC -Secure Online Registration Order Confirmation Number: 48844513 © 2014 Active Network, LLC and/or its affiliates and licensors. All rights reserved. I Terms of use I Copyright Policy I Your Privacy Rights I About Active.com Online Registration Event Management and Registration Software MM li w https://thrive.acti�netmrkcon✓Reg4/(S(4jc4sg45gzuOg35515qgmgbr))/Form.aspa?regl�r-RpYOYP>£37%2bZMUE%2bXBZ%2fuBUsGjWVD4JJ7WY2Zjs7mNIP/o3d 212 6/9/2014 Account O%er aew My Account IT, ,. Statement Log Out Account Make a Overview Payment ..:Show Detail r Hide,Defail .;... Printable Statement Participants in your Account Price: Balance: Click Oto show more information. Ahmad Hijazi MA Food Allergen On-line Training (7/1/2013 - 10.00 0.00 6/30/2014) • Food Allergen Fee ($10.00) on 6/9/2014 .,Show Detail ,- ,,. Hide. Detail Sub Total: $10.00 $0.00 Total: $10.00 $0.00 View Full Account History Home I Account Info I Make Payments I Change Password I Logout Your Account: #1735725529 1 Ahmad Hijazi I salem, MA, 01970 1 860-796-0146 1 hijazi.swat@live.com haps://thriva.actiwmtmrkconYMyAccount/AccountOverNew.aspx 1/1 KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD.OF HEALTH 120 WASHINGTON STREET, 4" FLOOR TEL. (978) 741-1800 FAX (978) 745-0343 1ramdin@sa1em.co Niaz Ahmad Sole Prop DBA Halal New York Food Market 21 Salem Street Salem, MA 01970 To whom it may Concern: IV PublicHea Ith Prevent. Promote, Protect. LARRY RAMDIN, RS/REFIS, CLIO, (:])-IS HL',ALTH AGENT March 17, 2015 This letter is to inform you that check #101 dated January 15, 2015 in the amount of $205.00 for Food Establishment Fee has been returned to the Board of Health because of nonsufficient funds. There is a $25.00 charge for this returned check along with the original amount of $205.00. Please send us a $230.00 money order or bank check to the Board of Health within 30 days of this notice. Thank you. For the Board of Health Larry Ramdin, Health Agent LR/hlp CERTIFIED MAIL: 7012 1640 0002 3313:4018 CITY OF SALEM GENERAL ACCOUNT ZBA ATTN TREASURERS OFFICE 120 WASHINGTON ST 2ND FL SALEM MA 01970-3527 Returned Item Notice Account Amount Description 9123881 205.00 Chargeback Item 4646661922 r E LE ED ��. 2o, _.0 ; ..,r Date: 03/10/2015 Account: 9123881 We are charging your account for items returned unpaid as listed below. Summa of Account Char es Number Amount Debit Total 1 205.00 Account Qebit Total 1 205.00 RETURN REASON D 'rNur!n raw ° ca°1°� OA F! / 1 N iLOSED, ACCOUNT ey 4 QS'�C�r3" ParF!"WLi :marmmn� M1d s:'_r �O -Ii• ` 0 "t7 °''Bsnkof,Ametks'�'{•U�� q "tri ?� r �. r> .K A, 4T 1 �� �''� .�# 3yMDDiDDiB` b0Li0D0�31i1'y00464666i9,22+t ..,_>�� 11900 100 Inn 41:0 11000 13131: 00464666 19 2 2111 .1100000 20 SOO-" 195 Market Street Y Lynn, MA 01901.1508 • 1 -800 -EASTERN (3278376) e www,easternbank.com EBF -1175 z� y ' a ysb11301798e s ,.03/10/,2015 u'!-; * a181i 5536 ri z i S"r R" 1s a LEGAL COPY of your 1r®� d1e614 You cenkBe d the x.� 777777F7 r NIA2 MAD 8011 PROPX ,. seine war yliuweuW �ett� • n �r�oowRtcer =', RETURN REASON D 'rNur!n raw ° ca°1°� OA F! / 1 N iLOSED, ACCOUNT ey 4 QS'�C�r3" ParF!"WLi :marmmn� M1d s:'_r �O -Ii• ` 0 "t7 °''Bsnkof,Ametks'�'{•U�� q "tri ?� r �. r> .K A, 4T 1 �� �''� .�# 3yMDDiDDiB` b0Li0D0�31i1'y00464666i9,22+t ..,_>�� 11900 100 Inn 41:0 11000 13131: 00464666 19 2 2111 .1100000 20 SOO-" 195 Market Street Y Lynn, MA 01901.1508 • 1 -800 -EASTERN (3278376) e www,easternbank.com EBF -1175 z� y s , .i c s RETURN REASON D 'rNur!n raw ° ca°1°� OA F! / 1 N iLOSED, ACCOUNT ey 4 QS'�C�r3" ParF!"WLi :marmmn� M1d s:'_r �O -Ii• ` 0 "t7 °''Bsnkof,Ametks'�'{•U�� q "tri ?� r �. r> .K A, 4T 1 �� �''� .�# 3yMDDiDDiB` b0Li0D0�31i1'y00464666i9,22+t ..,_>�� 11900 100 Inn 41:0 11000 13131: 00464666 19 2 2111 .1100000 20 SOO-" 195 Market Street Y Lynn, MA 01901.1508 • 1 -800 -EASTERN (3278376) e www,easternbank.com EBF -1175 ICIMBERLEY DRISCOLL MAYOR Halal Kennedy Food 19 Salem Street Salem, MA 01970 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4"FLOOR TEL. (978) 741-1800 Fax (978) 745-0343 Iramdin@salem.com Mart & Tobacco To whom it may Concern: LIVI pl1�iC]EiC81111 Prevent. Promote. Protect. LARRY RAMDIN, RS/I2E'FIS, CMO, CP -FS HL m,'n I AGEN'I' March 17, 2015 This letter is to inform you that check #101 dated February 27, 2015 in the amount of $320.00 for Food Establishment Fee has been returned to the Board of Health because of nonsufficient funds. There is a $25.00 charge for this returned check along with the originalamount of $320.00. Please send us a $345.00 money order or bank check to the Board of Health within 30 days of this notice. Thank you. For the Board of Health Larry Ramdin, Health Agent LR/hlp CERTIFIED MAIL: 70121640 0002 3313 4001 a+ CEastern Bank CITY OF SALEM GENERAL ACCOUNT ZBA ATTN TREASURERS OFFICE 120 WASHINGTON ST 2ND FL SALEM MA 01970-3527 Returned Item Notice REGENED MAR 16 71015 Date: 03/11/2015 Account: 9123881' We are charging your account for items returned unpaid as listed below. Account Amount Description 9123881 320.00 Chargeback Item 885596050 320.00 Returned Deposited Item Summary of Account Charges Number Amount Debit Total 1 320-00 TotalAccount Debit LX 21 i 3 70 5 Sat: Oaa 5 5960 SOit'0 LO 1 1100000 3 200014 195 Market Street • Lynn, MA 01 901-1 508 • 1 -800 -EASTERN (327-8376) • www.easternbank.com EBF -1175 Kimberley Driscoll Mayor Permit Number: Restrictions: City of Salem, Massachusetts IV Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 PubliCHealth Iramdin@salem.com Prevent. Promote. Protect. Larry Ramdin RS/RENS, CHO, CP -FS Health Agent FOOD ESTABLISHMENT PERMIT (must be posted on the Premises of the Food Establishment) 2015 FM -15-250 Permit Type: Retail Food < 1000 sqft Goods & Services: Retail Food: 0 -1,000 sq ft Name of License Holder: New York Food Market / Ahmad Hijazi Name of Food Establishment New York Food MArket Address of Food Establishment 21 Salem Street This License is granted in conformity with the statutes, Regulations and ordinances relating thereto,and expires on 12/31/2015 unless sooner suspended or revoked. Permit Fee: 70.00 Issued: 1/1/2015 KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OP HL'AL n i 120 WASHINGTON STREET, 4T" FLooR TEL. (978) 741-1800 FAX (978) 745-0343 lramdin(@salem.com salem.com 1�uultcxeaah LARRY RAMDIN, RS/R1;1-IS, CI 10, CP -FS HE-ALnIAGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: NAIV 2) Establishment Address: 21 S 4 ZYs Q -Z D 3) Establishment Mailing Address (if different): 4) Establishment Telephone No: t',P — 5) Applicant Name & Title: ` el i in &JA��Y7 6) Applicant Address: I -C-;O& WI, i fl 7) Applicant Telephone No: 24 Hour Emergency No: p , ZEmail: 4 cz�//-C 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association A corporation An individual' A partnership Other legal entity 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12 Person Directly Res onsible For Daily Operations Owner, Person in Char e, Supervisor, Manager, etc. Name & Title: Gf . Address: 714D /- Telephone No: - 2 Fax: Email: qu q `ts Emergency Telephone No: 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check #:—/0-5 Date:/ Amount: P O O �0 -coca 2 I'WO �y64, f6)t4 Nil i Food Establishment Information 14) Watet Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) 16) Days and Hours of Operation: I' 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type (check all that apply) (check one) ❑ Retail (1p 0 Sq. Ft) 13Caterer Permanent Structure ❑ Food Se ice - ( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service -Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and ---•--------------------•----...........----------- Establishents---------------------- ------ --- -- -------------------- 21) Length Of Permit:Breakfast (check one) RETAIL STORE ✓ U----- RESTAURANT Annual ❑ Less than 1000sq.ft. $ 70 ❑ Less than 25 seats $140 Seasonal/Dates: ❑ 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,OOOsq.ft. $420 ❑ 25-99 seats $280 ❑ More than 99 seats $420 - --------------- ---------- e------------------------------------------------- 0------ ❑ Bed & BreakfastlChildcare Services !Nursing Home $100 Temporary/DatesMme: ----------------------------------------------------------------------------- ADDITIONAL PERMITS -------------------------------------------- ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare 8 private club 23) Food Operations: Definitions: PHF— potentially hazardous food (timeltemperature controls required) that Non-PRFs—non-potentially hazardous food (no time/temperature controls required) (check all apply): RTE—read -to-eat foods Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale I Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: ,4A�yad_Ai` o2i Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: ! O' re - 3 2 A�/ 7 26) Signature of Individual or Corporate Name: �� Kimberley Driscoll Mayor Permit # TO -15-51 Date of Print 3/3/2015 Permit Issued 1/1/2015 Permit Expires 12/31/2015 Permit Fee $135.00 Late Fee $0.00 City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, MA 01970 Tel. (978) 741-1800 Fax. (978) 745-0343 Iramdin@salem.com TOBACCO SALES PERMIT License For: Tobacco Granted To: New York Food Market / Ahmad Hijazi Address: 21 Salem Street #3 Location of Establishment: 21 Restrictions: Notes: Salem SALEM STREET PublicmIieatth > Larry Ramdin RS/RENS, CHO, CP -FS Health Agent Ma 01970 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/31/2015 , unless sooner revoked or suspended. Health Agent y � CI"I Y OF S 120 W kst TEL. (978) KIMBERLEY DRISCOLL MAYOR NAME OF ESTABLISHMENT --,",(4.f ADDRESS OF ESTABLISHMENT,, DEPARTMENT OF REVENUE APPLICATION MAILING ADDRESS (if different) EMAIL - Business': 6719�Id Y.9 ADDRESS L( S /`f& -M 5 T STREET y!/,,'� EMERGENCY RESPONSE PERSON alv�yr 1A11; / Type of Products Sold: Cigarettes!' Cigars Devices ±Other Tobacco Product (list on additional 1M, MASSACHUSETTS ,RD OF HEALTH 'TON STREET, 4"' FLOOR -1800 FAx (978) 745-0343 J PublicHealth rre.ent. Promote. Pmtea. LtRRY RAMDIN, RS/REI IS, CNO, (T -PS Hio'm nIA('ENT ATION FOR PERMIT FOR SALES OF $ NICOTINE DELIVERY PRODUCT PERMIT FEqE�%%�� $135 1147'F .. �` a nn FAX # _--- Website: / TEL # E/0 — 7 Sof m ,� 6 97 CITY �t /� STATE / p {�ZIP �J A0yW 9 HOME TEL # 1/0/4 li fY " /�a i ving Tobacco ± Rpef0garette Tobaccoes Nicotine Delivery DAYS OF OPERATION Monday i TuesdayW nesday Thursday Friday Saturday Sunday HOURS OF OPERATION Please write in time of day. (For example t tam-tlpm) / I *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued up�rn change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before an such must be submitted to and approved by the Salem Pursuant to MGL Chapter 62C, Section 49A. 1 certify under the IN returns and paid all state taxes required under the law. re� APmpD 141 ;;z r� 12) rations, improvements, or equipment changes are made, all plans for of Health. penalties of perjury that 1, to my best knowledge and belief, have filed all state tax Social Security or Federal Identification Nt Updated 7/13/12 TOBACCO.doc Check# & Date 2 1 $ /�,,J C:p Massachusetts Department of Public Health 'Division of Food and Drugs City/Town of FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 4"' Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Address: Tel. Name/ / Print: Type of Operation(s) Type of Inspection Y ` ❑ Food Service Retail "ly.��71, Residential Kitchen u Mobile ❑ Routine JZRe-inspection Previous Igspection Date: Iv 13, AddressRik a, Level Telephone P _ c,D El Temporary ElPre-operati n Owner HACCP YIN ❑ Caterer E] Bed & Breakfast [I Suspect Illness ❑ General Complaint Person -in -Charge ( IC)Tim In. (,( r Out Permit No. ❑ HACCP ❑ Other Inspector Each violation 6hecketi requires an explanation on the narrative pages and a citation of specific provision(s) violated. Noncompliance with: Violations Related to Foodborne Illness Interventions and Risk Factors -(Red Items) Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT' ❑ 1. PIC Assigned/Knowledgeable/Duties 'EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOOD 'FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/Segregation/Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices -(Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Noncritical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2x590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4x590.005) 26. Water, Plumbing and Waste (Fc-5)(59o.om) 27. Physical Facility (FC -6x590.007) 28. Poisonous or Toxic Materials (FC -7x590.008) 29. Special Requirements (590.009) 30. Other n Anti -Choking 590.009(E) ❑ Tobacco 590.009(F) ❑. Allergen Awareness 590.009 (G) ❑ ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION'FROWCHEMICALS- ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMEITEMPERATURE CONTROLS i0oterdfally Hazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLYSU$CEP.TBLE=POPULATIONS:(H8?) ❑ 21. Food and Food Preparation for HSP CONSUMERADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signature: Print: PICS Signature: Print: Y�c, iPZ i Page o ages K/ 0 1 Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 590.003(A)As�mentof'Resop nsibility* --- 590,001(B) Demonstration of M_ nowledge* 2-103.11. Person in charge --duties EMPLOYEE HEALTH 2 590.()03(C) Responsibility of the person fit charge to Com rhance whir Faxi Law* 3-201.12 require r'cpo rting by foal employees and 3=201.13 Fluid Milk and Milk Products* a>>licamsW _ Shell E s'" 590.003(F) Responsibility Of A Fo(xl Employee Or An 3-202.16 lee Made From Potable Drinking* Water" Applicant To Report To The Person In Drinking Water from an Approved System' 590.006(A) Charge* 590.006(B) 590.003(G) Reporting by Person in (.h 1.r ge* 3 590.003(1)) - Exclusions and Restrictions* 3-201. 15 590.003(E) Removal of Exclusions and Restrictions C C C I FOOD FROM APPROVED SOURCE * Denotes critical nem in the federal 1999 Food Gore or 10 CMR 590.000. $ Food and Water From Regulated Sources 590.004(A -B) Com rhance whir Faxi Law* 3-201.12 Food in a Hermetically Sealed Container* 3=201.13 Fluid Milk and Milk Products* 3-202.13 Shell E s'" 3-202.14 Eggs and Milk Products, Pasteurized" 3-202.16 lee Made From Potable Drinking* Water" 5-101.11 Drinking Water from an Approved System' 590.006(A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Ve aables Shellfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201. 15 Molluscan Shellfish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrrwms Approved by Re utator Authont 3-202.15 Shelist(wkIdentification Present* 590.004(0) WildMusluoorrs* 3-201.1.7 GameALrimals* 3-70L.11 Receiving/Condition 3-202.1 l PHFs Received at Pro er Tem xantres° 3-20215 Package Integrity* 3-101.11. Food Safe and Unadulterated Togs/Records: Shelistock 3-202.1$ Shel'lsttxk Identification * 3-203.1.2 Shelistock identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3-402.12 Records. Creation, and Retention* 590.004(1) Labeling of Ingredients' Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* Conformance with Approved Procedures IHACCP Plans 3-502.11 Specialized processing Methods* 3-SQ2.'L2 Reduced oxygen pack'ayrrR. criteria* &1(13.12 Conformance wiih Approved Procedures* * Denotes critical nem in the federal 1999 Food Gore or 10 CMR 590.000. $ Cross -contamination 3-302.1.1(A)/1) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-30211(A)(2) '12aw Animal Foals Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Ve aables 3-304.11. - Food Contact with Equipment and t)tcnsils* Contamination from the Consumer 3-306.14(A)(B) Returned Foal and Reservice of Food* Disposition of Adulterated or Contaminated Food 3-70L.11 Discarding or Reeotttli,tioning unsafe Foal* 9 Food Contact Surfaces_ 4-501.1 f 1. Manual Warewashing - Hot Water Sanitization Temperatures' 4-501.112 _ Mechanical Warewashinb Hot Water Sanitization Temperatures* 4-501.11.4 -Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.1 I(A) - Equipment Food Contac. Surfaces and Utensils Clean* -1-602.1 L Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food -Contact Surfaces of E ui meat* 4-703-L1 Methods of Sanitization - Hot Water and Chemical* 10 Proper, Adequate Handwashing 2301.11 Clean Condition - Hands and Arms - 2 -301.12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401.11 Eating, Drinking or Using Tobacco* 2-401.12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventing Contamination When Tasting* 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Eiu tlo ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* acities* 5-204.11 Location and Placement* 5-20,5 L1 - Accessibility, Operation andMaintenance Supplied with Soap and Hand Drying Devices 6-301.11 HandwashinE Cleanser, Availability 6-301.12 Hand Dr Provssion CITY OF SALEM BOARD OF HEALTH Establishment Name: ,— T Date: all Page: Z of Item NO. Code Reference C - Critical Item R - Red Item DESCRIPTION OF VIOLATION / PILAN OF CORRECTION - PLEASE PRINT CLEARLY Date Verified S r J 4 - L" - Q. GG C_- - Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to p 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 your food permit. -T Corrective Action Required: ❑ No es ❑ luntary Compliance ❑ Employee Restriction Exclusion [L] Re -inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other: Violations Related to Foodborne Illness. Interventions and Risk Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 CFood or .16 117 TIME/ I EMPERATURE CONTROLS Gator Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-50L16(B) 590.004(F) Poisonous or Toxic Substances 7-101.1.1 Identifying Information -Original Containers* 7-102.11 Common Name - Working Containers* 7-201.11 Separation - Stora e* . 7-202.11 . Restriction - Presence andUse* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers -Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washinet Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205-11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7 -?06.22 Rodent Bait SmEians* 7-206.13 Tracking Powders, Pest Control and Monitoring* TIME/ I EMPERATURE CONTROLS * r rnotvs concal ilea in the federal 1999 F(W Code cm " 105 Ci11R 590.000. m 20 3-501.14(C) Proper Cooking Tempermurea for . 3-501.15 PHFs u 3-401.I1A(1)(2) Eggs- 155°F 15 Sec. 3-50L16(B) 590.004(F) Eggs- Immediate Service 1450FISsm* 3401.11(A)(2) - Comminuted Fish. Meats & Game 3-50 t. S 6(A) Animals - 155F 15 sec. * 3401.11(B)(1)(2) Pori: and Beef Roast - 130'F 121 min* 3401.11(A)(2) Ratites, Injected Meats -155°F 15 590.004(H) Variamce Re aitement 3-401.11(Ax3) Poultry, Wild Game, Stuffed PHFs, 27. Stuffing Containing Fish, Meat, FC - 6 Pont"or Ratites -1650F 15 sec. " 3401.11(C)(3) Whole -muscle, toast Beef Steaks FC -7 145T 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3-401.1 I(A)(1)(b) All Other PRFs - 145'F 15 see. -- Reheatlng for riot Holding 3-403AI(A)&(1)) PHR I65°F 15 sec. * 3403.1.1(B) Microwave- 165` F 2 Minute Standing Time* 3-203.11(C) Commercially Processed RTE Food - 140°F* 3403.11(E) Remaining Unsliced Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'17 to 7(PF Within Hours and From 70'F to 41°F/45'F Within 4 Hours. * 3-502.14(B) Cooling PHFs Made From Ambient Temperature ingredients to 41°F/45°1` Within 4 Hours* * r rnotvs concal ilea in the federal 1999 F(W Code cm " 105 Ci11R 590.000. m 20 3-501.14(C) PHFs Received at Temperatures According to law Cooled to 41'F/45'F Within 4 Hours. 3-501.15 Cooling Methods for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-50L16(B) 590.004(F) Cold PHFs Maintained at or below 41°145° F* 3-501.16(A) Hot PRFs Maintained at or above 140'F. * 3-50 t. S 6(A) Roasts Held at or above 130'F. " 25.- rime as a Public Health Control 3-501.19 Time as it Public Health Control* 590.004(H) Variamce Re aitement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATiDNS NSP 21 3-801.11(.A) Unpasteurized Pre-packaged Juices and Beverages with warning labels* 59o.1J00 3-801.11(B) Use of Pasteurized E gs* - I FC -2 3-801.11(D) Raw or Partially Cooked Amend Food and Raw Seed Sprouts Not Served. * Foal and Food Protection 3 801.11(C) Unopened Food Package Not Re -served. CONSUMER ADVISORY 22 3-603.11, Consumer Advisory Posted for Consumption of 59o.1J00 23. Animal Foods That are Raw. Undercooked or I FC -2 .003 Not Otherwise Processed to Eliminate Foal and Food Protection FC -3 -3 Patho ens.* `'b . r &MI 25.- 3-302.1.3 Pasteurized Eggs Substitute for Raw Shell "005 i 26. E * 590.009(A){D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (items 23-30) Critical, and non-critical violations, which do not resale to the foodborne illness interventions and risk factors listed above, can be found in the following sections of the Food Code and 105 CMR 590.000. Item 1 Good Retail Practices J,FC 59o.1J00 23. 1 Management and Person; _ I FC -2 .003 24. Foal and Food Protection FC -3 -3 .004 25.- E uioment and Utensils FC -4 "005 i 26. Water, Plumbing and Waste I FC -5 .006 I 27. Pts sicaf Facli ty FC - 6 ,W7 28. Poisonous a Toxic Materials FC -7 .008 �. S eclat Requirements , .009 _ 30. 1 Other -- Massachusetts Department of Public Health Division of Food and Drugs City/Town of FOOD ESTABLISHMENT INSPECTION REPORT Salem Board of Health 120 Washington Street, 40' Floor Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Address: Tel. Name (/Akf Dat Type of Operation(s) ❑ Food Service Fl -Retail Type of Inspection Routine Re -inspection Address 1 Ris A Telephone Level LJ Residential Kitchen ❑ Mobile Previous Inspection Date: q' /r}Z J 7` [j Temporary ❑ Caterer ❑ Bed & Breakfast Permit No. n ❑Pre` - o era i ❑ Suspect Illness ❑ General Complaint ❑ HACCP ❑.Other Owner - r HACCP YIN Person -in -Charge (PIC) Time In: Ou r) Inspector Each violation checked requires an explanation on the narrative pagid(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Violations marked may pose an imminent health hazard and require immediate corrective action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded .FOOD 'FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ,�Z6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/Segregation/Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices_ (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Noncritical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2X590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (Fc -4X590.005) 26. Water, Plumbing and Waste (r -c-5)(590.006) 7. Physical Facility (FC -6X590.007) 28. Poisonous or Toxic Materials (FC -7X590.008) 29. Special Requirements (590.009) 30. Other n Anti -Choking 590.009(E) ❑ Tobacco 590.009 (F) ❑ Allergen Awareness 590.009 (G) ❑ ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities PROTECTION fROM'CHEMICAL5 ❑ 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals TIMErrEMPERATURE'CONTROLS (PoterdlallyHazardous Foods) ❑ 16. Cooking Temperatures ❑ 17. Reheating ❑ 18. Cooling 1419. Hot and Cold Holding ❑ 20. Time as a Public Health Control REQUIREMENTS FOR HIGHLYSUSCEPTIBCE=POPULATIONS;(H&P)' ❑ 21. Food and Food Preparation for HSP CONSUMER ADVISORY ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions and Risk Factors (Red Items 1.22): Official Order for Confection: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: ��� ��(� aot� n I " Inspector's Signature: - Print: PICS Signature: V Print: Page oPages Violations Related to Foodborne Illness Interventions and Risk Factors (items 1-22) FOOD PROTECTION MANAGEMENT 1 590.003(A) Asci mment of ResponssId ...�.. � 590.003(6} Demonstr Won of KnowIe�*e* 2-103.11 Person in charge - duties FMPI.nYFF HEALTH 2 590,W3(C) Responsdnility of file person in charge to 5909tH A -B) require reporting by food employees and 3-201.1.2 a xlicants* 590.003(F) Responsibility Of A Farad Employee Or An 3-202.13 Applicant To Repot To Tlie Person In 3-20214 Char e* 590.003(0) Rgorting by' Penun i,n Cham* 3 590.003(D) Exclusions and Restrictions* 590.003(El Removal of Exclusions and Restrictions C ME Lo * Denoses critical item in tlae (edeial 1999 Pool Code or 105 CMR 590.000. PROTECTION FROM CONTAMINATION 8 Food and Water From Regulated Sources 5909tH A -B) Compliance with Food Taw* 3-201.1.2 Food In. it Hermeticall • Scaled Container* 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell E s* 3-20214 as and Milk Products, Pasteudfed* 3-202.16 _f Ice Made From Potable Drinking Water'° 5-101.11 Drinking Water f -on an Approved System"' 590906 A) Bottled Drinking Water* 590.006(B) Water Meets Standards in 310 CMR 22.0* Washing Fruits and Ve etables SheNfish and Fish From an Approved Source 3-201.14 Fish and Recreationally Caught Molluscan Shellfish* 3-201.15 Molluscan Shell Fish from NSSP Listed Sources* Contamination from the Consumer Game and Wild Mushrooms Approved Uy Regulatory Authority 3-202.1.8 Sh_ellstockIdemiliicauonPresent* 590.004(0) Wild Mushrooms* 3-201.17 Game Animals" 3-701.11 Receiving/Condition 3-202.11 PH;Fs Received at Proper Temperatures" 3-2{)2.15 Packa to luteexit 3-101.11 Food We and Unadulterated Tags/Records: Shelistock 3-202.18 Shellsnxk Identification 3-203.12 Shellstock Identification Maintained* Tags/Records: Fish Products 3-402.11 Parasite Destruction* 3.402.12 Records. Creation and Retention* 590.004(J) Labeling of Ingredients" Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* Conformance with Approved Procedures IHACCP Plans _ 3-502.11 1 Specialized Processing Methods* 3-502.12 Reduced oxygen packtadrig, criteria*�' 8-103.12 Conformance with A roved Procedures` * Denoses critical item in tlae (edeial 1999 Pool Code or 105 CMR 590.000. PROTECTION FROM CONTAMINATION 8 Cross -contamination 3-302.1 l(A)(1) Raw Animal Foods Separated from Clinked and RTE F/xxls* - Contamination from Raw Ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each Other' Contamination from the Environment 3-302.11(A) Food Protection" 3-302.1.5 Washing Fruits and Ve etables 3-304.11. Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306.14(A)(B) Returned Food and Rcservice of Food* Disposition of Adulterated or Contaminated Food 3-701.11 Discarding or Reconditioning Unsafe Food* g Food Contact Surfaces 4-501. i I I. Manual Watewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewaslune Hot Water Sanitization Temperatures* _ 4-501.114 Chemical. Sanitization- temp., pH, concentration and hardness. '" _ 4-001.1I(A) Equipment Food Contact Surfaces and - Utensils Cleats* 4-602.1 t Cleaning Frequency of Equipment Food - Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of -Equipment* 4-703.11 Methods of Sanitization- Hot Water and Chemical* t0 Proper, Adequate Handwashing 2-301.11. Clean Condition - Hands and Anns* 2-301.12 Cleaning Procedure* 2-301.14 When to Wash* tl Good Hygienic Practices 2401.11 Eating, Drinkin or Usin Tobacco* 240L12 Discharges From the Eyes, Nose and Mouth* 3-301.12 Preventina Contamination When Tasting" 12 Prevention of Contamination from Hands 590.004(E) Preventing Contamination from Enn tl0 ees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11. Numbers and Capacities* acities* 5-204.11 I-ocation and Placement* 5-205.11 Accessibility, Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Cleanser, Availability 6-301.12 _Handwashin im J 0 CITY OF SALEM BOARD OF HEALTH Establishment Name:—AL LW jn� gh2�G4`— Date: (c7(34(/cam_ Page:_ of I WIPTIN WAI - I A aW. MMMI ' Wo/ Al . -�. ��- al/,.c �.�s � :.. ., _•/ ice _.. rMIN !.' ,62ii�L!ltl�� c"_d-,_ . �L.r �_ . N`. • �ll7L�� �7� • i ��i�l' moi' ���f IL• too* a your .... ■ Voluntary Compliance ■ Employee Exclusion 74 -9e ­inspection Scheduled ci Emergency Suspension a Embargo o Emergency Closure Violations Related to Foodbarne Illness. Interventions and Risk Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 00 16 17 F10- Iii !t rr C ; ►?*lila;#le=i Food or Calor Additives 3-202.12 Additives* 3-302.14 Protection from Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying Information -Original Containers* 7-102.11. Common Name - Working Containers* 7-201.11 Separation - Stora * 7-202.11 . Restriction - Presence andUse* 7-202.12 Conditions of Ilse* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitize". Criteria - Chemicals* 7-204.12 Chemicals for Wiishina Produce, Criteria* 7-204.14 Drying Agents. Criteria* 7-205.11 Incidental Food Contact, Lubricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-206.12 Station Rodent Bait s" 7-206.13 Tracking Powders, Pest Control and Moai.torm ". . Iii !t rr C ; ►?*lila;#le=i * Ihnotex critimi item in the federal t 999 Fmd Code cu- 105 CMR 590.000. mm- F10 - 3 -501. C 3-501.14(C) Proper Cooking Temperatures for - 3-501.15 PHFs 3-401.11A(l)(2) Eggs- 155'F 15 Sec. 3-501.16(B) 590.004(F) Eggs- Immediate Service 145'F15sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(.A) Animals - 1550F 15 sec. * 3.401.11(8)(1)(2) Pork and Beef Roast - 130'F 121 min* 3-401.11(A)(2) Ratites, Injected Meats -155°F 15 590.004(H) sec. 3-401) UA)(3) Poulty, Wild Game, Stuffed PHFs, 2T Stuffing Containing Fish, Mear, - Poul or Ratites -165°F 1.5 sec. 3401 A I(C)(3) Whole -muscle, intact Beef Steaks ` FC=7 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165'F 3-401) I(A)(1)(b) All Other PHFs -145'F 15 sec. Reheating for Hot Holding 3-403.11(A)&(D) PHFs 165 OF 15 sec. * 3-403.11(B) Microwave- I65' F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Foal - 1400F� 3403.11(E) Remaining Unsliced Portitms of Beef Roasts4' Proper Cooling of PHFs 3-501.14(A) tooling Cooked PHFs from 140'F to 70'F Within Hours and From 70'F to 41*F145`F Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 41°F/45°F Within 4 H(xtrs* * Ihnotex critimi item in the federal t 999 Fmd Code cu- 105 CMR 590.000. mm- F10 - 3 -501. C 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Hours. 3-501.15 Cooling Methods; for PHFs 3-801.11(B) PHF Hot and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 410145° F* 3-501.16(A) Hot PRFs Maintained at or above l40'F. 3-501.16(.A) Roasts Held at or above 130'F. 25. Time as a Public Heaith Control 3-501.19 Time as a Public Health Control* 590.004(H) Varianic, Requirement REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS (HSP) 21 3-801.11(.A) Unpasteurized Pre-packaged Juices and .Beverages with Warning labels* . 590.OW i 3-801.11(B) Use of Pasteurized Eggs - FC - 2 3-801.11(D) Raw or Partially Cooked Animal Food and . Raw Seed Sprouts Not Served. Food and Food Protection 3-801.11(C) Unopened Food Package Not Rn -served. CONSUMER ADVISORY 22 3-603.11 Cansumer Advisory Posted for Consumption of 590.OW i 23. Animal Foods That are Raw. Undercooked or - FC - 2 003 Not Otherwise Processed to Eliminate Food and Food Protection FC -3 Pathogens.* a°. W&MI 25. 3-302.13. Pasteurized Eggs Substitute for Raw Shell 005 26. E 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Iteins 23.30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the folloxdng sectiones of the Food Code aid 105 CMR son nen - Item I Good Retail Practkes .FC 590.OW i 23. I Management and Pnrsonrrei - FC - 2 003 24. Food and Food Protection FC -3 004 I 25. j Equipment and Utensils FC -4 005 26. 1 Water, Plumbing and Was FC -5 .008 i 2T 1 Phvsical Facility FC -6 .007 28. Poisonous or Toxic Materials ` FC=7 .008 i 29. Special Requirements , .009 30. I Other Establishment No. Reference Oq C — Critical Item R — Red Nem CITY OF SALEM t j BOARD OF HEALTH Yl�i ✓C�1/O Date: Page i DESCRIPTION OF VIOLATION / PLAN OFCORRECTION U Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or s spension/revocation of your food permit. fie^( Corrective Action Required ❑ Voluntary Compliance Re -inspection Scheduled ❑ Embargo 0 Voluntary Disposal of ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure 13 Other: Violations Related to Foodborne Illness Interventions and Risk Factors (Item 1-22) (Cant.) *.i +ir111 , „ -TFoat or Color 15 I8 TIMOTEMPERATURE CONTROLS Additives 3-202.12 - Additives* 3-302.14 Protection from Unapproved Additives* 3-501.16(B) 590.004(F) Poisonous or Toxic Substances 7-101.11 Identifying information -Original Containers* 7-102.11, Common Name - Working Containers* 7-201.11 Separation - Stora * 7-202.11 Restriction - Presenceand Use* 7-202.12 Conditions of use* 7-203.11 Toxic Containers- Prohibitions* 7-204.11 Sanitizers.Criteria- Chemicals* 7-204.12 Chemicals for Washin Produce, Criteria* 7-204.14 n, Agents. Criteria* 7-205.11 incidental F(x)l Contact, Iatbricants* 7-206.11 Restricted Use Pesticides; Criteria* 7-206.1.2 - . Rodent Bait Stativas* 7-206.13 Tracking Powders, Pest Control and monitoring* TIMOTEMPERATURE CONTROLS * Denotes critical imat in the federal 1999 RW Code 01 105 CMR 590.000. l9 20 3-501.14(C) Proper Cooking Temperatures for - 3-501.15 PHFS 3-401.11A(1)(2) Eggs- 155"F 15 Sec. 3-501.16(B) 590.004(F) Eggs- - immediate Service 145'Fl5sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game 3-501.16(.4) Animals -155°F 15 sec. * 3-40131(B)(1)(2) Pork and Beef Roast- 130-F 121 min* 3-401.11(A)(2) Ratites, injected Meats -155oF 15 590.004(H) sec. * 3-401.11(A)(3) Poultry, Wild Game, Stuffed PHFs, 27. - Stuflmg Containing Fish, Meat, FC -6 Poultry or Ratites -165°F 15 sec. 3-401.11(C)(3) Whole -muscle, Intact Beef Steaks FC = 7 -009 145OF * 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3-401:11(A)(i)(b) All Other PHFs -14rF 15 sec. ' Reheating for Not Holding 3-403,11(A)&(D) PHFs 165-F 15 sec. * 3-403.11(B) Microwave- 165' F 2 Minute Standing Time* 3-403AI(C) Commercially Processed RTE Food - 140oF* 3403.11(E) Remaining Unsticed Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'F to 70OF Within 2 Hours and From 70'T to 41*F/45T Within 4 Hours. * 3-501.14(B) Cooling PHFs Made From Ambient Temperature Ingredients to 4lQR145oF Within 4 Hours* * Denotes critical imat in the federal 1999 RW Code 01 105 CMR 590.000. l9 20 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 417145g17 Within 4 Hours, 3-501.15 Cooling Methods for PRFs 3-801.11(B) PHF Not and Cold Holding 3-501.16(B) 590.004(F) Cold PHFs Maintained at or below 410/450 F* 3-501.16(A) Hot PRFs Maintained of or above 140`R * 3-501.16(.4) Roasts Held at or above 1301F. 25. Time as a Public Health Contra) 3-501.19 Time as a Public Health Control* 590.004(H) Variance R uiremcm: REQUIREMENTS FOR HIGHLY SUSCEPMOLE POPULATIONS (HSP) 21 3-801.11(.A) Unpasteurized Pre-packaged Juices and .Beverages with Warning Labels* - 590.0 3-801.11(B) Use of Pasteurized Eggs* FC - 2 3.801.11(D) Raw or Partially Cooked Animal Food and . Raw Seed Sproats Not Served. * 1 Food and Food Protection 3-801.11(C) Unopened Food Package Not Reserved. CONSUMER CONSUMER ADVISORY 22 3-603.11. Consumer Advisory Posted for Consumption of 590.0 23. Animal Foods That are Raw, Undercooked or FC - 2 .003 ' No Otherwise Processed to Eliminate 1 Food and Food Protection _ I FC - 3 Pathogens.' � 10&W? 25. 3-302.1.3 Pasteurized Eggs Substitute for Raw Shell 005, 26. Eggs * SPECIAL REQUIREMENTS 590.009(A) -(D) Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should be debited under the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. VIOLATIONS RELATED TO GOOD RETAIL PRACTICES (Iters 23-30) Critical, and non-critical violations, which do not relate to the foodborne illness interventions and risk factors listed above, can be found in the follondng sectionsof the Food Cade mrd 105 CMR 590.000. Item I Good R" Pracdces FC 590.0 23. 1 Management and Personnel FC - 2 .003 ' 24. 1 Food and Food Protection _ I FC - 3 .004 j 25. Ecluinment and Utensils ! FC -4 005, 26. Water, Plumbing and Waste - 1. FC -5 .006 27. - Physical Facility FC -6 .007 28. Poisonous or Toxic Materials FC = 7 -009 j .008 29. Special Requirements 30. 1 Other ' COUNCILLORS -AT -LARGE 2014 THOMAS H. FUREY WILLIAM H. LEGAULT ELAINE F. MILO ARTHUR C. SARGENT, III Citp of *ale t, laaf;5arbagrag Office of the citp (Council �itp fall ROBERT K. MCCARTHY ® PRESIDENT o CHERYL A. LAPOINTE CITY CLERK QOggp CT Z014 �O October 24, 2014 OF ._ N� N Mr. Ahmad Hijazi New York Food Market 21 Salem Street Salem, MA 01970 Dear Mr. Hijazi: WARD COUNCILLORS 2014 ROBERT K. MCCARTHY HEATHER E. FAMICO TODD A. SIEGEL DAVID W. EPPLEY JOSH H. TURIEL BETH GERARD JOSEPH A. O'KEEFE, SR. At a regular meeting of the City Council held in the Council Chamber on Thursday, October 23, 2014, the City Council voted to deny your request for extended hours for New York} TF_ood-Market located at 21 Salem Street to operate from 8:00 A.M. to 3:00 A.M. seven days a week. Your current hours of operation shall remain in effect. Very truly yours, CHERYL A. LAPOINTE CITY CLERK Cc: Police Chief Solicitor Building Inspector Board of Health SALEM CITY HALL • 93 WASHINGTON STREET 9 SALEM, MA 01970-3592 • WWW.SALEM.COM Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of S4Lzi-n FOOD ESTABLISHMENT INSPECTION REPORT Address: Tel Name &&L m iiKE� ate 9-).}t Type of Operations) ❑ Food Service Retail Residential Kitchen ❑ Mobile E] Temporary ❑ Caterer ❑ Bed 8 Breakfast Permit No. Type of Inspection ❑ Routine ❑ Re -inspection Previous Inspection Date: Pre-operation Suspect Illness ❑❑ HGeneral ACCP Complaint ❑. Other Address �l LL Risk Level Telephone P Cz ? ) 6 A Owner J1) -P0� /4 IJP 2�) r' HACCP YIN Person -in -Charge (PIC) Time In. Out: Inspector / , Go_Jtr 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 Anti Choking 590.009 (E) ElItems) Tobacco 590.009(F) ❑. Violations marked may pose an imminent health hazard and require immediate Allergen awareness 590.009 (G) ❑ corrective action as determined by the Board of Health. FOOq:_PROTECTION MANAGEMENT' �_�_ _� ❑ 1. PIC Assigned/Knowledgeable/Duties 'EMPLOYEE HEALTH ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 3. Personnel with Infections Restricted/Excluded FOODFROMAPPROVED SOURCE ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 7. Conformance with Approved Procedures/HACCP Plans PROTECTION FROM CONTAMINATION ❑ 8. Separation/Segregation/Protection ❑ 9. Food Contact Surfaces Cleaning and Sanitizing [110- Proper Adequate Handwashing ❑ 11. Good Hygienic Practices Violations Related to Good Retail Practices_ (Blue Items) Critical (C) violations marked must be corrected immediately or within 10 days as determined by the Board of Health. Noncritical (N) violations must be corrected immediately or within 90 days as determined by the Board of Health. C N 23. Management and Personnel (FC -2)(590.003) 24. Food and Food Protection (FC -3)(590.004) 25. Equipment and Utensils (FC -4X590.005) 26. Water, Plumbing and Waste (FC -5X590.006) 27. Physical Facility (Fc -6X590.007) 28. Poisonous or Toxic Materials (FC -7X590.008) 29. Special Requirements (590.009) 30. Other ❑ 12. Prevention of Contamination from Hands ❑ 13. Handwash Facilities (PROTECTION_FROWCHEMICALS _ ❑ 14. Approved Food or Color Additives �. ❑ 15. Toxic Chemicals ITIMFJTEMPERATURE"CONTROLS (Potentlatty Ma2ardous F_.o_od�_) _� ❑ 16. Cooking Temperatures ❑ 17. Reheating [118. Cooling ❑ 19. Hot and Cold Holding ❑ 20. Time as a Public Health Control ;REQUIREMENTS FORHIGHLY4USCEPTBLE-POPULATIONS'(HSP) ❑ 21: Food and Food Preparation for HSP ;CONSUMER ADVISORY - _ __ :3 ❑ 22. Posting of Consumer Advisories Number of Violated Provisions Related To Foodborne Illnesses Interventions U and Risk Factors (Red Items 1-22): Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an order of the Board of Health. Failure to correct violations cited in this report may result in suspension or revocation of the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you have a right to a hearing. Your request must be in writing and submitted to the Board of Health at the above address within 10 days of receipt of this order. DATE OF RE -INSPECTION: Inspector's Signator Print:'DA 4 ` Z) '--o Page_Lof7- Pages PICS Signature: Print: .I ,� J Y � Iw .� `� -"r+ �Yww n r•.-r�1- -- w r� w ' 1 ! yw • • ^�-'. Violations Related to Foodbome Illness Interventions and Risk Factors (items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 1 590.003(A) Assignment of R esponsibility* 590.003(B) Demonstration of Knowledge* 2-103.11. Person in charge - duties EMPLOYEE HEALTH 2 2 590.W3(C) Responsibility of the person in charge to Compliance with Food Law* 3-201.12 requirereporting by food employees and 3-201.13 Fluid Milk and Milk Products* applicants* Shell Eggs* 590.003(F) _ Responsibility Of A Food Employee Or An 3-202.16 Ice Made From Potable Drinking Water* Applicant To Report To The Person In Drinking Water from an Approved System* 590.006(A) Charge* 590-006(B) 590.003(G) Reporting by Person in Char>e* 3 590.003(D) Exclusions and Rcytrictions* 3-201.15 590.003(E) Removal of Exclusions and Restrict ons 4 C L Is - FOOD FROM APPROVED SOURCE ' Denotes critical item in.the federal 1999 Food Code or 105 CMR 590.000. 8 Food and Water From Regulated Sources 590.004(A -B) Compliance with Food Law* 3-201.12 Foci in a Hermetically ° Sealed Con 3-201.13 Fluid Milk and Milk Products* 3-202.13 Shell Eggs* 3-202.14 Eggs and i lilk Products, Pw�teurzed* 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved System* 590.006(A) Bottled Drink -in Water* 590-006(B) Water Meets Standards in 31.0 CNIR 22.0* Washing Fruits and Vegetables Shellfish and Fish From an Approved Sourre 3-201.14 Fish and Reereadonaliy Caught Molluscan Shellfish* 3-201.15 Molluscan Shellfish born NSSF Listed Sources* Contamination from the Consumer Game and Wild AAushrooms Approved by Regulatory Authority 3-202.18 Shellstock Identification Present* 590.004(C) Wild Mushrooms* 3-201.17 Game Animals* 3-701.1'1 Receiving/Condition 3-202.11 PHFs Received at Proper Tem ramres* 3-202.15 Package lute grit 3-1(11.11 Food Safe and Unadulterated Tags/Reroads: Shellstock 3-202.18 Shellstock Identification * 3-20312 Shellstock. Identification Maintained* Tags/Records: Fish Products 3-402.11 - Parasite Destruction` 3-402.1^_ Records, Creation and Retention* 590.004(.!) Labeling of Ingredients' Cleaning Frequency of Equipment Food -- Contact Surfaces and Utensils* Conformance with Approved Procedures IHACCP Plans 3-502.11. Specialized Processing Methods* 3-502.12 Reduced oxygen packaging, criteria* 8-10112 Conformance with Ap ved Procedures" ' Denotes critical item in.the federal 1999 Food Code or 105 CMR 590.000. 8 Crass -contamination 3-302.11(A)(I) Raw Animal Foods Separated from Cooked and RTE Foods* Contamination from Raw Ingredients 3-302.1 I(A)i2) Raw Annual Foals Separated from Each Other* Contamination from the Environment 3-302.11(A) Food Protection* 3-302.15 Washing Fruits and Vegetables 3-304.11. Food Contact with Equipment and Utensils* Contamination from the Consumer 3-306-14(A)(B) Returned Food and Reservice of Food* Disposdfon of Adulterated or Contaminated Food 3-701.1'1 Discarding or Reconditioning Unsafe Food' 9 Food Contact Surfaces 4-5.01..111 Manual Warewashing - Hot Water Sanitization Temperatures* 4-501.112 Mechanical Warewashing- Hot Water Sanitization Temperatures* 4-501.11.4. Chemical Sanitization- temp., pH, concentration and hardness. * 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 4-602.1.1 Cleaning Frequency of Equipment Food -- Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization --Hot Water and Chemical* 10 Proper, Adequate Handwashing 2-301..1 I - Clean Condition - Hands and Arms* 2-301..12 Cleaning Procedure* 2-301.14 When to Wash* 11 Good Hygienic Practices 2-401..11 Eating, Drinking or Using Tobacco* 2401:12 Discharges: From the Eyes, Nose and Mouth* - 3-301.12 Preventing Contamination When Tasting* 12 _590 Prevention of Contamination from Hands 004(E) Preventing Contammation.front Employees* 13 Handwash Facilities Conveniently Located and Accessible 5-203.11 Numbers and Capacities* 5-204.11 Location and Placement* 5-205.11. Access ibilit , Operation and Maintenance Supplied with Soap and Hand Drying Devices 6-301.11 Handwashing Cleanser. Availability 5-301.12 Hand -Dr in Provision CITY OF SALEM BOARD OF HEALTH Establishment Name: N2 -,W kUL en r)Q r_467 Date: L-2-7-1Page: of Z F-It—eml-Code I C — Critical Item DESCRIPTION OF VIOLATION / PLAN OF CORRECTION` No. I Reference I R —Red Item - _ _ _ __ __ __ __ _ _ _. _. VerMted Owe Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to 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 your food permit. (gip ❑ voluntary compliance ❑ Re -inspection Scheduled ❑ Embargo ❑ Voluntary Disposal ❑ No I ❑ - Yes ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: �`J`H1) S1Z7lL� 1� 6a i 'i�il OGLE'i G� ^� h10ca villk 9 t V\) Ytt� VG lriNa�A>✓60�— 2 1 t." i 6' �Vt`3lii( 13EcAv \J0 rx�'da Discussion With Person in Charge: I have read this report, have had the opportunity to ask questions and agree to correct all violations before the next inspection, to observe all conditions as described, and to 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 your food permit. (gip ❑ voluntary compliance ❑ Re -inspection Scheduled ❑ Embargo ❑ Voluntary Disposal ❑ No I ❑ - Yes ❑ Employee Restriction / Exclusion ❑ Emergency Suspension ❑ Emergency Closure ❑ Other: Violations Related to Foodbarne Illness. Interventions and Risk Factors (Items 1-22) (Cont.) PROTECTION FROM CHEMICALS 14 .Food or Color 15 U 17 .811:• Additives 37202.12 Additives* 3-302.14 _ Protection from Una 11 proved Addiuves* I FC -2 Poisonous or Toxic Substances 7-I01.11 Identifying Information - Original Containers* 7-102.11, Common Name - Working Containers* 7-201.11 Separation - Stora * 7-202.I1 Restriction - Presenceand Use* 7-202.12 Conditions of Use* 7-203.11 Toxic Containers - Prohibitions* 7-204.11 Sanitizers. Criteria - Chemicals* 7-204.12 Chemicals for Washing Produce, Criteria* 7-204.14 Drying, Agents. Criteria* 7-205.11 hicidental Food Contact, Lubricants* 7-206.1.1 Restricted Use Pesticides; Criteria* -206.12 Rodent Bait Stations* 7-206.13 1 Tracking Powders, Pest Control and Monitorin *. U 17 .811:• x iXnoav critical item in the federal 1999 Food Cate 01 105 CN4R 590.(h10. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Houm Proper Cooking Temperatures for 19 PRFs _ 3-401.I1A(l)(2) Eggs- 155°F 15 See. I FC -2 E ,-s-Immediate Service 145'1715sec* 3-401.11(A)(2) Comminuted Fish. Meats & Game '4-801.1](C) Animals -155°F 15 see. * 3.401.11(B)(1)(2) Port: and Beef Roast -130'F 121 min* 3.401.11(A)(2) Ratites, Injected Meats -155°F 15 226. SM * 3-401.11(A)(3) Poultry, Wild Crag, Stuffed PRFs, 27. Stiffing Containing Fish. Meat, : FG -6 Poul or Ratites -165'F 15 sec. 340Lll(C)(3) Whole -muscle, Intact Beef Steaks '.. FC _ 7 145°F * 3-401.12 Raw Animal Foods Cooked in a Microwave 165°F * 3-401:11(A)(1)(b) All Other PHFs -145'F 15 sec. Reheating for Hot Holding 3-403,11(A)&(D) PHFs 165°F 15 sec. * 3-403.11(B) Microwave- 165° F 2 Minute Standing Time* 3-403.11(C) Commercially Processed RTE Food - 140'F 3.403.11(E) Remaining Unslicad Portions of Beef Roasts* Proper Cooling of PHFs 3-501.14(A) Cooling Cooked PHFs from 140'17 to 70'F Within Hours and Front 70°F to 41'F/45'F Within 4 Hours. * 3-501.14(B) Cooling PRFs Made From Ambient Temperature Ingredients to 41"F/45°F Within 4 Hous* x iXnoav critical item in the federal 1999 Food Cate 01 105 CN4R 590.(h10. 3-501.14(C) PHFs Received at Temperatures According to Law Cooled to 41'F/45°F Within 4 Houm 3-501.16(B) Cold PHFs Maintained at or below 590.004(17) 41°145° F* 3-501.16(A) i Hot PHFs Maintained at or above 3 501.16(.A)j Roasts Reld at Time as a Publ Control* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 21 3-501.15Crmling Melbods for PHFs 19 PHF Hot and Cold Holding ' 3-501.16(B) Cold PHFs Maintained at or below 590.004(17) 41°145° F* 3-501.16(A) i Hot PHFs Maintained at or above 3 501.16(.A)j Roasts Reld at Time as a Publ Control* REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 21 3-801A I (.A) Unpasteurized Pre-packaged Juices and Bevels with Wanting Labels* 590.000 j 3-801.11(B) Use of Pasteurized Eggs*_ I FC -2 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Sprouts Not Served * Food and Food Protection_ '4-801.1](C) Unopened Food Package Not Ro-served. CONSUMER ADVISORY 22 3-603.11 Consumer Advisory Posted for Consumption of 590.000 j 23. Animal Foods That are Raw, Undercooked or I FC -2 . W3 1 Not Otherwise Processed to Eliminate Food and Food Protection_ I FC -3 Patho ens.* `"°"""'YYt2tlC1 3-302.13. Pasteurized Eggs Substitute for Raw Shell ` .005 i 226. Ems * Violations of Section 590.009(A) -(D) in catering, mobile food, temporary and residential kitchen operations should he debited udder the appropriate sections above if related to foodborne illness interventions and risk factors. Other 590.009 violations relating to good retail practices should be debited under #29 - Special Requirements. (Items 23-30) Critical, mid non-critical violations, which do not relate to the foodborne illness interventions and riskfactors listed above, can be found in the following sections of the Food Code mrd 10S CMR 594.00©. t Item ,Good Retail Practices I FC 590.000 j 23. Man ement and Personnel I FC -2 . W3 1 24. Food and Food Protection_ I FC -3 .004 Equipment and Utensils l FC - 4 ` .005 i 226. WWater, Plumbing and Waste j FC -5 .006 27. Plivisical Facility : FG -6 .007 28. Poisonous or Toxic Materials '.. FC _ 7 .008 29. Special Requirements .009 30. Other KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, AI c/� 10 MASSACHUSETTS ��"Z D PublicHealth BOARD or Hi;m:ni 7 Q 201A JUN, 120 WASHINGroN S mi"IFT, 4'- Flooic Tli- (978) 741-1800 FAX (978) 745-030TY OF SA LE� y......,...2 RAMDIN, RS/RENS, C110, CP -FS lmindint,salem.com - BOARD OF HtA HISALTI 1 AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: WgIL r-OD4 tA el -t K 2) Establishment Address: :,I Sa(eyn S -t 1et ALY1't MA � Wg7o 3) Establishment Mailing Address (if different): a S Q l Q Y N St Sa wv M A 7 4( 4 a 4) Establishment Telephone No: q79- S ( 6 � 0 5) Applicant Name&Title: ©WNEp JJ- �ma-d f-�a-z I 6) Applicant Address: 6a©l/r,,, 3 � l s. t P, sr` S q Qvy\ pp 7) Applicant Telephone No: 800 N-0 46 24 Hour Emergency No: Email: f11 AZI , �tnla�Q I(1 V 8) Owner Name & Title (if different from applicant): 9) Owner Address (if different from applicant): 10) Establishment Owned by: An association A corporation An individual V a nership Other legal legal ntity R 2n�e` ^ S&Lz P co ie�QY 11) If a corporation or partnership, give name, title and home address of officers or partner. Name Title Home Address 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor, Manager, etc. Name &Title: lTt�Q21 b//��INNEp} Address: nn 44�ma� �� -}- u�2W1 J`ieQl I2'w d(% Telephone No: /T`o-IOAYt(^ 86 l q; -6t (` 6 Fax: - �t Email: ht aZt. SWa-t S ck Oob Emergency Telephone No: 8 6 1? OILt6 - 13) District or Regional Supervisor (if applicable) Name & Title: Address: Telephone No: Fax: Email: Check #:OD Dete:S 2 Amount: C' ' -0yo Foodsta6lishment Information 14) Wafer Source: 15) Sewage Disposal: DEP Public Water Supply No: ( if applicable) rJ 16) Days and Hours of Operation: 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti -Choking Procedures ( if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type (check all that apply) (check one) Retail (-,7rp Sq. Ft) ❑ Caterer Permanent Structure ❑ Food Service - ( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service - Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service - Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and --------------------- - .Breakfast Establishments 21) Length Of Permit: (check one) RETAIL STORE Less than 1000sq.ft. $ 70 RESTAURANT ❑ Less than 25 seats $140 Annual Seasonal/Dates: ❑ 1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,OOOsq.ft. $420 ❑ 25-99 seats $280 ❑ More than 99 seats $420 -------------------------------------------------------------------------------------- ......------------........ ❑ Bed & BreakfastlChildcare Services /Nursing Home $100 Temporary/DatesMme: ADDITIONAL PERMITS ❑ MAKE ICE CREAM, YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑ ALL NON-PROFIT* $25 *Including, church kitchens, state funded childcare & private club 23) Food Operations: Definitions: PHF- potentially hazardous food (time/temperature controls required) (check that Non-PHFs - non -potentially hazardous food (no timeRemperature controls required) all apply): RTE - read -to-eat foods Ex. sandwiches, salads, muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self -Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan (including bare hand Service Within 4 hours contact alternative, time as public health control. Customer Self -Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage, Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application I, the undersigned, attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on howto obtain copies of 105 CMR 590.000 and the Federal Food Code. — r� 24) Signature of Applicant: Pursuant to MGL Ch. 62C, sec. 49A, I certify under the penalties of perjury that 1, to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 26) Signature, of Individual or Corporate Name: Permit # TO -14'-364 Date of Print 6/23/2014 Permit Issued 1' 6/2312014 ' Permit Expires-' 12/23/2014 Permit fee $135.00 Late Fee $0.00 This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/23/2014 , unless' sooner -revoked or suspended. ,a- Health Agent _ - CITY OF SALEM, MASSACHUSETTS lu BOARD OF HEALTH 120 WASHINGTON STREET, 4." FLOORPublicHealth TEL. (978) 741-1800 FAx (978) 745-0343 KIMBERLEY DRISCOLL Iramdinnsalem.com NIEIYOR LARRYILIMDIN, RS�REI 15, CflO, CP -IS H I ,A LT1-1 AG u',NT 2014APPLICATION FOR PERMIT FOR SALES OF TOBACCO & NICOTINE DELIVERY PRODUCT NAME OF ESTABLISHMENT NeW Y d.S !p 4MMG( ��l0: