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NICOLES MINI FOOD - ESTABLISHMENTS NlItok) AiAi food 406 e11@k DftJ ftNIVERSAL® UNV-12110 MADE IN USA SUSTAINABLE MEL pECyC1ID FORESTJOS Ig INITIATNF C.eedisbarswwng POST401OAS as JIIPmpmm.arg Yi alt90 — I Mas"sachusetts-Department of Pubilc Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name Date TVDe of Ooeration(sl T f Inspection I� �n ❑ Food Service Routine Address Risk Retail ❑ Re-inspection Level Residential Kitchen Previous Inspection Telephone ✓1 I ❑ Mobile Date: Owner 1 HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast El General Complaint l / In; ❑ HACCP Inspector k � 1 A, O`t Permit No. ❑Other Each violation checked requires an xwiariation on the narrative page(s)and a citation of specific provislon(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E)y 590.009(F) action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands 0 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH - - PROTECTION FROM CHEMICALS - '- ' '' ' "`° - ❑ 2. Reporting of Diseases by Food Employee and PIC "- ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded El__ 15.Toxic Chemicals s FOOD SO FROM APPROVED SOURCE --�4.z Food and Water from Approved Source ®TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foo ©4 5. Receiving/Condition ❑ 16. Cooking Temperatures _ da)_�- ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with�Approved Procedures/HACCP Plans ❑ 16.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding c. Pr [18. Separation/Segregation/Protection ❑20.Time As a Public Health Control S-�-- ❑ 9. Food Contact Surfaces Cleaning and Sanitizing - �REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS-(HSPp El 10. Proper Adequate Handwashing : El 21. Food and Food Preparation for HSP f ❑ 11. Good Hygienic Practices CONSUMERADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below c x 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (Fc-s>(sso.00s) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S 5WW Fo 1C.EOC 4 1k'3'InspecVn/to/r`''fs�U^S'ignature: Print: l�' ::::::4 PIC's Signature: Print: )a E Page of ;Pages J Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT tl Cross-contamination - 1 590.003(A) AssiomentofResonsibility* 3-302.11(A)(]) Raw Animal Foods Separated from Cooked and RTE Foods 590.003(6) Demonstration of Knowled ex' Contamination from Raw Ingredients 2-103.1 I. Person in charge--duties 3-302.11(A)(2) Raw Animal Foods Separated from.Each Other- EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of,the person in charge to 3-302.11(A) I Food Protection* require reporting by food employees and 3302.l5 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(.,) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Fond* 590.003(G) Reporting b Person in Charge* 3 590.003(D) Exclusions and Restrictions* FoodsdionofAdulterated orContaminated 590.003(E) Removal of Exclusions and Restrictions 3-701.1'. Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces - 590.004(A-B) Compliance with Food Law* 4-501..111 Manual Warewashing-Hot Water 3-201.12 Food in a Hennetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eaas* Sanitization Temperatures* 3-202.1.4 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness." 5-101.11 - Drinking Water from an Ap2roved S ,tem* 4-601..11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(6) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency q y of Equipment Food- ShefNish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and - 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP listed Chemical* Sources* 10 Proper,Adequate Handwashing Regulatory Authority Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices - 9 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.1.1. PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package lnte it v* Mouth* 3-101.1 i Food Safe and Unadulterated* 3-301.12 Preventin g Contamination When Tasting 6 Togs/Records:Shellstock 12 Prevention of Contamination from Hands. 3-202.18 Shellstock Identification " i 590.004(,E) Preventing Contamination from 3-203.12 Shellstock Identification Maintainedk Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* ConvententtyLocated and Accessible 3-402.12 Records,Creation and Retention* 5-203.11. Numbers and Capacities* 590.004(7) Labeling of Ingredients- 5-204.11 Location and Placement* g Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance IHACCP Plans Supplied with Soap and Hand Drying _ 3-502.17 Specialized Processine Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6 301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures'" 6-301.12 Hand Drying Provision Denotes,critical item in the federal 1999 Paw Cade or 1115 CMR 590.000. CITY OF SALEM BOARD OF HEALTH �<` A Establishment nC& n Date: �(— -/ Page: o� of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Rem Vermed PLEASE PRINT CLEARLY ^, ll (� // 0 nAl _ 0�A ,.1 ` I 7� /�n 1_-u.l�. O �T �. /� n.t n, ",i, Pa �L//1 R / C..� n c: A/1 / Ing)�Il h/� �-{ �J�l /Ong 7 0 ) I r!�`� .�,.�-=1N PVIL/lok �{ O _ _ ')> _ O 4-1 o d _o u ,ni, u �� V P {� nn Al j Vi - n pp , (� VAo �a X� iei � i li A< x /� /!X(t � � ( O M I M A v. MA A i A nnn �A I 11 o - i . n 'P Inn n v t Discussion With Person in Charge: Corrective Action Required: Cl No Yes Voluntary C pliance ❑ Employee Restriction/ I have read this report, have had the opportunity to ask questions and agree to correct all /J. �°f violations before the next inspection, to observe all conditions as described, and to h✓v�2_Up aC fJ Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that ❑ Re-inspection Scheduled 13 Emergency Suspension noncompliance may result in daily finP>,s Of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure ?four food permit. N/1 �-� , 0 Voluntary Disposal ❑ Other: i 3-501.t4(C) PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Fedora(Hems 1-22) (Cont.) 41'F/45F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 _ Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12Additives* 3-501.16(B) Cold PHFs Maintained at or below -r590.004(F) 41°145°F* 3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140 7-101,11 Identifying Information-Original . 3-50i.16(A) Roastc Held at or above 130°F. Containers* 7-102.11. Common Name-WorkingContainers* 20 Time es a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizecs.Criteria-Chemicals* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* . with Warning Labels* 7-204.14 Drying Agents.Criteria* 3-801.11(B) Use of Pasteurized Egg * 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(0) Raw or PartiallyCooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served * 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. ^' 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMErrEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs - Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155T 15 See. Pathogens.'&".. Eggs-Immediate Service 145°FISsec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155°F 15 sec. 3401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in see. * catering,mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,intact Beef Steaks interventions and risk factors. Other 145°F+° 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3401A I(A)(1)(b) All Other PHFs-l45°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3403.11(A)&(D) PHFs 165°F 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 Titre* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sectiones of the Food Code and 105 CMR 140°F* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef Hem I Good Retail Practices J FC 590.000 Roasts* i 23. Management 3 24. i Food and Food Protection I FC-3 .004 i 18 Proper Cooling of PHFs 25. Equipment and Utensils . FG-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26, Water.Plumbing and Waste i FC-5 .006 1 70°F Within 2 Hours and From 70°F _ 27. Physical FacilityFC-6 .007 to 41°F145°F Within 4 Hours.* 28_ Poisonous or Toxic Materials FFG-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. -Special Requirements ,003 Temperature Ingredients to 41°Fl45°F Other -- -.- Within 4 Hours* I &'"°'"'"'°"`a a 'Denotes critical item in the federal 1999 Foal Cate or 105 CMR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978)745-0343 Name Date Twe of Ooeration(s) f Inspection lit n I - ❑ Food Service Routine AddressI I Risk (Retail ElRe-inspectionHO Level ❑ Residential Kitchen Previous Inspection Telephonev n S L6__-� [I Mobile Date: Owner HACCP Y ❑ Temporary ❑ Pre-operation / a,r n A ❑ Caterer ❑ Suspect Illness Person in Charge(PLC) Time ❑ Bed&Breakfast ❑General Complaint In:�,10 ElHACCP Inspector �( �rZ�U Out: . Permit No. ❑Other Each violation checked requires an explan\a1ffon on the narrative pages) and a citation of specific provislon(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) [� 599.009( action as determined by the Board of Health. l / FOOD PROTECTION MANAGEMENT . _ -- _ '9� El 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties _ 13. Handwash Facilities �PLOYEE HEALTH _ PROTECTION FROM CHEMICALS � "� [1 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved.Flood or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded `�J �_ El 15.Toxic Chemicals FOOD FROM-APPROVED SOURCE _ 1 -- - - - TIME/TEMP ATURE CONTROLS P ❑ 4. Food and Water from Approved Source E(i (_otentlally taiardoua Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ! ❑ 17. Reheatin C36. Tags/Records/Accuracy of Ingredient Statements 9 ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION C3 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing .REQUIREMENTS FOR HIGHLY_SU-SCEPTIBLE POPULATIONS(HSP)! El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11.Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories 1 Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions , 2 immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): L� of Health. Non-critical (N).violations must be corrected . Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Boartoday, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below c N by a Board of Health member or its agent constitutes an G 23. Management and Personnel (FC-2)(590.0 4)) order of the Board of Health. Failure to correct violations/ 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-a)(sso.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you Q 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. \ 30. Other DATE OF RE-INSPECTION: s:s&o�nsc�comisia eac Inspector's Signature:-6 �-�xn..,� �,e A /� Print:: ,V) (9D PIC's Signature: / ` \ Print: Pa /) ` r e of /� Ll l Cil 1 h R / I f� I E L� g ages r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Crass-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(]) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Calked and RTE Foods* 590.003(B) Demonstration of Knowledge" Contamination from Raw Ingredients 2-103.11 Terson in charge-duties 3-30211(A)(2) Raw Animal Foods Separated from Each Other' EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302,11(A) I Food Protection* require reporting by food employees and 3-3021.5 Washing Fruits and Vegetables applicants* 3-304.1.1 Food Contact with Equipment and 590.003(F) Responsibility Of A Foal Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003 G) Reporting by Person in Chv ge* 3 590.003{D) Exclusi,onsand Restrictions-* DlspositiortofAdulteratedorContaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-7011.1 Discarding or Reconditioning Unsafe Food- FOOD FROM APPROVED SOURCE 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food taw* 4-501.1.11 Manual Warewashing-Hot Water 3-20112 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* Sanitization Tem eratures* 3-202.1.4 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical.Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-107.11 Drinking Water from an Approved System* 4-601._11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinkin Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food- Shelflish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreafionally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Regulatory Authority Game and uMushrooms Approved try 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-30112 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2.301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices y Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401,12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records;Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* TagstRecords:Fish Products 13 Handwash Facilities 3-402.11Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention` 5-203.11. Numbers and Ca acries* 590.0040) Labeling of Ingredients' 5-204.1.1 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.1 L Specialized Processing Methods* Devices 3-502.12 Reduced oxygen acka hg,criteria* 6-301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with A. roved Procedures* 6-301.1.2 Hand Drying Provision Denotes critiail nern in the federal 1999 Foot Cale or 105 CMI2 590.000, �\B OARD OF HEALTH 'p Establishment Name: )Pzp_L < /Y�e ne_ �Y-� // �ryY� Date: Page c of F' Item Code C—Critical Item DESCRIPTION OF VIOLATION / PIAN OF CORRECTION Date No. :Refer ce R—Red Item Verified :PLEASE PRINT 6LEARU �, ',("SzL �. fM' r PI P t )a? l�-�On A,w s 1 -U PAtAP dux Smv,n _�� or d ,e� rayl W - n QAIX U to (-a u�A l , :r r u .v. Sl — \66C/ 'b-�c- -40� 4 I'_t u, r nvA, A.i,r d�'tilsX��'Oy, — vr_JV1, (A ,.Wn q!)//Y' iii U - � I n1 p o t n W A nn n _ (1Y—S6 _ k WArno F Ck (l1� ' pp Discussion With Person in Charge: I t Corrective Action Requir6d': ❑ No Yes ✓� Voluntary Compliance ❑ Employee Restriction/ ` /j / Exclusion / ❑' Re_-innsspl(e,Xctiion Scheduled ❑ Emergency Suspension m ❑ Ebargo ❑ Emergency Closure ❑ Voluntary Disposal ❑ Other rFORM 734B (REV. 7/2000( HOBBS & WARREN— BOSTON BOSTON This Form Approved by the Department of Public Health .r Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Hems 1-22) (Cont) According to Law Cooled to 41°F/45"F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19. PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(8) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°E* Containers* 3-501.16(A) Roasts Held at or above 130°F.* 7-102.11 Common Name-Working Containers* 'i"'-:20 = Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS (HSP) 7-204.11 Sanitizers,Criteria-Chemicals* ""21,,;: 3-801.1 l(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* .._ 3-801.1 l(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contac[,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13, Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY °22 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS F Animal Foods that are Raw,Undercooked or 16 Proper Cooking Temperatures for "'K not Otherwise Processed to Eliminate PHFs �W"W Pathogens.* Err�n"atnrrom 3-401.11A(1)(2) Eggs- 155°F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145"F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals-155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(B)(I)(2) Pork and Beef Roast- 130°F 121 Min.* catering, mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodborne illness Poultry or Ratites- 165°F 15 Sec.* interventions and risk factors.Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 145°F* practices should be debited under 1129- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 1T Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165°F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165°F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. - 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140°F to 26. Water, Plumbing and Waste FC-5 .006 70°F Within 2 Hours and from 70°F 27. Physical Facility FC-6 .007 to 41°F/45*F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(6) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. - -nTM'w r' '"�, w`';r'-.^n'�A.,....�.,.qr•-4'f•- r`1,+..syS,�!'}�V'S,M`T'�M1f�.p!'.h?ii` ;:.,�e,.�"�, .> ti.T�l-' 13..$fi��`' ri�t?1�'ji�4{!h-�,D+".y.! �!.>:{t�lt��sr:w.�t. Massachusetts Department of Public Health IlkW Board Sreeahh Division of Food and Drugs Sal Washington Street,4'" Floor ' i Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT ; Tel. (978) 741-1800 Fax(978) 745-0343 Name, ( � Date Tvoe of Operations) Tyne of Inspection - 1 I< S Y L(Nt (i C X � ' ❑ Food Service ❑ Routine Address ' Lv Risk (5,Retail ❑ Re-inspection t n Level ❑ Residential Kitchen Previous Inspection Telephone (1 n �� 3 1 0 3 ❑ Mobile Date: ElTemporary [IPre-operationOwner HACCP Y/N ❑ Caterer ❑ Suspect Illness Person in Charge\jPIC) Time ❑ Bed&Breakfast ❑ General Complaint [I HACCP Inspector In.l,3. Permit No. ❑Other Each violation checked requires an wiplanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking / Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E)Z] 590.009(F)� action as determined by the Board of Health. ,amu " �z ""FOOD PROTECTION INANAGEMEN7;,r,; ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties y rl 13. Handwash Facilities EMPLOYEE HEALTH is y„ F-142 ¢Reporting of Diseases by Food Employee and PIC i � u y PROTECTION FROM CHEMICALS g;= ' F i r�.� µym? ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE,E,.r,; �'nµ„� �"�,' ,u' „TIMEREMPERATUFiEC0NTROLS{PoteittlaTly#lazaidoUs fodtls)3fl•Ilia ❑ 4. Food and Water from Approved Source ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling � m- „ El19. Hot and Cold Holding PROTECTION FROM cONTAMINATfbN �}!" "'_1'M", ,� 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing If REOUIREMENi'SFOR HIGHLYSUSOEPTIBLE P_OpULATIONS (� ❑21. Food and Food Preparation for HSP V ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices T!CONSUMER AbvISORX''t`,,�'' [122. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related C J Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C , by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(sso.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other ++ ii DATE OF RE-INSPECTION`:) �ector Inspector's Signature: (� /, Print: ' - IC's Signature: �? (� Print: �� ,^ Page of 2Piiges rvI t Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination ( 1 TSy .003(9) Assignment of Responsib lity" 3-302.1I(A)(1) Raw Animal Faods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge--duties Contamination from Raw Ingredients 3-302.1.1(.4)(2) Raw Aniaml Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require repaying by food employees and L302.I I(A) Food Protection* a tlican[s* 3-302.15 _ Washin Fruits and Ve.�es 590.003(F) Responsibility Of A Food Employee Or Art 3-304.1 I. Food Contact with Equipment and - Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Chula* 3-306.14(A)(B) Returned Food and Rescrvice of Food* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of F,aclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe. FOOD FROM APPROVED SOURCE Food* 4 '.' Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 7501.111 Manual Warewashing-Hot Water 3-20112 Food in a Hermetically Sealed Container* Sanitization Te!n eratures* 3-201.13 Fluid,Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Sanitization Tem eratures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.11.4 Chemical Sanitization-temp.,PH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101.11 DrinkingWater from an Approved System"tem" 4-601.A I(A) Equipment Food Contact Surf=aces and 590.006(A) Bottled Drinkin Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0r, 4-602.1 t Cleaning Frequency of Equipment Food- Sfteittish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Oontact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-20[15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 111 Proper,Adequate Handwashing Regulatory Authority Game and ur Mhorit ushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* 3-202.15 Shellstock Identification Present* -T-301 12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* L LIGood Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PHFe Received a[Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.0(4(F.) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Employees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of ingredients' 5-204.11 Location and Placement* 9 Conformance vidh Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Srnwialized Processiti Methods* Devices 3-502.1.2 Reduced oxygen packagam,.criteria* 6-301.11 Hindwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* Hand Drvim 6-301.12 �Provision *Denotes critical item in the federal 1999 Roti Code or 105 CMR 590,000. CITY OF SALEM BOARD`OF HEALTH 1 Establishment Name:1' n s �� fc \I�� : t .� C 1, r c� Date: I_ 2 -r1 Gt I ( 4y"Page: l of 1 , rte , c Item Code C-Critical Item _ DESCRIPTION OF VIOLATION/PLAN OF/CORRECTION Clete r. No. Reference R–Red Item Verified t�[! PLEASE PRINT CLEARLY R � r10,) .t A so _ I I �,OA ,moi� �( I A �Ya A yh n A.1 I/ 1 � I n/I n --1 1} J7) nn 1\1 '/FAI _ - _ 1 I 1 ��it'c _ann._ Xl�— _ rI k i I0 A - �l)rl i_I i _ r .00 \ n OA I ) ( )f) — O AI O ' 1 0 � II D , r, On.✓1O ma Ann _/e In r/nn ` (1 Fn /J .10A n�� (\—�,� •'. --- � �D h✓V rn \ 0 r 't—Ix ,Il, vO/! e AO nA !J 0 X� nw 0 nrnaDA . !: U � —A �r�� iI� -00 - - — — � - - - (I On,> . rx _ tiff _ 1 t QJ�,_ a (O n �— tnv oQ c>� I E '+ Discussion With Person in Charge: Corrective Action Required: ❑ NYes I have read this report, have had the opportunity to ask questions and agree to correct all N xZ 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. t ❑ Voluntary Disposal ❑ Other: -561.14tC� PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Lain Cooled to Factors(Items 1.22) (Cont) _ 51`F/45"F Within 4 How s. * _ 3-5 PROTECTION FROM CHEMICALS 01.15 Coolim>Methods for PHFs -- 19PHF Hot and Gold Holding 14 Food or Color Additives 3-501.16.(B) Cold PHFs Maintained at nr below 3-202.12 Additives'" 590904(F) 4V/45`F- 3-302.14 Protection from Unapproved Additives 1-51)1.16(:`<) lint PMaintained ainfained at or above 15 Poisonous or Toxic Substances 40 F. -101.11 i ldentit m info(m mon--0innnal Container''` {filINA) Ro'i,iS Held at orabove 130°H- _— I Time as a Public Health Control j 7-102,11 i Comrfjot Name 9; I� i �_ Pim+_ he Health Control* - 201.1 i � m rut n -Stu(a < as a Pub .�� --- — --1 7-262 11 petit st on--Yr St nu and f,.�' {{ k1`IOt�{i., �8 in rnee R utrcmeut --_ 7-202.12 Condo on of[Rv — 203 Toxic C osis liner Probibr:un REOUiREMENTS FOR HIGHLY SUSCEPTIBLE f 1 �—�- _POPULATIONS�HSPt__— _ 1 -204.11 Sannvca C;tireisr Chcnuc Is — 2 — t :;-8111 1 NAi tin) tcurizcd Prt pac i�cd Juices tinct 64.1 Cits.nuc tls telt N'achi� t nd_uu. C nu-ria" 1}t rets e.witb N nrivabals�' 7 204.4.4 U,'tn li,eotc(nuri i ;J 801 1I'Bi I e o Pato in d Es-, .14. lnerdt nt it f xxf Cumnu I. kni aih ___a! 2 Svt ilti�) �deu eir 'ti)irll f s+<i(, dAaiitiat Foodand �2U6.ts Recisi led 1 ,c I'e mote. t -t iii' —1-- —, t r4. S d o)n sits Not SeI Vc - + , (16.12 , tiixl n Ii t 14.+t nn, ' i ..— .— —_.. i 801 1 s C i U4. i s d Fixxt 3 i<t -, Not It .;,-ced I r Qb.l"t IYa i`s g".,% P C. sett . an.l '_-- c.__.._ �__.t_ _...__ .—____—.�...� �— Siornt ur CONSUMER ADVISORY TIMFJ('EMPERATURE CONTROLS 2" 1 3 b0_ I I e primo r tet o; Pti n 1 for C ort umption of 7(ice-- —� ProperCooking 7eirpatmutes for —' I �'sss all fds fht icf>, u tndesttixiled t, L— PHPs Pu�t t i)0u r se 1 r> e sv + i'-fit to 4.0 ' 3ti0LL 15yrI >S 1 tt:'s r ! sttcry ..i ls. : S d s:tiir for Ray. She') _ c hnn�di tt 4c ru i 15,i:1 .ec E .— �— ,r,,.<G & L. ---- ( .-" SPECIAL FEOWREMENTc i ,n4. t 1 Plt i 74. 1 t et s 3 4.3 Po st t <S I ' �.� .— .�... —.__ ..-., -+ - — 1 sb)tx )t.i�- r>, f tic;at,i, 56t t,{, lsl.tr,1) rt:2i;n 7)1.11(4)( i nisut btico tilt ells. I fcaitriotI. rnokil::fi.xisl, t nili irai r and i y ._� .. rt.ti d rl 11 4..t tC , i 40 1.11 A-.3i , ou ry 1Vild Gaw Si€lk ilia;,, i 1 F~�n Csp) t isisnt Aityuld 3x i E S , Iim-a"on au n. 1, i.:F. hf„t. c 0);ted a �d, fh y Pruncrtttie(!;011s I Pol ! or k it, i %i c l ah itc f t ' (trd' i i-r ISt�s=t. ll::ee f he,cttic wr ;,•. -iter s....t ;;at ,y, +e:lcs C'ttlies a .`+o_'c's , ,_xrCi.a;=F3tS. !11417, ._ 1"1 ",heating for Hot holding •_.__ P + __. _ ._. ._... VIOLA DONS RE-LA O G100LRT'AhPRACTi._ (hems 23-34H llt i !67°E s 0311(1Mmovavc- 165 F 2NNw `_ ndin.; C,iwaf _cdr e e i al n t -s whi,hdonar teire 4.,r l ( 9 tt° iroi n4. ire. ii i ss n rs"ait i .,1 r4. {1 xt_ sticrtd6 r c;;e66r }03.111(4. i c mincretah Pui ....•d F1t F ++d ,j 1 n4. q c heFo do rd.a, a Ji / t"? !40T' _ j _ 'UdteU _403-1 lrL) Rutnnrn 1.nslireo Por.ions if 13a riem GootRetail P+acfeecs FC 530.000 h last _ ? fganagrmE !a tt Pe arri f ' FG 2 00; `24 Ft><xt and�cnxf 1'r0£C tc,n GC: 3 vOJ ! (g Proper Cooling of PRFs - - -- t__.__� --_-� i 2' cgurpnsern and Utenss s F d t 7ti I ,501,14(A) Ctn.iine Ccok n PHF= fim rlit)Flo i i . � i � Vda,«r,Pit t .,b,Qsrc ,N >,e -i Fc-7 'Xiv j il ltnhintiTour,and From ,`.1"fs ? t ys ,tF t " t 6 i "P W t1 in 4 !!Ow t - 2d aos no t or }xi h .,t'S rC 7 Cot, ..—_ — 3 501.1.41-fi" f ry!in PHF Made [tom kinhie ut _ ° poc Sa1 t,..�s r in ti 00 1 m moirein rediewx t 1 F 3e Other 'With; 1-irxus 1 . _ CITY OF SALEM BOARD OF HEALTH 10 Establishment Name0.i�-I� tv 'f>-YYAt-yg � ^Lk:j� C,-,zY F' Date: (-X 7 Page:_ of Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF 4CORRECTIONDate No. Reierence R-Red Item '- _..t1� Verified PLEASE PRINT CLEARLY \ >' � NCiti � I ice, Tj r J j . j (J: . t•v� 1 0 cAC T—nkti _ D u �. h 1 ) �. W � w 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 ❑ Other: G & G PEST CONTROL *George A. Young 39 Coolidge Park, Wakefield, MA 01880 �� r� Licensed& Insured (781) 724-8877 or (617) 777-1027 A Commercial& Residential CUSTOMER INFORMATION, 4DATE:g 1 - , `� y r HOME#,..-; Y ')(. - �Cs? BUSINESS 4h ,,,,F STREET4i:'tf l j'I(-�y `�'7� CITY. STATE/7�;'s*� ZIP: PROPERTY DESCRIPTION � e,5^7,0Z j RERVICESPERFORMED: ' SERVICES PERFORMED,NOT WARRENTED: CHECK LIST ©'INSPECTION ❑ WALL VOID TREATMENT ❑ CRAWL SPACE TREATMENT ❑ FOGGING ❑ BARRIER TREATMENT ❑0CELLAR TREATMENT ❑OUTSIDE PERIMETER TREATMENT ❑ RODENT BAITING/ IZIAASEBOARD TREATMENT LM FLOOR TREATMENT ❑ CABINET TREATMENT ❑ OTHER NOTES: Please allow30d{ayfss for re--treatment; if necessary......(RESIDENTIAL ONLY) 6J 5 ;`•r x�P.ESTICIDE USE REPORT PERSON REPORTING: George Young LICENSE It:25495 Trade Name of Method of Major Pest(s) Percent of Amount of Pesticide Used A lication Eliminated Formulation Applied Formulation Applied a-No NT DUE: r-S� . WARRANTY EXPIRATIoNDATE: s .US R SIGNATUR :f TECHN/cAN$IG1q,- E-:Xf . �/ 2' X JF www.ggpestcontrol.com — -- A. G & G 'PEST CONTROL *George A. Young 39 Coolidge Park, Wakefield, MA 01880 Licensed& Insured (781) 724-8877 or (627) 777-3027 Commerciale& Residential CUSTOMERINFORM) A-TION r. DATE. HOM�E1#:i, ' BIJSINESS#: NAME ., STREET: ii"J}� 7 :s CITY: \ ` i Jf' P-z STATE;%` r !{ 71P: PROPERTY DESCRIPTION: � n�:,,,r `� SERVICES PERFORMED: l"}`) e'�p"t.111 7ENTR SERVICES PERFORMED,NOTWARRENTEIiCAECRiGIST INSPECTION D WALL VOID TREATMENT ❑ CRAWL SPACD B BRIER TREATMENT D CELLAR TREATMENT D OUTSIDE PERBAITINGIV 61 t.J ASEBOARD TREATMENT Fe FLOOR TREATMENT Cl CABINET TRENOTES: Please allow 30 days for re-treatment; if necessary......(RESIDENTIAL ON 7 •,� RESTICIDE USE REPORT PERSON REPORTING: George S Outt LICENSE#:25495 Trade Name of Method of Major Pest(s) Percent of Amount of Pesticide Used Application Eliminated Formulation Applied Formulation Alied e AMOUNT DUE:�; - � r WARRANTYEXYIRATtotV DATE: 4 UST EX SIGNATURE: TECHNICAN S161hATURh _ f www.ggpestcontrol.com ,' ", G & G PEST CONTROL P George A. Young 39 Coolidge Park, Wakefield, MA 01880 Licensed& Insured (781) 724-8877 or (617) 777-1027 Commercial& Residential CUSTO ER.I IFOR ATION , x DATE:t BUSINESS STREET: L 2& - \e- S' _ CITY: {j G $TATE: if ZIP: PROPERTY DESCRIPTION: M SERVICES PERFORMED: -A t!1 J SERVICES-PERFORMED.-NOT WARRENTED: CHECK-LIST INSPECTION ❑ WALL VOID TREATMENT ❑ CRAWL SPACE TREATMENT ❑ FOGGING ❑ BARRIER TREATMENT ❑ CELLAR TREATMENT ❑OUTSIDE PERIMETER TREATMENT ❑ RODENT BAITING ❑ BASEBOARD TREATMENT FLOOR TREATMENT ❑ CABINET TREATMENT 4 OTHER NOTES: Please allow 30 days for re-treatment; if necessary......(RESIDENTIAL ONLY) q /rvn9 011 boor'-f1 prN/ M01)40/ r 4'' 7 " 'Z ;.-:. r , , xPESTICIDE USE REPORT ; PERSON REPORTING: George Young LICENSE II:25495 Trade Name of Method of Major Pest(s) Percent of Amount of Pesticide Used Application Eliminated Formulation Applied Formulation Applied AMOUNT DUE: J V - WARRANTY EXP/RAT/ON DATE: CUSTOMS S/Gr\'ATURE: f TECHNICAN SIGNATURE.: x f - www.Ogpestcontrol.com a •_ _ � _ .�. 'i...�"-.:ia. 'e-r:u:. .r!" A.nmtx.r�x: ..- a :s,. fl'kKwm4aa?:+•a _ G & G PEST CONTROL *George A. Young 39 Coolidge Park, Wakefield, MA 01880 Licensed& Insured (781) 724-8877 or (617) 777-1027 Commercial& Residential GtIST(3MRR INFORINATIQ2� DATE: I H E#. G BUSINESS# f DAME: 1'/�/ 00 STREET: I CITY: o e— S I ZIP: PROPERTY DESCRIPTION: ( '? SERVICES PERFORMED:M© L7//j SERVICES PERFORMED,NOT WARRE D: CHECKLIST ATINSPEcTION ❑ WALL VOID TREATMENT ❑ CRAWL SPACE TREATMENT ❑FOGGING ❑ BARRIER TREATMENT ❑ CELLAR TREATMENT ❑OUTSIDE PERIMETER TREATMENT ❑ RODENT BAITING ❑ BASEBOARD TREATMENT 4ff FLOOR TREATMENT ❑ CABINET TREATMENT Z@ OTHER NOTES:Please allow 30 days for re-treatment; if necessary......(RESIDENTIAL ONLY) PESTICIDE USE REPORT PERSON REPORTING: George Young LICENSE#; 25495 Trade Name of Method of Major Pest(s) Percent of Amount of Pesticide Used Application Eliminated Formulation Applied Formulation Applied AMoI uNT DUE. ")� L;iTf yfy�/j WARRANTYEXPI.RATION DATE, CUS MER SIGNATURE., --4 TECHNICAN Sko-PNf�TURE. l r x Lx 6,7� :% I ,r' J www.ggpestcontrO1.COTn,"// I� l� Commonwealth of Massachusetts « ` City of Salem Board of Health Kimberley Driscoll ram 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2011 ESTABLISHMENT NAME: Nicole's Mini Food Store File Number:BHF-2004-000065 406 Essex Street Salem MA 01970 LOCATED AT: 0406 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes Y� � RETAIL FOOD BHP-2011-0072 Jan 1,2011 Dec 31,2011 $280.00 TOBACCO VENDOR BHP-2011-0071 Jan 1,2011 Dec 31,2011 $135.00 Total Fees: $415.00 PERMIT EXPIRES December 31, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS n BOARD OF HEALTH urt 120 WASHINGTON STREET,4"i FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR DGREENBAUM&ALEM.COM DAVID GREENBAUM,RS ACTING HEALTH AGENT '7` �l'Y11 1g(nd S oof 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTAB!.ISHMENTMI1��/r_��L C9 ' _dtyIC NiccL�L#�.7_,Y= I40 3_�0-3 ADDRESS OF ESTABLISHMENTLTOC , LSFC4,S-k. SI9LEFAX MAILING ADDRESS(if different) �1/ � � - . O 1 C` 1 EMAIL-Business': �? EMa1L `— Website: OWNER'SNAME 1+ rValu OPm(7aTz ( ±eL TEL - 233 Z� 1 ADDRESS 6rcl�I CP wyl ti _�p� t STREET c CITY / r STATE ZIT P CERTIFIED FOOD MANAGER'S NAMES) 1``IL' M(AW CERTIFICATE#(S) (Required in an establishment where potentially hazardous food is prepared) 77� I EMERGENCY RESPONSE PERSON U�j1A0 o "Od) 'V• Vc (f'C_ HOMETEL# DgYS,OF'OP,ERATION - Monday , "I: Tuesda i< ' aWednesday v ;T)tursday r l < Pdday , Saturday Suhtla: " HOURS OF OPERATION - G w 6_cs� t^F q-1 P M' lV1 6 = Please verde in time of day. I To TU TO TV T� l For example 11am-11pm ': wpm.l0 .d0IA1 I 0 ,-Or) 1 0 0'- Cro ( 0 C>J 6 TYPE OF ESTABLISHMENT (g FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 70 L/(000-10,000sq.ft. =$280I,-- more than 10,000sq.ft. =$420 RESTAURNT-- -----------------------Y -S------NO--------------------------------------------I e"s"s-t-h-a-n---2-5...s-e-a-t-s---------------=-$-1-4- -0---- (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ------------------------------------------------------------------------------------------------------------------------------------------------------------------ BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOME---------------------------------------------------------------------------------- ------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax ret d paid all state taxes required under the law. (I Lz@�T 4" (V0 0e4 I �r 2-0 C' Signatu Date Social Security or Federal Identification Number Revised 10/7/11 FOODAP201 Ladm Check#&Date] . $ ,2-9-10 C� .� Commonwealth of Massachusetts s r City of Salem Board of Health lClmberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED:. Q2/05/2010 ESTABLISHMENT NAME: Nicole's Mini Food Store File Number:BHF-2004-000065 406 Essex Street Salem MA 01970 LOCATED AT: 0406 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2010-0348 Feb 1,2010 Dec 31,2010 $145.00 TOBACCO VENDOR BHP-2010-0349 Feb 1,2010 Dec 31,2010 $135.00 Total Fees: $280.00 PERMIT EXPIRES December 31, 2010 Board of Health I This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS + / * BOARD OF HEALTH 120 WASHINGTON STREET,4:"FLOOR-,.:. TEL. (978) 741-1800 c KIMBERLEY DRLSCOLL FAX(978) 745-0343 MAYOR DGREENBAUM@SALEM.COM DEC — 7 2009 DAVID GREENBAUAI, (A r Y,OF SALEM ACTING HEALTH AGENT BOARD OF HEALTH 2010 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT�C° bee M(V (r FCCDJS3 TEL# �j 7 (�- -7 401_3 ADDRESS OF ESTABLISHMENT Lf-© b C �Se�S�, _-QrL� R k9 7<�i MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAIVE J U 12 er CIS cI TEL# 2-33� �� 3 ^�ZS ADDRESS l CtCIG11'1(:f `JZcI� SAVC10VS / C�fE 01j©)' STREET f CITY I STATE ZIP CERTIFIED FOOD MANAGER'S NAME(SK9 fP�1 CERTIFICATE#(S) (Required in an establishment where potentially hazardous food its prepared) J EMERGENCY RESPONSE PERSON �i kV 10 o `-1 i�� HOME TEL 7� I ^�� gAYSPERgTION , Tmesday , Wtlnesday hThursday�ry, Saturday Sunday ��Alontlay ;� HOURS OF OPERATION ! 6 (1- M- I p c f{, M O 9 •1 ' Ii G ? ... M b G� � ^ � T' 6 T, G T. G Please write in time of day. I -�-b � ': -�(� i � I Forezample 11am-11pm 1 ^o0 •'rrt, gmi �"C_ic' 'm TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 V more than 10,000sq.ft. =$420 RESTAURANT YES NO less than 2 5s eats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ------------------------------------------------------------------------------------------- BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES/NURSING HOM ----------------------•----------------------------------------- ----.-.-------------------------------------------------------------------------- ADDITIONAL PERMITS _/� MAKE (notjust serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES 135 3Yt ALL NON-PROFIT(such as church kitchens) YES O *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returmLand paid all state taxes a uired under the law. 1Z o�( Signa Date Swia#-Seeerity or Federal Identification Number Revised 424—/07 FO—O=DAP2-0-08.a—dm---C—heck#&-D—a—te �---------------- ---�( - - --- r �� 21 ,21-"" � 0406 Essex Street Nicole's Mini Food Store City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 740-3103 Food and Food Protection FAIL Critical BLUE Owner: Comment:There are many price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price Bhupendra M. Patel labels. PIC: The following items removed outdated: Mike Patel 3-slim fast Inspector: 1 -Chef Boy Ardee 4-Salad dressing David Greenbaum 11 -Juicy Juice Date Inspected:Correct By: Closely monitor all expiration dates. '8/512008 Equipment and Utensils FAIL Non-Critical BLUE Risk Level: Comment:All metal shelves in the side reach in need a thorough cleaning. Permit Number: BHP-2008-0353 Status: PARTIAL COMPLY #of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 06,2008 ) Page I of2 b - Item Status Violation Critical Urgency RED: e Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) 1� City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 06,2008 ) Page 2 of Commonwealth of Massachusetts i City of Salem Board of Health IGmberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/23/2008 ESTABLISHMENT NAME: Nicole's Mini Food Store File Number:BHF-2004-000065 406 Essex Street Salem MA 01970 LOCATED AT: 0406 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2009-0104 Dec 23,2008 Dec 31,2009 $70.00 TOBACCO VENDOR BHP-2009-0105 Dec 23,2008 Dec 31,2009 $135.00 Total Fees: $205.00 PERMIT EXPIRES IDecember 31, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR IDIONNE04SALPM.COM JANET DIONNE, ACTING HEALTH AGENT 2009 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1 I CO Le 'S (fit I � 1 �Cdt3�� (� -740 -,310-37 ADDRESS OF ESTABLISHMENT l�06, e�S�E-�(al�thF41"I' ) MAILING ADDRESS(if different) _ EMAIL- Business': Website: OWNER'S NAME L TEL# S- - 3 SZ5I ADDRESS 1 Sl1vcw o 9 O STREET 1 CITY STATE IP CERTIFIED FOOD MANAGER'S NAMES) YIIIQ Q'7( �C{ CERTIFICATE#(S) (Required in an establishment where potentially hazardous fo d is prepared EMERGENCY RESPONSE PERSON HOME TEL#7M —2�3 C1 `-5 1 'DAYSOF,OPERATION. Monda -. Tuesday: Wednesda r . Thursda ,': ' P, .,,Friday-': i L Saturday- 1 Sunday. HOURS OF OPERATION ; p M 1 6 ffm M Tol A ml1 A (Y Please write in time of day. �•f, 'j-G ` ! (For example 11 am-11 pm) ' , • o ,. , TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE Y S NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 --------------------------------------------------- ---------- RESTAURANT YES NO less than 25 seats $140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 --------------------------------------------------------------- - - - - BED/BREAKFAST/ YES O $100 CHILDCARE SERVICES ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YE (0 $25 TOBACCO VENDOR NO $135 ALL NON-PROFIT(such as church kitchens) ES $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns id all state taxes requi under the law. t ► 2oa� � � �fa4 -34� �336 Signat r Date Social Security or Federal Identification Number ------- --------------- Revised 424/07 FOODAP2008.adm Check#&Date $ Z 5 G Commonwealth of Massachusetts City of Salem Board of Health IGmbedey DriSooil 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/14/2008 ESTABLISHMENT NAME: Nicole's Mini Food Store File Number.BHF-2004-000065 406 Essex Street Salem MA 01970 LOCATED AT: 0406 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2008-0353 Jan 14,2008 Dec 31,2008 $70.00 TOBACCO VENDOR BHP-2008-0354 Jan 14,2008 , Dec 31,2008 $135.00 Total Fees: $205.00 PERMIT EXPIRES December 31, 2008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 2 of 3 .P1tI . QTY OF SALEM, MASSACHUSEM BOARD OF HEALTH A4gr 120 WASHINGTON STREET,4"'FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL FAx(978) 745-0343 MAYOR IS00Tr((ZSALEM.OCIM JoANNE ScoTr, HEALTH AGENT 2008 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT 1 nI/ ( C 0�,e S FvNI'/I �OUfSfCaf TEL# Z 6c / O 3 ADDRESS OF ESTABLISHMENT 6 Q•e:tS-' S �err7/'"FAX# MAILING ADDRESS(if different) EMAIL-Business': /� Website: OWNER'S NAME 0kU 12 Fel c� TEL# ADDRESS (0 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) W kr ]�9n Q6T-/ CO( CERTIFICATE#(S) (Required in an establishment where potentially hazardous footl is prepared) �A -�3 2-kZS j EMERGENCY RESPONSE PERSON ( 1� U►� (`� HOME TEL#?� J / DAYS OF OPERATION I Monday Tuesday �vt WednesdayThursda FridaySaturdaySunda HOURS OF OPERATION j G (V1 \.; " �° �: �1 Please write in time of day. 70 �p 1 0 T� _Z For example 11am-11 m o CTU •c'ro 0000 0" 1 • op i • i9e> ' TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 --------------------------__.-----------------------. ...........-------- RESTAURANT YES NO less than 25 seats =$140 (Outdoor Stationary Food Cart$210) 25-99 seats =$280 more than 99 seats =$420 ---- ------------- _---------------------- ----------------------------------------------------- BED/BREAKFASTI YES N $100 CHILDCARESERVICES -------------------------------------------------- ---- ..-------------------------------- ---------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE �Y-E�S NO $25 TOBACCO VENDOR ( YNO $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 'Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax returns an a state taxes requir d nder the law. Signature Date Social Security or Federal Identification Number ------------------- ------------------------ - - -------- ------— FOODAP2008.adm Checkq cSb ` 0406 Essex Street Nicole's Mini Food Store City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 740-3103 Food and Food Protection FAIL Critical BLUE Owner: Comment:There are many price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price Bhupendra M. Patel labels. PIC: Shilpae Patel GENERAL COMMENTS: Inspector: David Greenbaum All other violations cited in the 6/14/07 inspection report have been corrected. Date Inspected:Correct By: 6/2112007 Risk Level: Permit Number: BHP-2007-0069 Status: SIGNED OFF #of Critical Violations: 1 Time IN: Time OUT: - Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 21,2007 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 21,2007 ) Page 2 oft i / I i ■ NOTES _ __ COURT DOCKET NO. CITATION NO. CITY OF SALEM VIOLATION NOTICEPD 6027 NAME(LAST,FIRST,INITIAL) /1�tCG i 3j'l(� Gly{ I STREETADDRESS ` CITV/TOWN STATE ZIP 40L 6-sSty S k 5- t-m t"4 01970 LICENSE NO, LIC.EXP DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) pvt-z. gihv f�Cl✓w STREET ADDRESS CITV/TOWN STATE ZIP *fa 51vtem 1"A O/S 70 REGISTRATION NO. STATE EXP DATE MAKE/1YPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATI N WRITTEN FERSONAL 71.2 NJURY V ❑PM O DYES ❑NO LOCATION OF VIOLATION ENFORCING DEPT. -jUc cSSt" T c SlfCh1-7/i OFFENSg -ItY Lw(- /jf' CHAP. SECT FINES A#F i/?t S74?e f1VV1—pV2ver0e Sita lL�t�' B C OFFICER/7e7 �!'-Z� ) - I.D.NO. TOTAL . " FINE �,QQ t DUE !OFFICER CERTIFIE COPY GIVEN TO VIOLATOR X ' ItIN HAND BV MAILL 2'0 NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE H SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL 0406 Essex Street Nicole's Mini Food Store City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 740-3103 Good Hygienic Prac' FAIL Critical ❑d RED Owner: Co ent:The Beverage air cooling unit on the counter had employees food stored in it.Store employees food in a dedicated Bhupendra M. Patel employee refrigerator to prevent cross contamination. PIC: Mike Patel Inspector: David Greenbaum Date Inspected:Correct By: 6/14/2007 Risk Level: Permit Number: BHP-2007-0069 Status: VIOLATION #of Critical Violations: 2 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 14,2007 ) Page I of Item Status Violation Critical Urgency RED: Violations Related to Good Retail Practices (Blue Items) Violations Related to Food and Food Protection FAIL Critical BLUE Foodborne Illness Interventions and Risk Factors (RequireComment:There are many price labels obscuring expiration/sell by dates. Do not obscure any expiration/sell by dates with price immediate corrective action) labels. The following items removed from the shelves outdated: 1 -JJ Nissen canadian wheat bread 6-Bagel bites to go 1 -Ben&Jerrys ice cream 8-Tortilla chips 2-Wise popcorn 42-Wise Bravos tortilla chips 12-Natures tley granola bars 6-moon s 3-Ca ells soup 1 - pbells gravy 1 iracle whip -Ah So sauce 3-Grey poupon 2-flour 11 -TheraFlu 2-Contact cold 1 -Sudafed 1 -Nyquil 4-Midol Owner ust closely monitor all expiration dates to insure no expired product is out for sale. e slush freezer has uncovered food. All food in storage must be covered. Equipment and Utensils FAIL Non-Critical BLUE C ment• a slush freezer has an accumulation of food spills and splatter. Thoroughly clean this unit. T Re r II unit on the counter needs a visible,accurate thernometer. :- The Beve a ai11 r unit on the counter needs a visible,accurate thermometer. a cone freezer on the back wall has an accumulation of food spills,splatter and debris. Thoroughly clean tis unit including all ves. GENECOMMENTS: Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS@ 2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 14,2007 ) Page 2 of Item Status Violation Critical Urgency City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 14,2007 ) Page 3 of i I COURT DOCKET NO, CITATION NO, N N ` ' CITY OF SALEM n CQ VIOLATION NOTICE PD 7 {�' q NA (LAST,FIRST,INITIAL) L_ £ o STREET ADD] � CITVROWN STATE ZIP SOL �SS�x f em ivA 0�f to y LICENSE P.DATE DATE OF BIRTH �/'j/ O( 2e Ni S BEET ADDRESS CITYROWN $TATE ZIP • o 1n Es -T-" S' $RLQ �,a ot, C) '5 7b NREGISTRATIQN NO, STATE EXP.DATE MME/TYPE YEAR COLOR � 1 O DATE PF VI TION TIME DATE C TI N WRITTEN PE 50NnL o� C IWUav❑YESI O f g�� O � NO �. P ', LOCATION OF VIOLATION ENFORCING DEPT - � t}C' SL S l C-j j O OFFEN r' l [/ CH P. SECT. FINE AOA -%tc- s��?O svVr,�n, ae � 11c i a B „ y i Ln G LO OOFFICER LD.NO. TOTAL O. Q O ! It v' 7 1J Lr jJ�`�;' DUE -OFFICER s f�� 0. ri Q {��' a -OFFICER CEFJTI��OPY GIVEN TO VIOLATOR z. °I (� Z LLEi 1�r rC a ;n `` ♦ // {/.///f AND U7 U^7{ ti, X j Y:� l�.�..�.�---- BY MAIL Cn '&w /...�A iry°" " i 4 400 NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY Ir, W v d r I I Int { ORDER 09 BY CHECK MADE PAYABLE TO: Q rn ! I I fir, vI. ! CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 '' ru TEL.(508)745-9595 X 251 k ht \ �F \7 AJr Y I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON m REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE � Q 7 PAYMENT IN THE AMOUNT OF SIGNATURE . SEE OTHER SIDE FOR FURTHER INFORMATION LUX4 ' ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL aa� i LL �R t. e 0406 Essex Street Nicole's Mini Food Store City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: - Violations Related to Good Retail Practices (Blue Items) 740-3103' " Food and Food Protection PASS BLUE Owner: Bhupendra M.Patel Equipment and Utensils PASS BLUE PIC: Physical Facility PASS BLUE Bob Patel Inspector: GENERAL COMMENTS: John Gehan 717:AII violations have been corrected unless noted. Date Correct By: Inspector to meet with Health Agent regarding monetary citation. Risk Level h Permit Number: BHP-2006-0162 Status: SIGNED OFF:i: #of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices(Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 - GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 03,2006 ) Page / of Item Status Violation Critical Urgency RED: r Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) 1r�P�-"2 � City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Aug 03,2006 ) Page 2 of 0406 Essex Street Nicole's Mini Food Store City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: FOOD PROTECTION MANAGEMENT 740-3103 PIC Assigned/Knowledgeable/Duties PASS ❑./ RED -Owner: ) Non-compliance with: Bhupendra M. Patel PIC: Anti-Choking PASS 3. Bhupendra Patel Tobacco PASS Inspector: JOhni Caehan EMPLOYEE HEALTH Date ' '-; 'Correct By: Reporting of Diseases by Food Employee and PIC PASSJ❑ RED 17MMA Personnel with Infections Restricted/Excluded PASS 0 RED Risk Level 4 FOOD FROM APPROVED SOURCE Permit Number: Food and Water from Approved Source PASS ❑d RED BHP-2006-0162 Receiving/Condition PASS RED Status: i; t Open - ' Tags/Records/Accuracy of Ingredient Statements PASS ❑d RED #of Critical Violations: Conformance with Approved Procedures/HACCP Plans PASSd❑ RED 2 :Time IN: "time OUT: Urgency Description(s): BLUE: 11 Violations Related to Good Retail Practices(Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 31,2006 ) Page I of Item Status Violation Critical Urgency RED: 'i. PROTECTION FROM CONTAMINATION Violations Related to x Separation/Segregation/Protection PASS RED Foodborne Illness Interventions and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing PASS RED immediate corrective action)' a. Proper Adequate Handwashing PASS RED Good Hygienic Practices PASS Q RED Prevention of Contamination from Hands PASS RED Handwash Facilities PASS RED PROTECTION FROM CHEMICALS Approved Food or Color Additives PASS ❑d RED Toxic Chemicals PASSd❑ RED TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Cooking Temperatures PASS ❑J RED Reheating PASS ❑J RED Cooling PASSd❑ RED Hot and Cold Holding PASS RED Time As a Public Health Control PASS RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) Food and Food Preparation for HSP PASS RED CONSUMER ADVISORY Posting of Consumer Advisories PASS RED City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 31,2006 ) Page 2 of Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Food and Food Protection FAIL Critical BLUE Comments:The following items were found outdated: 8-peanuts 6-baby food 1 -theraflu 6-miracle whip 5-doritos 7-chips 6-gravy 1 -salad dressing 1 -Kraft cheese 2-bisquik 3-cake mix 6-cat food Owner MUST closely monitor all expiration/sell by dates to insure no expired product is out for sale. There are many price labels obscuring expiration/sell by dates. DO NOT obscure any expiration/sell by dates with price labels. These violations are repeat violations and a monetary citation will be issued. Equipment and Utensils FAIL Critical BLUE mments: Beverage air unit nexty to coke refrigerator requires general ceaning. oke refrigerator requires general cleaning. tone unit in back requires thorough cleaning. �S`ame unit has temperature of 64`F. All refrigeration units to be holding at 41°F or below as mandated. unit missing lightbulb on left side. Provide bulb. x. atone Freezer has build up of ice in back. Remove ice. Isle 2 me unit.has temperature of 10°F. Freezer to hold at 0°F or below as mandated. e cream unit in front requites new thermometer. provide thermometer. -Slush unit requires general cleaning. rerigerator requires general cleaning. Water, Plumbing and Waste PASS .BLUE Physical Facility FAIL BLUE City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 31,2006 ) Page 3 of Item Status Violation Critical Urgency mments:Water stained ceiling ties in store. Find source of leak and repair. Replace tiles. t-PFonk snack bar/coffee area requires thorough cleaning in and around shelving areas. ore requires thorough cleaning for floors,walls,and shelves. is a ceiling tile with holes above the counter. Replace the ceiling tile. Management and Personnel PASS BLUE Poisonous or Toxic Materials PASS BLUE Special Requirements PASS BLUE Other-See Notes PASS BLUE GENERAL COMMENTS: 714: W / City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jul 31,2006 ) Page 4 of ,p Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/03/2006 WHO'S PLACE OF BUSINESS IS: Nicole's Mini Food Store File Number:BHF-2004-0065 406 Essex Street Salem MA 01970 LOCATED AT: 0406 ESSEX STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes RETAIL FOOD BHP-2006-0162 Jan 3,2006 Dec 31,2006 $50.00 TOBACCO VENDOR BHP-2006-0163 Jan 3,2006 Dec 31,2006 $50.00 Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. ❑r accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 5 of 10 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH R s 120 WASHINGTON STREET, 4TH FLOORC igu SALEM, MA 01970 I'y �t II Ip TEL. 978-741-1800 (/ STANLEY J. USOVICZ, JR. FAx 978-745-0343 DEC 0 5 2005 W W W.SALEM.COM MAYOR JOANNE SCOTT, MPH, RS, CHO CITY OF SALEM BOARD OF HEALTH - HEALTH AGENT 2006 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT f\ COLCs Mt'nl' I—GodS&AL# ADDRESS OF ESTABLISHMENT 4 O E if E7 sst-� Sl L M ) M 'A V170 MAILING ADDRESS (if different) ES P�St/- S�QLPTY) �M ' � , 0 k9 7 6 OWNER'SNAME (2k.I [YJC-)C -te/ +cL TEL# ADDRESS 6 — &(W0')rn G D)-'l CITY S STATE ZIP o CERTIFIED FOOD MANAGER'S NAME(S)-nkQ09t3 adf2i CERTIFICAT #(s)_�rkl ^ Z33—�-Z5 i (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON T31AUiP"dr*-04 ' ct - HOME TEL# 233 HOURS OF OPERATION: MooA(Tue.r;Ta(XNed�hu.6 o 11 Fri. [aJJSat. o ( S�un.� O (A-r4) M, 0,M - Ate • � M. TYPE OF ESTABLISHMEN /n more than 0 FEE (check only) CRETA IL-$T_QRE� Y NO � less than I 10 1000-10,000sq.ft.q.ft. ft. =$250 $100 D'r YY"( RESTAUR4NT YES NO less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 - .......................................................-------------------------------------------------- BEDIBREAKFAST YES /� ----------------------------------------------------------------------------- $100 --- ------......--- ADD!T iONAL PERMITS MAKE_(not-just-serve) ICE CREAM, YO URT, SOFT SERVE YES $5 C-TOBACCO-VENDOR — Y NO 9 ALL NON-PROFIT(such as chur�ki ch�� S $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge elief, have filed state tax returns and paid all state taxes required under the law. I t 1 .2q 2-065 ©Lt- -3'tg-- - 1330 Signature Date Social Security or Federal Identification Number ------------------------------------ ----------------------------------------------------------- ----- --------------------- Revised 11/03/05 FOODAP2.adm Check#&Date 2 ( 0 0406 Essex Street Nicole's Mini Food Store City of Salem RETAIL FOOD - Food Establishment Inspection HACCP: ❑ Telephone: Item Status Violation Critical Urgency Nature of problem or correction 740-3103 - Non-compliance with: Not Done Owner: Anti-Choking PASS ❑ Bhupendra M. Patel " = Tobacco PASS ❑ PIC: - - FOOD PROTECTION MANAGEMENT Not Done Bob Patel' Inspector:: .. PIC Assigned/Knowledgeable/Duties PASS RED lDavid Greenbaum Y` = EMPLOYEE HEALTH Not Done Date Inspected' Correct By:'- Reporting of Diseases by Food Employee and PIC PASS ❑ RED `9/19/2005 ' Personnel with Infections Restricted/Excluded PASS Q RED Risk Level: FOOD FROM APPROVED SOURCE Not Done Permit Number* Food and Water from Approved Source PASS ❑Q RED `BHP-2005-0057 Receiving/Condition PASS ❑d RED Status. Tags/Records/Accuracy of Ingredient Statements PASS RED SIGNED OFF Conformance with Approved Procedures/HACCP PASS ❑/ RED ,#,of Critical Violations. Plans ..e PROTECTION FROM CONTAMINATION Not Done - Time IN: ' Time OUT Separation/Segregation/Protection PASSd❑ RED ri Notes: Food Contact Surfaces Cleaning and Sanitizing PASSd❑ RED 304 Owner must notify the, " ° Proper Adequate Handwashing PASSd❑ RED Board of Health within one week that all violations cited Good Hygienic Practices PASS ❑D RED have been Corrected. Prevention of Contamination from Hands PASS ❑/ RED Urgency Description(s):: Handwash Facilities PASS ❑d RED BLUE: a Violations Related to Good " Retail Practices (Critical GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 20,2005 ) Page I o{3 0406 Essex Street Nicole's Mini Food Store violations must be corrected PROTECTION FROM CHEMICALS Not Done immediately or within 10 Approved Food or Color Additives PASS ❑d RED days)(Non-critical violations must be corrected immediately Toxic Chemicals PASS ❑D RED or within 90 days) TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done RED: ' Cooking Temperatures N/A ❑ RED Violations Related to _ Foodbornelllness Interventions Reheating N/A ❑d RED and Risk Factors (Require cooling N/A RED immediate corrective action) Hot and Cold Holding PASS RED Time As a Public Health Control PASS ❑Q RED REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done Food and Food Preparation for HSP N/A RED CONSUMER ADVISORY Not Done Posting of Consumer Advisories N/A ❑J RED Violations Related to Good Retail Practices (Blue Not Done Management and Personnel PASS ❑ BLUE Food and Food Protection FAIL Non-Critical ❑ BLUE There are many price labels covering expiration/sell by dates. Do not cover expiration/sell by dates with price labels. t^p/_'f_Zr'WW 47 items removed from shelves found past 26 / the expiration dates. Owner must closely ` /dl monitor all expiration/sell by dates to insure ffw- no product is expired. NOTE: Repeat violations of this nature will result in monetary citations being issued. Equipment and Utensils FAIL Non-Critical ❑ BLUE The counter Coke cooling unit needs a visible, accurate thermometer. The slush freezer needs a thorough cleaning. Water, Plumbing and Waste PASS ❑ BLUE Physical Facility FAIL Non-Critical ❑ BLUE The wood shelving units in the walkin are unfinished. Wood shelves must be made impervious. Poisonous or Toxic Materials PASS ❑ BLUE Special Requirements PASS ❑ BLUE Other-See Notes PASS ❑ BLUE GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 20,2005 ) Page 2 of 0406 Essex Street Nicole's Mini Food Store GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Sep 20,2005 ) Page 3 of IMPORTANT MESSAGE FOR yy � � DATE 9-�z G�as' TIME OF n �j PHONE 1 `y�- 7-/O - 310-3 AREA CODE NUMBER EXTENSION ❑ FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED PLEASE CALL CAME TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU MESSAGE SIGNED M OC FORM 4009 ��■��TTTT1��iiii.... MARE IN U.S.A. NOTES ` CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR + SALEM, MA 01970 ye4m� TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Nicole's Mini Food Store Address of Establishment: 406 Essex Street Owner's Name: Bhupendra M. Patel Restrictions: Application Date: 11/16/04 Permit for Food Establishment 011-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 005-05 These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT t CITY OF SALEM, MASSACHUSETT h5 �a O BOARD OF HEALTH I� o g' 120 WASHINGTON STREET, 4TH FLOOR yYY SALEM, MA 01970 NOV 16 2004 ^'^" TEL. 978-741-1800 FAX 978-745-0343 CITY OF SALEM STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO BOARD OF HEALTH MAYOR HEALTH AGENT 2005 APPLICATIONFORPERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT ►V/iCOLe 's rv);''ni rood _S' ra,eTE/L�# q7 —31 c9-3 ADDRESS OF ESTABLISHMENT 1 MAILING ADDRESS (if different) ' t 0�, _ESSe A LtYYI1�^ ) OWNER'SNAME TEL � �S, 2-33 ADDRESS �f Ill"YI11`I, 'uEL_— CITY (/ Cl�(le STATE (�- ZIP o CERTIFIED FOOD MANAGER'S NAME(S) d3�\u o em cwqCERTIFICATE#(s)T-233 '—&2Ej (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON Njej HOME TEL#7S( - X33 Fk,m.6'To I I HOURS OF OPERATION: Mon. Tue T°1) Wed.(r°I1Thuj��'j'ull Fri. _of/Sat. X11 Sun.1/1M• T. 0 r-iv). .A (-(%\ . pm. f.M. PM. rm -7 TYPE OF ESTABLISHMENT FEE check only RETAIL STORE E NO less than 1000sq.ft. -$ 5 1000-10,000sq.ft. =$100 7T�(n more than 10,000sq.ft. =$250 RESTAURANT YES NO �\\xV less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BEDIBREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERE YES $5 TOBACCO VENDOR .A 1CV YE NO (0• ALL NON-PROFIT(such as church kitchen (�l// ES 0 $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Cade, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. 04 - S'- 1330 Signature Datel I]IJ Social Security or Federal Identification Number ----------- -- - -- ----------.-- 2cylr--------------------- -------------------------- Revised 11/03)03-F&GD R2� Check#8 Date ray 63 TA - ��,1 ��j -Z CIO CITY OF SALEM, MASSACHUSETTS J BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR g SALEM, MA 01970 .pB TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: RETAIL FOOD Name of Establishment: Nicole's Mini Food Store Address of Establishment: 406 Essex Street Owner's Name: Bhupendra M. Patel Restrictions: Application Date: 11/14/2003 Permit for Food Establishment 23-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 009-04 These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT .eq. • u CITY OF SALEM, MASSACHUSETTREK BOARD OF HEALTH tM -14 I 120 WASHINGTON STREET, 4TH FLOOR Y SALEM, MA O1970 rr NOV 13 2003 TEL. 978-741-1800 FAX 978-745-0343 Cl Y Of: SALEM STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO M �OA+FtD OF HEALTH MAYOR HEALTH AGENT 2004 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT W1 C04e'Sr�M1"rl l Food gtTE�L# 9 7�a- 3 ) (33 c� ADDRESS OF ESTABLISHMENT J/ 400' , ES3� ,S�• , � 11 LE CUl _ � ' A •�, /7� MAILING ADDRESS (if different)s-1- O6 L•S 5� S* S R��M . o1• A <3 119-70 OWNER'S NAME t6hueF� pGteL TEL# :T 23.3 ADDRESS \ M 3)a'1'� CITY '\S- t V STATE ZIP o I CERTIFIED FOOD MANAGER'S NAME(S)_aht1eiand ar{ CERTIFIC T #(s)�Z-3-�- ,�--z5/ (required in an establishment where potentially hazardous food is prepared.) EMERGENCY RESPONSE PERSON 43 kU(P-n 4-3c1 tDa+eL HOME TEL# Z-33 , k25) 6'nmTOIIPM • CAMTo11P•m•� Pte, HOURS OF OPERATION: Mon. Tue Toll Wed.E Tol"L I hu.6TO I) Fri. SatC l- 11 Sun. Ci Tom' � ` V0 Ari Q�•nl,Am•T� �r�Am f'M TYPE OF ESTABLISHM FEE check only RETAIL STORE YE NO less than 1000sq.ft. _$ 50 1000-10,000sq.ft. 0 more than 10,000sq.ft. =$250 RESTAURANT YES �O less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES (NuJ P TOBACCO VENDOR E �IVG $50 0/ _6 ALL NON-PROFIT(such as church kitchens) YES N $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. o it - s Signatur Date S ( � I( IZ�Social Security or edera Identification Number ------------- - ------ - ------------------------------- --------- ------ -- - - - - ---------------------------------- Revised 11/03/03 FO 2.adm Check#&Date (��t 1 9i_ )J J J( 1 ' COURT DOCKET NO. S CITATION NO. CITY O 111 SALEM PD q 1 q 3 VIOLATION NOTICE r NAME(LAST,FIRST,INITIAL) r4sc scss 141111 FraaD STREET ADDRESS CITY/TOWN STATE ZIP y46 &rs€ # sr .?Ljm ev 01910 LICENSE NO. I LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) �A�i-, 611dotta,fif STREETADDRESS CITY/TOWN STATE ZIP 5A us REGISTRATION NO. STATE EXP.DATE MAKERYPE YEAR COLOR DATE OFaVjIO TION TIME DATE CITATION WRITTEN PERS NAL lW r} Y' PM iwunvO NES O LOCATION OF VIOLATION - ENFORCING DEPT. N0 4 X6.05 ST OFFENSE CHAP. SECT. FINES A ftrY49- (lltl CA n 4 NS Gi a B Ayt C O((F^'F'��ICER sem' �p I.D.NO. TOTAL jay Y� DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ffr&HAND )t ❑ BY MAIL DO NOT MAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE. SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT INTHIS ENVELOPE,PEEL AND SEAL COURT DOCKET NO. CITATION NO. CITY SALEM PD 1113 • VIOLATION NOTICED NAME(LAST,FIRST,INITIAL) e)e'2sS L[4MY F"fl STREETADDRESS CITY/TOWN STATE ZIP PSIE4 -5-AA-cm l4w L"916 LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) RAS �wv sr. STREETAADDRESS CITY/TOWN STATE ZIP JA REGISTRATION NO. STATE EXP.OATE MAKETYPE I YEAR COLOR DATE FVIO TION TIME ( DATE CITIObNINIRYW ERSO. L EIYE �IOOPM ❑NO LOCATION OF DILATION EN ORCING DEPT. qo, gss Sv- OFFENSE CHAP. SECT. FINES A v-4e Pl tl N B5 � 5 C OFFICER I.D.NO. TOTAL 4� FINE DUE Is sr� lsr1 r OFFICER CERTIFIES COPY GIVEN TO VIOLATOR X n HAND } ❑ BY MAIL DO NOT AAIL CASH-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL COURT DOCKET NO. CITATION NO. CITY OF SALEM �] j� r0 VIOLATION NOTICE A2910 NAME(LAST,FIRST,INITIALI rn / x tszsr�Start STREETADDRESS CITY/TOWN STATE ZIP 4,010 Es<ey' ST �Solern.Miq O)q LICENSE NO. LIC.EXP.DATE DATE OF BIRTH OWNER'S NAME(LAST,FIRST,INITIAL) STREETADDRESS I CITY/TOWN STATE ZIP llt ex f. d r),M14 d) REGISTRATION NO. STATE EXP.DATE MAKE/TYPE YEAR COLOR DATE OF VIOLATION TIME DATE CITATION WRITTEN RERsorvaL ./ /] /� /� INJURY ��llrv+4/ ❑,PMOO� ,V [ NOS LOCATION OF VIOLATION EN ICING D P . ' 4t�tP Es-SeX ST aW d OFFENSE }}�� CHAR]SECT. FIN ES A -TC lC B C OFFICER I.D.NO. TOTAL FINE 1$ f„ B f DUE OFFICER CERTIFIES COPY GIVEN TO VIOLATOR ❑ IN HAND x rtl��% 6YMAIL DO NOTMAIL CASH'-PAY ONLY BY POSTAL NOTE,MONEY ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL 93 WASHINGTON STREET SALEM,MA 01970 TEL.(508)745-9595 X 251 1 HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF $ CASE# SIGNATURE SEE OTHER SIDE FOR FURTHER INFORMATION ' ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL DOCKET NO. CITATION NO CITY OF SALEMq Ae�A VIOLATION NOTICE GG J 1. NAME LAST FIRST,INITIAL) $( m S ETADDRESS CITY/TOWN STATE ZIP titl1 cr O I I LICENSE NO, LIG EXP DATE DAT OF BIRTH 0 I OWNER'S NAME(LAST,FIRST INITIAL) STREET ADDRESS CITY/TOWN STATE nnZIP . ♦^ I e r 1 REGISTRATION NO. STATE EXP DATE MAKETYPE YEAR COLOR 1 r ! 1 DATE OF VIOLATION TIME DATECITATION WRITTEN PERSONAL /} iwwtr ru T �9✓'[it� a'MCLIYECl NO I Ln : I LOCATION OF VIOLATION r ENFORCING PT. OFFENSE CHAP. SECT. FINES I Ir A Y G � ! B w C DFFIC R r' LD.NO. TOTAL ` FINE 0 �� DUE (n ; OFFICER CERTIFIES COPY GIVEN TO VIOLATOR Q LIT O O ❑ IN HAND c. OCC !r` '� .''' 1L � 1 [ B(MAIL LL N m M DO NO'� AIL1 CASH PAY ONLY BY POSTAL NOTE MONEY O X r r, '� ORDER OR BY CHECK MADE PAYABLE TO: CITY CLERK CITY HALL y, I 93 WASHINGTON STREET W fn P w( fy SALEM,MA 01970 Z J < ,/ � , " > TEL(508)745-9595 X 251 ao V ani•= ,°; — I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON n u REVERSE,CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT W THE AMOUNT OF a fi, s t13 Er CASE CD 0 0 1 SIGNATURE ? SEE OTHER SIDE FOR FURTHER INFORMATION -^- ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL wmw , bbb rt t �,'(GOURT'DOCKET NO. CITATIONNO C!. CITY OF SALEM T h�oD VIOLATION NOTICE FD m I� m�j NAME(LAST,FIRST,INITIAL) f i mm 11 - STREET ADDRESS CITYrTOWN STATE ZIP µOb �ss� sr s L'fol na ot9 0 ) LICENSE NO. LIC.EX D OWN ERS NA T E(LAST,FIRST,INITIAL) - O F—..L Q�1 tfa}7�y1 *t STREETADDRESS CITY/TOWN STATE ZIP Y \V D3 {� z03 SA _ O + O i� REGISTRATION NO. STATE EXP.DATE MAKEtTYPE YEAR CDLOR c (n > r z k Z g 9 mm N m 7,P DATE VI TKiN TIME DATE CiT TIONW RTEN FlEURY "y m �,, , /pj/,��/�j/yam, fj AM OYES �lwj �1 IHIUPY w PM MI >m Z_ Q n` L�O)CATIION OFF VIIOOLLAATIONN ENFORCING DEPT. wo Q •D OFFENSE ' AR. SECT. FlNES O O u's a U/�4v it o NS G LfI ^ � r � Q B5 9419 `.1 R 4'rf f__ Ct >X- .. m g C ti O/F�FICER I.D.NO. TOTAL O ) V� G'TL' 1• �fY�• 1 DUE 03 OFFICER CERTIFIES COPY GIVEN TO VIOLATOR I C•Py p.I ¢j,.f+f, /�,.r�� IN HAND 0 Q �p '-X ❑ RV MAIL r` ' DO NOT WIL CASH-PAY ONLY BY POSTAL NOTE,MONEY O 4i N-' ORDER OR BY CHECK MADE PAYABLE TO: - - �� L!1 4k L CITY CLERK CITY HALL n. 98 WASHINGTON STREET SALEM,MA 91979 i • m III TEL(508)745.9595 X 251 .. I HEREBY ELECT TO EXERCISE THE FIRST OPTION AS STATED ON REVERSE, CONFESS TO THE OFFENSE CHARGED,AND ENCLOSE PAYMENT IN THE AMOUNT OF - tJf $, CASE A` Oh, SIGNATURE o Pp SEE OTHER SIDE FOR FURTHER INFORMATION - a �: _: ENCLOSE PAYMENT IN THIS ENVELOPE,PEEL AND SEAL Co Do 7i I S >l P. t9 I I n^^ 1 Cru, CITY OF SALEM (fC1 L BOARD OF HEALTH 721--7act-027 G&G PEST CONTROL_ (787)M9857 Licensed&Insured GeorgeA. Youn , 133 Summer Sl,Medford,MA 02155 Commeraal&ResldentiV Date: S- Q 3- Ci',^ Homek Busines 7 S"'-7 41, Name'.n _C01 Po r4.. Street: c S �� S� City: S 0 L -i� Stato-VI-to PropertyAescri tion: Services I?erformed: . P Services Performed, not warranted: inspection 0 Wall Void Treatment Gcrawl Space Treatment C1Foggwg d Bander Treahnent 0 CellarTmatmeat 00owde Perimeter Treatment CRtodent Bai ing ed Baseboard Tmannem 0 Floor TreapAnt ❑C �j abinet Trealmr�eot JCr Notes:'".:_.,r/.4 Pldtce OIIU�Cef ✓6V d /ij✓ L7 e!✓Ip s Person my Geo Young Udi 2M95 Trade a me of Method of Major Pesi(s) Percent of Amormt of Pesticide used AM&cation Etiranuded Formulation 'ed Formulation lied .9.rrorrrrtArre: - i Warrmi iramon Castemcr Signaiurr 1t:S? \ ; Tecbaictan Sigaatu�a i Ay. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4'h Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Type of Ooeration(s) T e of inspection e ! a -oZ -4(/ oodService Routine Address I Risk El Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone 4w) �- 3 ❑ Mobile Date://-S-O3 Owner HACCP YIN ❑ Temporary ❑ Pre-operation ❑ Caterer ❑,Suspect Illness Person in Charge( I r�G P �� / Time ElBed& Breakfast j[] General Complaint / In: ❑ HACCP Inspector C5,.49.0 is v VZ Out: Permit No. ❑ Other Each violation checked requires a explanat'ion'on the narrative page(s)and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. � FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties 13. Handwash Facilities EMPLOYEE HEALTH aPROTECTION FROM CHEMICALS " ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ El 3. Personnel with Infections Restricted/Excluded 14. Approved Food or Color Additives ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous F66dis) ❑ 5. Receiving/Condition [116.Cooking Temperatures ❑ 6. Tags/Records/Accuracy,of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION" ' "LL ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP. 71 ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices '. CONSUMER.ADVISORY ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): 3� of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health.Nr 590.000/federal Food Code. This report, when signed below C S 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food ,26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S,5901ne &Fc/m6 UAW s ecto ' gn re: // Print: PIC's Signature: _- N Print: la G'q EIA FO Page of Pages ' I L - Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S1 Cross-contamination 1 590.003(A} 1 Assioiment of Reslxm�ibibty* 3-303.11(A)(1) Raw Animal Foods Separated from 590.003(B) DenxansL r m of KnoMedges" Cooked and RTE Foods" Lit-103.11 Person in char e-done, Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 540.003(C) Responsibility of the person in charge to Contamination from the Environment require neporting by foots employees and 3-302.1 l(A) Food Protection* a licants* 3-302.15 Washimit Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11. Food Contact with Equipment and Applicant To Report'ro The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Re wort n b Verson in Chage* 3-306.14(A)(B) Returned Food and Reservice of Food's 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.121. Manual Warevrashing-Kot Water 3-201.12 Food in it Hermetically Sealed Contaiuer* Sam ttzati on Tem erattues" 3-201.13 ,Fluid Mi I and Milk Products* 4-501.112 Mechanical Warewashino Hot Water 3-202.13 Shell Sanitizaton Tem ete 3-202.14 Eggs and Milk Prod4-501.114 Chemical Sanitization-temp ' pH, concentration and hardness. 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 DrinkingWater from an Approved Svstem* 4-601.11(A) Equipment Food Contact Surfaces and I tensing Clean" 590.006(A) Bottled Drinking Water" 4-602.11 Cleaning Frequency of P.gnipment Foal- 5t)0.006(B) Water Meets Standards in 310 CMR 22.04' Contact Surfaces and Utensils' Shellfish and Fish From an Approved Source -4-70211 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed ! Chemical* sources* Ip Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re Mato Autharit 2-301.11. Clean Condition-Hands and Arms" 3-202.15 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash" 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.11. Eatinsu Drinking or Using Tobacco" 3-2,02.1'1. PHFs'Received at Primer Tcut eratures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated * 3-301.12 Prevendris Contamination When Tasting' fi Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202,18 Shellstock Idendfieation* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained, Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records-Creation and Retention* 5-203.17 Numbers and Ca-pacitSes* 590.004(7) Labeling of Ingredients" 5-204.1.t Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance IHACCP Plans Supplied with Soap and Nand Drying Devices 3-502.11 Sped Processing Methods* 3-502.12 Reduced oxygen aacka rine,criteria* 6-301.11 Handwaqhing Cleanser, Availability 5-103.12 Conformance with A. roved Procedures* 6-301.12 Hand D ins*Provision fDmo es critical ICem in the federal 1999 Food Codeot 105 CMI?590000. CITY OF SALEM ��" BOARD OF HEALTH " Establishment Name: �kd/rS /!/i�y/ is J S ,ep Date: y1.94-,9 ey Pager_ of Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item - - - 'Verified PLEASE PRINT CLEARLY 7 7L -ilO d G' 2 /�t e i U r Ll/ORP.M /f �, f l as aGs PJve , dP o CS u �! / I , ✓ X»i !L Vii%! 1'li r Diseussi n With erson in ChargQ: Corrective Action Required: El No El Yes ` 6/ 1�1 f� `Y ❑ Voluntary Compliance ❑ Employee Restriction/ 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 Exclusion P :3 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 doll s or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. P ❑ Voluntary Disposal L3 Other: 3 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. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hat and Cold Holding 3-501AO(B) Cold PHFs Maintained at or below 3-202.12 Additives* 590.004(F) 41'145° F 3-302.14 Protection from Unapproved Additives"Li-5 Poisonous or Toxic Substances 3-50t.t6(A) clot PHFs Maintained at or above 4017. * 7-101.11 IdeContainers Information-Chiginal 3-50L16(A) Roasts Held at or above I'WR Containers" 7-102.11 Comrrton Name -Working*Containers* 20 Time as a Public Health Control 7-201.1 I Se.aration-Stora e* 3-5171.19 Time as a Public Health Contiol* 7-202,11 Restriction-Presence and Use" 590.004(H) Variance Reipaircructit 7-202.12 Conditions of Use, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-20311 Toxic Containers-Prohibitions* REQUIREMLA NTSFO 7-204.11 Smntizers,Criteria-Chemicals" - 7-204.12 Chernieals for Washine Produce, Ceiteria* 21 3-801_7?(A) Unpasteurized Pre-packaged Juices and EL Beveraees with A6 ening 1-,abets* 7-204.14 Drill Agents,Contac, 3-801,11(B) Use of Pasteuuzed Eggs* Parti7-205.11 Incidental Food Contact, f_ubricants* 7-206. etid 11 Restricted Use Pesticides. Criteria* 3-801,11(D) Raw ored Sp Cooked Animal Food and Raw SS xonts Not Served. * 7-206.12 Rodent Bait Stations' 3-801.1](C) Uno�ened Focx!Pucka=e hot Re-served. " 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3603A I Consumer Advisors Posted for Consumption of 16 Proper Cooking Temperatures for Anhnal Foods Thu are Raw, Undercooked at _ PHFs Not Otho,ru rse Processed to Eliminate 3-401.1 lA(1)(2) Eggs 155`17 15 Sec. Pathogens,* .a�uj„111,VX1 Eggs-immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comtninuted Fish,Meats&Game Eecs° Animals- 155'F 15 sec. 3-407.t 1(13)(()(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratitest Injected Meats-155°F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * catering. mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish, Mear, debited under the appropriate sections Poultry or Ratites-165°P 15 sec. * above if related to foodborne illness 3-401.1 1(C)(3) Wbole-musele, Intact'Beef Steaks interventions and risk factors. Other 145F 4` 590.009 violations relating to good retail 3-401.12 Raw AnimatFoods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401.11(A)(1)(b) All OtherPffF 145'F'15 sec. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165'F 15 see.a` (Items 23-30) 3-403.11(B) Microwave-165'F2 Minute Standing Critical airrl non-critical violafrons, which do not relate to the Time* foodhorne illness interventions and risk factors listed above, can he 3-403.11(,C) Commercially Processed RTE Fwd- ,found in the following sections of the Food Code and 105 CAIR '140'F* 590.000. --- - oo- 3-403.i.I(E) Remaining Unsliced Portions of Beef Item Gaod Retail Practices___ FC 580b000 Roasts` 23. Management and Persamel FC-2 .003 1g Proper Cooling of PHFs 24. Food and Food Protection __--- _FC-3 004 25. E ui meet and Utensils FC 4 I .005 3-5(17_14(A) Cooling Cooked PHhs frau 140'17 to - y-..-- 26 Water Plumbin and Waste FC 5 , .006 70'17 Within 2 Hours and From 70'F 27 Physical Facility FC 6 1 .007 _ to 41'F/45'F Within 4 Hours. 28. Poisonous or Toxic Materials FC-7 1 .008 3501.14(B) Cooling PHFs Made zrom Ambient 29 Spacial Requirements _ _ ,009 Temperature Ingredients to 410F/45'17 30._ Other Within 4 Hours* or 11a"all *Denotes on ical item m the,tevteral 1999 Food Code or 105 CMR 590.000. ' CITY OF SALEM, MASSACHUSETTS Ca�T BOARD OF HEALTH �m 120 WASHINGTON STREET, 4TH FLOOR SALEM. MA 01970 sq TEC. 97B-741-1800 BC FAx 978-745-0343 STANLEY USOVICZ, JR. JOANNE SCOTT, MPH. RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to : Owner ' s Name : Bhupendra M. Patel Name of Establishment : Nicole ' s Mini Food Store Address of Establishment : 406 Essex Street Type of Establishment : RETAIL FOOD Application Date : 12/04/2002 Restrictions : Permit for Food Establishment 3-03 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products 1-03 These Permits Expire December 31, 2003 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 3 120 WASHINGTON STREET, 4TH FLOOR r}[(� 2002 SALEM, MA 01 970 LICIT TEL. 978-741-1 800 FAx OTT, MPH, RS BOARD OF HEALTH Y OF SALEM STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2403 APPLICATIONFORPERMIT TO OPERATE A FOOD ESTABLISHMENT MIC NAME OF ESTABLISHMENT t i Ot t y) t fi TEL# ADDRESS OF ESTABLISHMENT SS e:� C f-oQp� MAILING ADDRESS (if different) ,, � a 6 S-� 2y Sf Ski M ^1q • O 119 70/ OWNER'S NAME r117YlVY?ery) oie(vL TEL#—.��- �'�J�J ADDRESS b C;�-1 c4 me 1Sr 3'a"7 I-Q CITY CU t C fitr Q STATE _ ZIP !g 0 CERTIFIED FOOD MANAGER'S NAME(S)-P-16 :ERTIFICA #(s) _Sd_ 233 -(�2_5 f (required in an establishment where potentially hazardous food is prepared.) , / EMERGENCY RESPONSE PERSON6r1Lly} �.3nj �c +eL HOME TEL# '?�I 2-x.3 tS`ZJ� f HOURS OF OPERATION: Mon T¢ Tue L+Wed.61-i IThu. �I t—Fri.—Sat.IG" I(Sun. 6 r� It 7 9� TYPE OF ESTABLISHMENI FEE check only RETAIL STORE YE NO Tess than 1000sq.ft. _$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES Nb less than 25 seats =$100 25-99 seats =$150 more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE ICE CREAM, YOGURT, SOFT SERVE Y $5 TOBACCO VENDOR NO i�Q ALL NON-PROFIT(such as church kitchens) YES (9 25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law. O O Signature Date 1213 )o2-Social Security or Federal Identification Number Revised 11/25/02 1F00DAP2.adm Chedc#&Date ) 2 ) '23 `''�"� �� 1637 oere, , ~- r ,'C:".. ' �... rT^/hd` 'YY('^s' ./tir � � '„e�,e'rWY'wMMMW-�1'�,nw.vtiMF".y"'v""'�'� -- e�ykQy�ry..�.. S.'M1"W'..Sh+.' N:r.✓v4'�gy THE COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM Address: 120 Washington Street, 4th Floor w BOARD OF HEALT}i Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343 Name Date Type of Operation(s) r / Ins oectio n JJCL' I ❑�d Service D�iRotine AddresRisk 2Retail El Re-inspection 4C)e � : % Level ❑ Residential Kitchen Previous Inspection Telephone 1 -7yo' �'Orz. El Mobile Date: Owner '�// HACCP Y/N [I Temporary ElPre-operation �. ✓"��.� p'+f Lam- ❑ Caterer ❑ Suspect Illness Person In ChargetPIC) Time ❑ Bed 8 Breakfast ❑ General Complaint m In: ❑ HACCP Inspectoro Out: Permit No. ElOther Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. Local Law ❑ FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/ Knowledgeable/ Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH El2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS El3. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) El 16. Cooking Temperatures El 5. Receiving/Condition El6. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating El7. Conformance with Approved Procedures/HACCP Plans El 18. Cooling El 19. Hot and Cold Holding PROTECTION FROM CONTAMINATION ❑ 20. Time as a Public Health Control ❑ 8. Separation/Segregation kProtection REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) ❑ 9. Food Contact Surfaces.Cleaning and Sanitizing I T ..4'#" . ❑ 21. Food and Food Preparation for HSP rid ❑ 10. Proper Adequate Hawashing • rd ,1F"- I CONSUMER ADVISORY ❑ 11. Good Hygienic Practices �` ❑ 22. Posting of Consumer Advisories Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/Federal Food Code.This report, when signed below c N by a Board of Health member or its agent constitutes an o 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation.of.food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing F, 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's S�nofd Print: PIC's Signature: . Print: Page / of4e Pages FORM 734A HOBBS&WARREN -BOSTON ,y Violations Related to Foodborne Illness Interventions and Risk FactorsRed Items 1-22 ( ) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302:H(A)(1) Raw Animal Foods Separated from 1' 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw Ingredients 2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment r . 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) Food Protection* require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables Applicants* 3.304.11 Food Contac[with Equipment and 590.003(F) Responsibility of a Food Employee or an Utensils* Applicant to Report to the Person in Contamination from the Consumer Charge* 3-306.14(A)(B) Rammed Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Restrictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE g Food Contact Surfaces Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water 590.004(A-B) Compliance with Food Law* Sanitization Temperatures* 3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water 3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures* 3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H, 3-202.14 Eggs and Milk Products,Pasteurized* P'P gg Concentration and Hardness 3-202.16 Ice Made from Potable Drinking Water* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization- Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 2-301.12 Cleaning Procedure* 3.202.18 Shellstock Identification Present* 2-301.14 When to Wash* 590.004(C) Wild Mushrooms* 7-11 Good Hygienic Practices 3-201.17 Game Animals* 2-401.11 Eating, Drinking or Using Tobacco* 5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and 3-202.11 PHFs Received at Proper Temperatures* Mouth* 3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting* 3-101.11 Food Safe and Unadulterated* Prevention of Contamination from Hands 6! Tags/Records:Shellstock 590.004(E) Preventing Contamination from 3-202.18 Shellstock Identification* Employees* 3-203.12 Shellstock Identification Maintained* `13 Handwash Facilities Tags/Records:Fish Products Conveniently Located and Accessible 3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities* 3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement* 590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance 7" Conformance with Approved Procedures Supplied with Soap and Hand Drying /HACCP Plans Devices 3-502.11 Specialized Processing Methods* 6-301.11 Handwashing Cleanser,Availability 3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH _ Establishment Name: M Cc(.iS Mild #"fit ST c8-S Date: c3 Page: of y Item Code c-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified PLEASE PRINT CLEARLY 4[ LM j M ifA C O ® r -- to /r CT!;, -0,j CLQ. L,3 F4110iNt Y/d in A t WIl�tdl� Pt(UJr C AltOU; dfJ,UE YA-1,ai t/ I-F 5- C4- Z i F 4 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 p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that f noncompliance may result in daily fines of twenty4fiv'e'dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. (/ r ❑ Voluntary Disposal ❑ Other: 3-501.14(0) PHFS Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to Lnw Cooled to Factors(items 1-22) (Cont.) ,,. 41'F/45°1`Within 4 Hours. '* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PRFs - ------------ --- 19 PHF Hot and Cold Holding 1q Food or Color Additives 5 3-202.12 Additives" Cal/PHEs Maintained at or below 590.004(F)0.004(Fs 41`!45°F* 3-302.14 Protection from C1nat tnvad Additives" 15 Poisonous or Toxic Substances 3-501,16(A) Hot PRFs MainYairted at or above 140°F - 7-101.11 Identifying Information-Original 3-501.16(A) Roasts I'leld at or above 130°F. Containers" 20 Time as a Public Health Control 7-102.11. Common Name-Working Containers* 3-5(}1.1.9 Time Its a Public Health Control* 7-201.11 Se.oration-Slot(gee' 7-202.11 Restriction-Presence and Use" )90,004(I-1) VarianceRecuhEment 7.202.12 Conditions of Use* 7-203.11 'Toxic Containers-Prohibitions REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.1 t Sanitizers.Criteria-Chemicals* POPULATIONS(HSPS_ 7-204,12 Chemicals far Washing Produce,Criteria"` 2'1 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Eaibels* 72{)5.1.1 Incidental Food Contact,Lubricants* 3-801.11 B) Use of Pasteurizer(Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1.1(D) Raw or Partially Ceased Animal Food and Raw Seed Sprouts Not Served. 7-206 12 Rodent Baitdere, PStations" 3-801.1.1(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY TIM EITEMPER_ATURECONTROLS 22 3-603.11 Consumer,Advisory Posted for Consumption of Animal Foods Mature Raw- Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eves- 155°F 15 Sec. Pathogens.* ft-s-Immediate Service, 145"F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A Eggs* )(�) Comminuted Fish.Moats&Game Animals-155°F 15 sec. * 3-401.11(B)(1)(2) Pork andBeef Roast- 1.30`F121art n* SPECIAL REQUIREMENTS 3401.11(A)(2) Ratites,Injected Meats- 1.55 F 15 590.009(A)-(D) Violations of Secdcnt 590.009(A)-(D) in sec catering,mobile food, temporary and -, 401.11(A)(3) Poultry,Will U tme.Stuffed PHF,, residential kitchen operations should be stumng cont hong Fish,Meat, .r..o..1., .:ndei the _:.i nI-rut„,,,,., ,,,,, Poultry or Ratires-165°F 1.5 sec. * above if related to foodborne iIlness 3-401.1 BC)(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) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHFs 165°F 15 sea. °` (Items 23-30) 3-403.11(B) Microwave-165°F 2 Minute Standing Critical and non-critical violations, which Ito not relate to the Tune* foodborne illness interventions and risk facmrs tested above, can be 3-403.1 l(C) Commercially Processed RTE Food- found in the folloning sections of the Food Code and 105 CMR 140°F* 590.000. _ 3-403,11(E) Remaining Unsliced Portions of Beef IL Item I Good Retail Practices FC 590.000 Roasts* 23___j Management and Personnel ` FC-2 .003 24 Food and Food Protection FC-3 004 1g Proper Coding of PHFs - ------ a 25 Equipment antl_Utensis _ �_FC 4 005 3-501.14(A) C�croling Cooked PHFs from 140°F to 26 Water Plumbinq and Waste _ FC-5 006 7WF Within 2 Hours and From 70'F 27. Physical Facility IFC-8 .007 _-----111 to 41.°FJ45'F Within 4 Hours. * 28. -- Poisonous or Toxic Materials i FC-7 .008 3-501.14(B) TWo'pc�iPbtacture Or Fro'rtsttoAmbient 1 29, S FJ4S°F 30----- Other _-mems = Within 4 Hours* *Denotes critical iters in the tWeral 1999 Fred Code or 105 CD4R 590.000. HEATH DEPARTMENT NOTIFICATION FORM IF YOUR APPLICATION INCLUDES THE SERVING OF FOOD YOU MUST HAVE THIS FORM SIGNED BY THE HEALTH DEPARTMENT PRIOR TO SUBMITTING YOUR APPLICATION TO THE LICENSING BOARD. (this form MUST be signed and returned with your application). NAME OF BUSINESS V�,� r �T Ca ,r7 Corporate name: `� LOCATION: 406 LSJ e� St-1 S ALP-m, M d g 7 0 TELE.# q7 e _ 7L(-p --3103 4 TYPE OF LICENSE W (N e S M ce + &C j�—q C t -Si* �,( CeWS C APPLICANTS INFORMATION j3Ff U OOPQV.�42 f q f#"-r4EL Name: / Home address: GCt U x'191 G City: S11 V GeV_S State: 01 A Zip: d 1 06' Home Tele.# 7 HEALTH AGENT/INSPECTOR'S COMMENTS: DATE S `Z Health e health dept.norif.Form 2/09 BOARD OF HEALTH SALEK MA 011170