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' _ a .. ,R _ a. s. �✓ ........ .�..r. .� i..rr ..�n.r ,.n. .�. r.er.- -.wi< rr..e..a... ^%a�!tw-�..'x� �.r �..n. -.--.Cir=1GW���-�.'�A�'�"' a+P' .ate , r ���w .. � �1. i r f i u t � M i Ii c - - • - - � _ i ., i ., - � ,, r '. .. �. t � / .. � x,, � s 1 .. i. . _ � b �. �t,.. .. � '_rS N1Z!aJ hit �t►ZZ 1 d So �Sn�l '�1.�71� r .• ff *�w ^s a= aa k a �*'_Gil '.' 5 -�y" t57" 4,' .m� „°"a : �jCommonwealth of Massachusetta a k n z • " " `�' 1C t Of Ix- 119.1 Wsslungton StrikAth'-Floor rv 'y'a� � v -+. „r sT$ x s s e ' a Food%Retall Establishment PermltEA 1�1 DATE ENTER , ' s01/06%2014 � S Oro 'a as a ,S S '�` ' L - Lx -m_r3s+s Rsy� Vo i . -;' ' ESTABLISHMENT NAME: t� �` '�'k- -SN orth House of•P>aa s '� �' r a a $ •F a ` , '»sitz;„sc`�' � �;i i "� a ` � si`# .'Y$5rt`Y$ra n.ii� ai%'Y �s. q✓��. .� - 'File Numtier BHF 2 14 OSet008-000008 lif r $ ew axe as Xfi � SALEM - MA 01970 W., 4'a} w u 'LOCATED'AT ;� g ��"& sx,'" y� SALEM 1V1A �01970� �� �t v = �t3` ti Permit Type Permit No Pernut IssuedPermtt Eap�res Fee Restnchons/Notes 4 ;aCl 5 � Janl 2014x Dec 31 2014x $14000 H w 0'` `t` FOOD SERVICE BHP zma o3i7 5 ESTABLISHMENT z �r >iv^ a ” a x Total Fees s x$140 00rr y � .r: §-.,.: l M' M-0- - j! s a c# } Al s farx a x r 31 Y v�"^i' s"'�e#3^L€5 ,3%,t eet"5 ,s^'°• f .-'r. ` t f°mf,a '! t „- 4 C PERMIT EXPIRES: ecetuber 31, 2014 ` ` ' 41; r x w Board of Health '"3 AS° ryS�1 ' {: a � f #,y,f -All'' "va.:.` & x r, Al $ a This Permit is not transferable and moat be reissued up6n change of owneralup or locedon The permit must be posted in a prominent locahosin the Establishment 33 R" L , _, 4-In accordance with the State Samfary Code,beofre any revonahone,unprovements,or egmpment changes are made, -� �. I.Mplans for such must be submitted to and approved by the Salem Board of Health a y p s L "• .p.. to s =vr '�¢ S a : 0 CITY OF SALEM, MASSACHUSETTS tet, BOARD OF HEALTH ftp k.o-ma..1 .-1. 120 WASt INGI'DN S'nu:v'r,4m FLOOR KIMBERLEY DRISCOLL TEL.(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/REHS,CHO,CP-FS MAYOR jmmdin@salenLcom HEALTH AGENT Food Establishment Permit Application (Application.must be submitted at least 30 days before the planned opening date) 1) Establishment Name: v a � vok V�re�& 2) Establishment Address: 2 VA Q 3) Establishment Mailing Address(if different): rr 1� "��� 4) Establishment Telephone No: q4 g — �R V `00 5) Applicant Name&Title: e 2 ( 6) Applicant Address: ` � S�\eV� � C) V 7) Applicant Telephone No: b- 6 24 Hour Emergency No: Email-&A a (( t ri 6) Owner Name&Title(if different from applicant): c 0 p C-0 V zC(_ C) 9) Owner Address(if different from applicant): C�V 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An association Name Title Home Address A corporation cc An individual A partnership Other legal entity 12 Person Directly Res onsible For Daily Operations Owner,Person in Char e,Su ervisor,Manager,etc. Name&Title: e Address: l2 VV-\ Telephone No: Fax: Email: Emergency Telephone No: 13) District or Regional Supervisor(if applicable) Name&Title: Address: Telephone No: Fax: Email: Check#:- Date: �� Amount: 1 Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: - 17) No. of Food Employees: 18) Name of Person in Charge Certified in Food Protection Management: Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(If 25 seats or more): ❑ Yes CN 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( Sq. Ft) ❑Caterer Permanent Structure ,d Food Service-( �_O Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑Food Delivery ❑Residential Kitchen for Bed and 21) Length Of Permit: ............................................... Establishments ............................... (check one) R AIL STORE TAURANT Ann ess than 1g00sq.ft. $70 ess than 25 seats $140 Seasonal/Dates: ❑ 000-10,006sq.ft. $280 ❑Residential Kitchens $140 ❑More than 10,000sq.ft. $420 ❑25.99 seats $280 ❑More than 99 seats $420 Temporary/DatesMme: _--- H---om-----e-----------------------------------------------$_1_0__0------- ❑Bed&BreakfastlChildcare Services/Nursing -----`----------------------------•---•----..-..-..--.....--..-•--------------------------•-•---...-.-.......-.-..-•--------------------- ADDITIONAL PERMITS ❑MAKE ICE CREAM,YOGURTISOFT SERVE $25 ❑PASTURIZATION $25 ❑ALL NON-PROFT" $25 *Including, church kitchens, state funded childcare&private club 23) Food Operations: Definitions: PHF-potentially hazardous rood(fimdtemperature controls required) apply): Non-PHFs-non-potentially hazardous food(no flmattempendure controls required) (Check all that pp y): RTE-ready-to-eat foods Fir-sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application 1,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. 1 have been Instructed by the Board of Health on how to obtain copies of 105 CMR 590.000 and the Federal Food Code. 24) Signature of Applicant: (1 � kE✓V��— Pursuant to MGL Ch.62C, sec.49A,I certify under the penalties of perjury that 1,to my best knowledge and belief, Have filed all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: f)� !�Z'-aG -G 8 c 26) Signature of Individual or Corporate Name: S 16 In C _ ( In� Q Nos �lS� 'ice \N v Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,40'Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax(978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name Date Type ofOperation(s) Type of inspection �2 /O ! IR Food Service ❑ Routine Address �r Risk LJ Retail einspection Telephone Level ❑ Residential Kitchen Previous ns ction ❑ Mobile Date: � Owner 1 HACCP YIN ❑ Temporary Pre- p al on ✓ c Aad. �r ❑ Caterer ElSuspect Illness Person-in-Ch a(PIC) Time ❑ Bed&Breakfast ❑General Complaint LlHACCP Inspector Ou _y� Permit No. ❑.Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors-(Red Items) Anti-Choking 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) El❑, corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) FOOD.PROTECTION MANAGEMENT: - _ _ _ _ _ _ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties F _. ❑13. Handwash Facilities 'EMPLOYEEHEALTH PROTECTIONFROM`CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC "- ❑ 14.Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded ,- - ,__ - _ _ -_ - _ _- ., ❑ 15.Toxic Chemicals ,.FOO.Food APPROVEDfrom Approved _ _ . �_ __.. _._ -+ +TIMEREMPERATURE.CONTROL'S.(Potentlalty Hazardous F.00ds)- ❑ 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 [118. Cooling PROTECTION FROM CONTAMINATION _ _ ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection W ❑20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ,REQUIREMENTS FOR;HIGHLY4USCEPTIBLE-POPULATIONS'lHSP).`, C]21. Food and Food Preparation for NSP El 10. Proper Adequate Handwashing __ El 11.11. Good Hygienic Practices vi - ❑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): v of Health. Noncritical (N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-3X990.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4X590.005) the food establishment permit and,cessation of food 26. Water, Plumbing and Waste (FC-5X590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) 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: �R °t b-adoc Inspector's Signature: Print: PICS Signature: Print: V Ck,n �. Page__�f_?_pages Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Crass-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(B) DemAssonstration of Responsibility*Knowledge* Cooked and RTE Foods* 590 3.11 ) Demonstration of Knowled e" Contamination from Raw Ingredients 2-103.11 Person in charge--duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Otho* Contamination from the Environment 2 590.003(0) Responsibility of the person in charge to 3-302.11(.0) Food Protection* require reporting by food employees.mit 3-302.15 Washing Fruits and Vegetables applicants* - 3-3{)4.11 Food Contact with Equipment and 590.003(F) Responsibility Of AFood Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-306.14(A)(B Returned Food and Res, ice of Food* 590.003 G Reporting b Person in Charge* 31 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 59O(03(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE F0W* 4 Food and Water From.Regulated Sources 9 Food Contact Surfaces - - 590.004(A-B) _Com 1R iance with Food Law* - 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Te ratures* 3201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.73 Shell Eggs* - Sanitization Tem ratures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 320116 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.7.1 Drinking Water from an A roved S .tear* 4-601.11(A) Equipment Food Contact Surfaces and- 590.006(A) Bottled Drinking Water" Utensils Clean* 590.006(B) Nater Meets Standards in 310 CMR 22.01 4-602.11 Cleaning Frequency of Equipment Food Shel ish and Fist From an Approved Seume Contact Surfaces and Utensils" r 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught �vlolluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201-15 Ntollusean Shellfish from NSSF lasted _ Chemical* Sources* 10 Proper,Adequate Handwashing Game and uthorushroomsApprovedby Regulatory Authority 2-301,.11 Clean Condition-Hands and Arms* _ 3-202.18 Shellstock identification Present* 2-301_12 Cleaning Procedure* 590.004 C) Wild Mush ooms* 2-301.14 When to Wash* 3-201.17 1 Game Animals* Il - I Good Hygienic Practices 3 Receiving/Condition 2-401.17 Eating,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Tem ratures* 2-401.12 Discharges.From the Eyes,Nose and 3-202.1.5 Package integrity* Mouth* 3-101.11 _ Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Togs/Records:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em plo ees* Tags/Records:Fish Products 13 Handwash Facilities 3-40^^<.1f ParasiteDestructiora* '-- Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 .Reduced oxygen packagin&criteria* --6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-30.1.12 HandI)r ' :Provision Denotes critical item in the Weral 1999 Foci Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name:' Date: eO ty 1.7 Page: -- � � Item Code C-Crmcal Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date' No. Reference R-Red Item Verified PLEASE PRINX CLEARLY lJo 1t U -7br i Discussion With Person in Charge: Corrective Action Required: ❑ No t4c yes I have read this report, have had the opportunity to ask questions and agree to correct allvolunta Com lla ❑ Employee Restriction/ inspection, to observe all conditions as described, and to , Exclusion violations before the next ins p Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or pension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �� ❑ voluntary Disposal ❑ Other: I _ - 3-501.14(C) PRFs Received at Temperatures Violations Related to Foodborne Illness interventions and Risk According to Caw Cooled to Factors(items 1-22) (Cont.) 41'F/45`F Within 4 Hours. PROTEC_TIOPB FROM CHEMICALS 3-501,.15 Collin Methods for PRFs 3,202.32 ^• Additives'• 14 � Food or Color Additives 19 CHF Hot and Cold Holding -- --•--•• 3-501.16(B) Cold PIIFs iM3ainuined at a below Hot 590.044(() °F* P 3-302.14 Protection from Un roved Additives* 15 Poisonous or Toxic Substances 3-541.16(A) HHot PHFs Maintained at or above 140°17• 7-101.11 Identifying Information-Original 3-503.16(A) Roasts Held at or above 130°F, Containers* 7-10211. Common Name-Working Containers* 20 Time as a Public Health Control 7?O1.11 Separation-Storage* 3-501:19 Time as a Public Health Contrail* 7-202.11 Restriction-Presence and Use* - 590.404 H) Variance Requirement 7-242.12 Conditions of Use* 7-203.11 Toxic Containers-prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals* POPULAT10N3 HSP 7-204.12 Chemicals for Washin Produce,Criteria* 2fl 3-801.1](A) Unpasteurized Pte-packaged iuices and 7-204.14 Drying Agents.Criteria* Beverages with Warning Labels* Use of Pastemizecl Ea * 7-245.11 Incidental Food Contact.Lubricants* 3-801.11(6 - 3-801.11(D) Raw or Partially Cooked Antutal Food and 7-206.11 Restricted Use Pesticides,Criteria" Raw Seed Sprouts Not Served- ,-206-12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Momtorin x CONSUMER ADVISORY TIMEtd EMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted fur Consumption of 16 Per Cooking Temperatures for Animal Foods That are Raw,Undercooked or PropHFs - - - Not Otherwise Processed to Eliminate Patho ena.* E Immediate Servicc 145°FI_Sse.: 3 401.11A(L)f2} Eggs- mSec. * 3-302.13 Pasteurized Eggs Substitute for Raw Shell > - - medat 3-401.11(A)(2) - Comminuted Fish.Meats&Game Eggs* Anim:il3-155'F 15 sec. + SPECIAL REQUIREMENTS 3-401.31(A)(2) 3-401.31(B)( Ratites,Injected Meats-155`17 15 Pada and Beef Rest- I30°F 121 min* 590 4ag(A)-(D) Violations of Section 59p.W9(A)-(D)in sec.* cratering, mobile food,temporary and 341.11(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 Fouxls Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-40LI I(A)(3)(b) All Other PRFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACT7CES 3403A 1(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 Time* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sectionsofthe Food Code and 145 CMR 1400F* 590.000. 3403.1l(E) Remaining Unsiiced Portions of Beef item [ Good Retail Practices I FC 590,00o Roasts* j 23. 1 Management and Personnel FC-2 .003 1g Proper Cooling of PHFs `24. i Food and Food Protection I FC-3 .004 . 1 225_, _, �Equipment and Utensils i FC-4 .005 1 3-501.14(A) Coating Cooked PHFs from 140`F to 26, 1 Water.Plumbino and Waste ' FC-5 006 70`F Within 2 Hours and From 70°F 27. Physical Facility i FC-6 ' to 41`F/45'F Within 4 Hours. ' 1 28. Poisonous or Toxic Materials i FC-7 ,008 3-501.14(B) Cooling PRFs Made From Ambient 29. S sial R uirements .009 Temperature Ingredients to 41'17!45'1 X30' Other -_f-- WithinA Hous* SSgCfomi�vlGZcc 'Denotes rxitieal item in the federal 1999 Fwd Calc a'105 C.MR X90.000. i Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4h Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 City/Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name DateType of Operation(s) Type of Inspection ZZ Food Service ❑Routine Address ( RisW ❑ Retail (fie-inspection TelephoneLevel ❑ Residential Kitchen Previous inspection C( ❑ Mobile Date: c� �� Owner v HACCP YIN El Temporary ❑ Pre-o ergtior? ry ❑ Caterer ❑Suspect Illness Person-in Ch a(PIC) ITime, El Bed&Breakfast El General Complaint El Inspector In.1 Permit No. Other Out the Each violation checks 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 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑. q Allergen Awareness 590.009(G) ❑ corrective action as determined by the Board of Health. r.FOOD:PROTECTION MANAGEMENT' _i- r ❑12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities .'EMPLOYEEHEALTH '-- ..- "' `PROTECTIONcfROM'CHEMIdALs' ❑ 2. Reporting of Diseases by Food Employee and PIC - ❑ 14.Approved Food or Calor Additives ❑ 3. Personnel with Infections Restricted/Excluded _�_ ____. .-. ❑ 15. Toxic Chemicals ,171 4. FROM andAPPROVEDfrom Approved _ JIMErTEMPERATURE'CONTROLS(P.otentially ka¢erdousFoods) � ❑ 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 PROTECTION FROM CONTAMINATION_ __. _ R19. Hot an .oI Holding ❑ 8.Separation/Segregation/Protection K20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing rREQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPULATIONSi(HSP):.,; E]21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices ;,CONSUMER AOVI50RY_ - ❑22. Posting of Consumer Advisories v ry 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. Noncritical(N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590.0 order of the Board of Health. Failure to correct violations 4. Food and Food Protection (Fc-aXs90.o04)) cited in this report may result in suspension or revocation of Equipment and Utensils (FC-4X590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FC-SX590.006) establishment operations. If aggrieved by this order,you 7. Physical Facility (FC-6X590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7X590.008) 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 DATEOFRE-INSPECTION: Oct (ciao 15 (¢ Pri Inspector's Signature: _ nt: V J� PICS Signature: Print: �� Page4o Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination 1 590.003(1) Assig ment of Res onsibiH[ * 3-302.1](A)(]) Raw Animal Foods Separated from Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge Contamination from Raw ingredients 2-103.1 1. Person in charge-duties 3-302.1.1(.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) Food Protection* - require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants* 304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A FEmployee Or<1n Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting b Person in Charse* 3 590.003(D) ExclusionsandRestrictions* Disposition ofAduReratedorContaminated Food 590.003(E) Removal of Exclusions and Restrictions 3-701.,i/ Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(.1-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 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 Temperatures* 3-202.1,4 Eggs and Milk Products.Pasteurized" 4-501.114 Chemical.Sanitization-temp.,pH; 3-202.1.6 Ice Made From Potable Drinking Water* concentration and hardness. 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standurds in 310 CMR 22.0* 4"602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and 3-201.1.1 Fish and Recreationally Caught[vfollu-can Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-'Hot Water and 3-201.1; Molluscan Shellfish from NSSP listul Chemical* Sources* 10 Proper,Adequate Handwashing Re u/atoAut Game and uthorlrity ooms Approved by 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellsteck Identification iresentk 2-301.)E �_Cleanm Procedure* 590.004(C) Wild Mushrooms* 2-301.14 1 When to Wash* 3-20).0 Game Animals* - 11 - Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eating,Drmkmg or Using Tobacco* 3-202.7.1 PHFs Received at Proper Tem ratures* 2-401.12_ Discharges:From the Eyes,Nose and li 3-202.15 Package Integrity* Mouth* 3-I'GL1l Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands _ 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 ShellstockIdentification Maintained"'' p Em lo es* - TagstRecords:Fish Products 13 I Handwash Facilities 3402.11 Parasite Destruction* -- Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Ca acities* 590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement* � Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Suppled with Soap and Nand Drying 3-502.17. Speciali7.edPraleessin Methods* Devices- 3-502:12 Reduced oxygen p packaging criteria-* 6-301.11 Handwashing lability 8-103.t2 Conformance with Approved Procedures* 6-301.1.2 Hand Drying Provision *Denotea euncid near in the Ii�leral 1999 rood Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: t Page:_ of Rem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dete7. No. Reference R-Red Item - - PLEASE PRINT CLEARLY Verified t7- C C k 2Aj,c !W l _ l , N -3 ,( Mir A111PA15iA4O)I k � / l I t an / 7KF 15 N of ,,Ar �e 111,401A ( V-eJ-=41:2Vel" -Um —Ur � r ,, Discussion With Person in Charge: Corrective Action Required: ❑ No s I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p )4/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 twepty-five dollars or spension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. (�ZJ 0 Voluntary Disposal ❑ other: 3-i01,t4(C) PHFs Received at Temperatures Vfofstfons Related to Faadborne Illness Interventions and Risk According to Law Cooled to Factors(ftems 1-22) (Cant.) 41'F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 Coohne Methods for PHFs jg Food or Color Additives i9 PHF Not and Cold Holding 3-501.16(B) Cold P13Fs Maintained at or below 3202.12 Additives* 590.004(F) 41°145°F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PIFs Maintained at or above i 15 Poisonous or Toxic Substances o * 7-101,11 Identifying Information-Original 140 F. 3-501.16(A) Roasts Held of or above 130'F. Containers" 7-102.11. Common Name-Working Comamem* 20 Tune as a Public Health Control 7-201.11 Separation-St 3-501.19 Time as a Public Health Control* r 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance R uirement i 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REOUdflEMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizes.Criteria-Chemicals* POPIDLATIDNS HSP 7-204.t2 Chemicals for WashingProduce,Criteria*'- .21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.14 n eats.Criteria" .Bevera es with Warning Labels* 3-801.1 I(B) Use of Pasteurized Eggs* 7-245.11 Incidental Food Contact Lubricants* ' 3-801.11(D) Raw or,Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* e' i" 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 ` - Monittxin * - � CONSUMER ADVISORY TiMEt6 EMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of P6 - Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or PHFs - - Not Otherwise-Processed to Eliminate *FWBeDVB t/Y.'2QCt 3-401.11A(1)(2) Eggs- d55°F 15 Sec. Pathogens. f Eos-immediate Servicc 145'Fl5sec* 3-302.13 Pasteuri�d Eggs Substitute for Raw Shell ? 3-401.11(A)(2) Comminuted Fish.Meats&Game E i Animals-155'F 15 sec. j NTS 3.401.11(B)(1)(2) Pork and Beef Roast-130'F t21 min* SPECIAL REQUo t 3-401.I1(A)(2) Ratites,Injected Meats-155°F 15 590.004(A)-{D) Violationss of f Section .590.009(A) (D)in ( sec. * catering,,mobile food,temporary and 3 40i.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be i Stuffing Containing Fish,Meat, debited under the appropriate Sections Poultry or Barites-]65'F 15 sec. * above if related to foodborne illness 4 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F 4' 590.009 violations relating to good retail j 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Y Microwave 165"17* Special Requirements. r 3-401AI(A)(1)(b) All Other PHFs- 145'F 15 sec.' i7 Reheating for Not Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES t 3-403AI(A)&(D) PHFs 165-F 15 sec. * (Items 23-34) # 3-403.11(B) Microwave 165'P 2 Minute Standing Critical.and non-critical violations,which do not relate to the Time* foodbonse illness interventions and risk factors listed above, can be i 3403.i 1(C) -Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 140017* 590.000. } 3403.11(E) Remaining UnsiicedPortions ofBeef ! Item j Good Retail Practices FC 590.LVO Roasts* 23. Man amen and Pnmonnel i FG-2 .Qq3 gg Proper Coating of PHFs 24. Food and Food Protection FCL-3 .004 125. i Equipment and Utensils ! FC-4 =5 - 4 3-501.14(A) Cooling Cooked PHFs from 140`F to i 26, Water,Ptombina and Waste i FC-5 .006 700F Within 2 Hours and From 70'17 27, I Physical Facility FC-6 007 to 4I`F/45'F Within 4 Hours. * 1 28. ' Poisonous or Toxic Materials 1 FC-7 .Goa j 3 3-501.14(.6) Cooling PHFs Made From Ambient 1 29. S ectal Requirements .009 1 7l7 Temperature Ingredients to 41'F/45'F 30 I Other _ I .ti Within 4 Hours* Lt *DenMea critical tura in the£-dent 1999 Food Cale w 105 CMR 590.000. - 'S f r Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978) 741-1800 Fax (978) 745-0343 Cit /Town of Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Name �� Dat Type of Operadon(s) Type of inspection l Food Service Routine -AddressS Risk LI Retail )Re-inspection Telep-i34hone Level El Residential Kitchen Previous Jnspeglion C1 ❑ Mobile Date: VC?%jA Owner HACCP YIN ❑ Temporary ❑Pre- pera'on J e J t C ❑ Caterer ❑Suspect Illness Person-in rge(PIC) Time ❑ Bed&Breakfast ❑General Complaint In:,*{go_ ElHACCP IPermit No. El. Inspector Ou{ Each violation checked ib4ulrim 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 590.009(E) ❑ Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) El corrective action as determined by the Board of Health. Allergen Awareness 590.009(G) El -,__ T_ _ - -- -- _-_ t FOOa PROTECTION.MANAGEMENT�_____ �.R.__.. El12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH ._. PROTECTION FRONI'CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC _ El 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded ,_.._- _�.�„_,_ ❑ 15 Toxic Chemicals �OOD FROM APPROVED SOURCETIMFJTEMPERAT . _ URE:CONTROLS(PotenIli Hazardous,-s F14. Food and Water from Approved Source '- --� tiaFo_ods) �1 ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy.of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling . ;._-_ PROTECTION FROM CONTAMINATION__-.-_ - n 1 9. Hot and Cold Holding X18'. Separation/Segregation/Protection P 20.Time as a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY-$USCEPTIBCE�POPULATIONS';(H8P)J ❑ 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices [CONSUMER ADVISORY_ A 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. Noncritical(N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2X590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (Fc-4X590.004) ) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-axs9o.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc-5X59o.00m) establishment operations. If aggrieved by this order,you 27. Physical Facility (Fc-6X590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (Fc-7X590.008) 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 bf.ba Inspector's Signature: Print: - f PICS Signature: �j dot qY] Page!of Pages 4nY Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 I 590.003(A) Assp0ig went of Res nsibilit * 3-302.11(A)(1.) Raw Animal Foods Separated from e 590.003(B) Demonstration of Knowledge" _ Cooked and RTE Foods* Contamination from Raw ingredients 2-1.03.11. Person in char ge--duties 3-302.1.1(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) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Ve etables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 590.003(G) Reporting'n b Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* - 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated Food 590.003(E) Removal of Exclusions and Restrictions 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..111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical W arewashing-HM Water 3-202.13 Shell Eggs* - Sanitization Tem ratures*. 3-202.14 ,Eggs and Milk Products.Pasteurized* 7501.114 Chemical Sanitization-temp.,pH, 3-202,16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101..11 DrinkingWater from am Approved System* 4-601.11(A) Equipment Food Contact Surfaces and- 590.006(A) Bottled Drinking Water* - Utensils Clean* 590.006(B) Water Meets Standar(is in 310 C&IR'22.0* 4-602.11 Cleaning Frequency of Equipment Food- Sholl fish and Fish From an Approved Source Contact Surfaces and Utensils* 3-201.14 Fish and Recreationally Caught Ivioliuscan 4-702.11. Frequency of Sanitization of Utensils and - Shellfish* Food Contact Surfaces of Equipmew 3-201.15 Molluscan Shellfish from NSSP 1 1sted� 4-703.11 Methods of Sanitization--Hot Water and Sources* Chemical* 10 Proper,Adequate Handwashing Regulatory Authority rm Game and Wild ushrooms.4pproved by 2-301.11 - Clean Condition-Hands and As* 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 3 Receiving/Condition 2-401.11 Eating,Drinking or UsinE Tobacco* 3-202.11 PRFs Received at Proper Tem eratures* 2-401.12 Discharges.From the Eyes,Nose and 3-202.15 Package lute rim Mouth* 3-101.11 Riod 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 3-203.1.2 Shelistock Identification A?aimained* Employees* Tags/Records;Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Convenientty Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Caacities* - 590.004(1) Labeling of Ingredients' S-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 4-301.11 Handwashing Cleanser,.Availability 8-103.12 Confoimance with An oved Procedures* - 6-301.12 Hand DryingProvision Denotes critical item in the federal 1999 Food Code or IW CMR 590.000. N No RM MINIMA MMMUNIM Wim' �- . -. M , AM HIM, r ��� Fri - .. - { b 3-501,144C PHFs Received at Temperatures Violations Related to Foodborne Ulnas&Intereenfions and Malt According to Law Cooled to r Factors thams 1-22) (Cont.) 41"F/45`F Within 4 Hours, PROTECTION FROM CHEMICALS 3-501.15 CoolilrE Methods for PHFs 14 Food or Color Additives 19 PHF Not and Cold Holding 3-501.16(B) Cold PlIFs Maintained at or below 3-202.12 Additives* 590.004(M 410145'F* 3-342.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances _ - 140*F * 7-101,11 Identifying Information-Original 3-501.1 (Al Roasts Held at or above 13VF. " { Containers* 7-102.11. Common Name-WorkingContainers* 24 Time as a Public Health Control i 3-501;19 Tante c a Public Health Control* 7-201.11 Separation-Stora " r 7-202.11 .Restriction-Presence and Use* - 594.004(H) Variance R airement 7-202.12 Conditions of Use* 7-2033.11 Toxic Conners-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIDLE 7-204.11 Sanitize".Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals far Washing Produce,Criteria' 21 3-841.11(A) UnpastettaiTed Pte-packaged juices and r 7-204.14 n ants.Criteria* Beverages with WarningLabels* { 3-801.11(B Use of Pasteurized E * 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served 7-306.12 Rodent Bait Stations* 3-801.11(C) Unopened Fax]Package Not Re-served. i 7-206.13 Tracking Powders, Pest Control and Momurrin * CONSUMER ADVISORY 71MEI TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of r 16 Proper Cooling Temperatures for Animal Foods Thaz are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate Patbo yens.* -3-40 1.11 A(l)(2) Eggs- 155°F 15 Sec: 3-302.13 P Eggs-Immediate Semite 145°F15see- E asteurized Eggs Substitute for Raw Shell . 3-441.11(A)(2) Comminuted Fish.Meats&Game Animals-155°F 15 sec. SPECIAL REQUIREMENTS y 340111(B)(1)(2) Pork and Beef Roast-130°F 121 min* 590.409(A)-(D) Violations of Section 590.009(A)-(D)in J 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 k we. * catering,.mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Staffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail F 3-40LI2 Raw Animal Foods Cooked in a practices should be debited under#29- t Microwave 165F* Special Requirements. } 3401:11(A){1)(b) A11 Other PHFs-145°F 15 sec. i 17 Reheating for Hot Holding WOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403.4l(A)&(D) PHFs 165-F 15 sec. * (Items 23-36) 3-403.11(B) Microwave-'165°F 2 Minute Standing Critical,and neon-critical violations, which do not relate to the t - Titer* foodborne illness ixterventiants and risk factors listed above, can he 3403.11(C) Commercially Processed RTE Food- found in the following sections,of the Food Code mrd 145 CMR 140°F* 590.000. 3403.11(E) Remaining Unsiiced Portions of Beef Item I Good Retail Practices FC 590.000 Roasts* j 23._ i Manaaament and Personnel FC-2 .003 18 Proper Coaling of PHFs 1 24. 1 Food and Foal Prdecuon FC 3 .004 1 25. Equipment and Utensils 1 FC-4 .005 3-501.14(A) Cowling Cooked PRFs from 140`F to ! 2g, Water.Plumbinq and Waste i FC-5 .006 70*F Within 2 Hours and From 70*F 27. j Physical FaciftyFC-8 007 to 41`F/45'F Within 4 Hours.* 128. Pasonovs br Toxic Materials FC 7 .008 3-501.14(6) Cooling PHFs Made Front Ambient '-29. -Special R viremsrns l Temperature Ingredients to 41°F/456F 30 1 Other Within 4 Hours* Demtc;critical hem in the federal 1999 Food Case ot10 CMR 590.000. 7 M 011 OMPA F4 WA J_ s.i.:. � -._ .. . .'. : , w :. . . , . _ .�L _iA l _ TIOMMMPIFIr�. - 4117MJ.E V. + s. . , , �►��17>t�• �"/L�L:I� =��Wq HIM WFILHIMM-10.101 MAO TVA OF MAMMA ARTM IS M F. h ORION m mra. ffm you ... .- 1 f r t 3.501,14(C) PHFs Received at Temperatures r Violations Relafed to Foodiwrne illness interventions and Risk According to Law Cooled to Factors(Items 1-2Z) (Cont.) 41'7/45°F Within 4 Hours. t PROTECTION FROM CHEMICALS : 501.,15 Coolie Methods for PHFs 14 - - Food or Color Additives i9 PHF Not and Cold Holding 3-202.12 Additives* 3-50116($) Cold PHFs Maintained at or below 590.004(F) 4101450 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. " 7-101,11 Identifying Information-Original 3-50L WA) Roasts Heid at or above 130'F. Containers* 20 Time as a Public Health Control 7-102.11. Common Name-WorkingContainers* 7-201.11 Separation-Storage* 3-501:19 Time as a Public Health Control* r 7-202.11 ,Restriction-Presence and Use* 590,004(H) Variance R uireme 1 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE " 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitize".Criteria-Chemicals* 1 7-204,12 Chemicals for Washing Produce,Criteria* 21 3-841.11{A) Unpasteurized Pre-packaged Iuices and Beverages with'Warning labels* 7-204.14 Drying Agents.Criteria* 3-801-II(B) Use of Pasteurized Eggs* 7-205-11 Incidental Food Contact,Lubricants* 3-801.1 I(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent:Bait Stations' i 7-206.73 3-801.11(C) Unopened Food Package Not Re-served. Tracking Powders, Pest Control and Monitoring* -CONSUMER ADVISORY_ - TIMEIFEMPERATURE CONTROLS 22 3-603.11 Consumer.Advisory Posted for Consumption of ;� Proper Cooking Temperatures for Animal Funds That are Raw,Undercooked or PHFs Na,OtherwiseProcessedto Eliminate Pathogens,' 3 401.11A(1)(2) Eggs- 155°715 Ste: Dern + Fg Immediate Service 145°F15sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell + 3401.11(A)(2) Comminuted Fish.Meats&Game E * �i Animals-155'F 15 sec. 3-401,11(B)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS * 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 ,j sec.* catering,mobile food,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections r Poultry or Ratites-165'F 15 sec, * above if related to foodborne illness t 3-401.11(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 Fords Cooked in a practices should be debited under#29- I Microwave 165°F* Special Requirements. li 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3-403.41(A)&(D) PHFs 165-F 15 sec. * (Items 23-30) 3-403.11($) Microwave-165`F 2 Minute Standing Critical,mid non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sectionsofthe Food Code and 105 CMR 140°F* 590.000. t 3-403.1I(E) Remaining Unsliced Portions of Beef ` Imin 1 Good Retail PracVcas I .FC .59a0w Roasts* 23. , Management and Personnel I FG-2 003 18 - 24. i Food and Food Protection FC-3 004 Proper Cooling of PHFs i 25. + Equipment and Utensils ! FG-4 005 i 3-501.14(A) Cooling Cooked PHFs from 140°F to ! 2g, 1 Water.Plumbinq and Waste ! FG-5 .W6 f e 70°F Within 2 Hours and From 70°F 27. 1 Ph sisal FaciN FC-6- .007 to 41'F/45'F Within 4 Hours. * 12B. ' Poisonous br Toxic Materials ' FC-7 .008 (, 3-501.14(B) Cooling PHFs Made From Ambient 29. ; ecial R airemerns i A09 Temperature ingredients to 41°F/45°F 0. I Other Within 4 Hours* st*"'°"'�"�'` "Denotes Critical iiia in the federal 1999 FwA Cale w'105 CMR 590.000. { CITY OF SALEM BOARD OF HEALTH Establishment Name: 2 Date: d Page:_Lof Item 'Code C—Critical Item DESCRIPTION OF VIOLATION/PLAW OF CORRECTION Date --' No. Reference R—Red Item ' PLEASE PRINT CLEARLY Verified /S ) ♦lit/ `. ,IfLeowc-7 s '. . G 1A"inGc i✓ 1/ P1 � Discussion With Person in Charge: rRe-inspecition tion Required: ❑ No es I have read this report, have had the opportunity to ask questions and agree to correct all Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to 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 susp sion/revocation of ❑ Emergency Closure your food permit. jt5-� Disposal ❑ Other: n L" i 3-501,14(C) PHFs Received at Temperatures - 4 Vloiffilons Related to Foodborne 111ness Inrerventlons and Risk According to Law Cooled to Factors(ltemsY-22) (Cont.) - 41°Fi45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PRFs 14 Food or Color Additives - 19 PliF Hot and Cold Holding 37202.12 Additives*, 590.004{F)3-50136(B) Cold P°IiFs Maintained at or below t 3-302.14 Protection from Una roved.Additives' 3-501.16(A) Hat Hot PP F* 15 Poisonous or Toxic Substances . * Maintained at or above t 7-101,11 Identifying Information-Original 1�� 3-501.16(A) Roasts Held at or above, 130'F. Containers" * l 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590,004(H) Variance Requirement 7-202.12 Conditions of Use* 1 7-203.11 'Toxic Containers-Prohibitions* P U REQUIREMENTSS(HSP)FOR HIGHLY SUSCEPTIBLE t 7-204.11 Sanitizers.Criteria-Chemicals* .1Yta 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-g61.11(A)A} Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agrnts.Criteria° .Bevera es with Warning Labels* . 7-245.11 Incidental Food Cemtact,Lubricants* 3-$01,1 l(B -Use of Pasteurized Ba * - 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(0) Raw or Partially Cooked Animal Food and 7-206.12 - . Rodent Bait Stations* Raw Seed Sprouts:Not Served. 3-801.11(C) Unopened Food Package Not �ae 7-206.13 Tracking Powders,Pest Control and Rened. Monitoring* CONSUMER ADVISORY TIMEITERMPERATURE CONTROLS 22 3-603.11 Consumer:Advisory Posted for Consumption of 1 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or Proper t P - - Not Otherwise Processed to Eliminate 3 401.I1A(1)(2) Eggs- 155°F 15 See. .Patlao ens.*eTx'w�nr<TNn { - Eggs-Immediate Service 145°F15sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell 3E a 3-401-11(A)(2) Comminuted Fish.Meats&Game q Animals-155'F 15 sec. * 3-401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 min* SPECIAL REQUIREMENTS r 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 590.009(A)-(D) Violations of Section 594.009(A)-(D)in i1 sec.* catering,mobile food,temporary'and t 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 3-401.11(C)(3) Whole-muscle,Intact Beet'Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Fonds Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3 301A I(A)(1)(b) All Other PHFs- 145°F 15 sec. t- 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 4 3-403.11(A)&(D) PRFs 16PF 15 sec. ° (Items 23-30) 3-403.11(B) Microwave- 16.5°F 2 Minute Standing -Cnticat and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listen above, carrbe 3403.11(C) Commercially Processed RTE Food- found in the following sections-of the Food Code and 105 CMR 140°F* 590.000. i 3-403-11(E) Remaining Unsiiced Pomoas o£Beef Ham I Good Retail Practices .FC _ 590.000 i Roasts* j 23_ I management and Personnel I FC-2 .003 '. r 1t3 Proper Gosling of PHFs i 24.- 1 Food and Foci Protection FC--3 .1104 I 25. Equipment and utensils FG-4 W5 j 3-50L14(A) Cooling Cooked PRFs from 140°F to 26. Water.Plumbi and Waste i FC-S .006 70'F Within 2 Hours and From 70°F 27. 1 Physical Faciff FC-6 W7 to 41`F(45°F Within 4 Hours. * 1 28. ' Poisonous or Toxic Matena[s s FC G=7 .008 i 3-501.14(6) Cooling PHFs Made From Ambient 29. I Special Requirements 1 Temperature Ingredients to 41°F145°F 30 1 Other Within 4 Hoar-" °Denotes critical itzru in the£edea] 1499 Food Code or 105 C-MR 590.000 i rh`.twwc 4kkx •.'. °�' i"3n s$ € ,+ Saye a�- , R r -$ � - y d _ r•'x. . �' "A" ;e �ei�'°=, Q N,' "'�' w -°P vc�,7 x<#.�'s'' ,�: W ` a iz. °#� r3nw'.�,�s s, »'�'' " dr ,."-' �, :th` 1 'r � r r .%a, w:� a .m .� '*ir<e,.. W b i` ,i+ , S a #,�'m ,a. .�, 's,r p'¢ a4 r 4 - 7 •aa y "' - !`� .'$'"' c'' &9 a n e rA et 4 wa, x '�` rf a, wi ,�• .br �.,a'+ g',^'°'q,., ".Y' ro e e '€ n - �!u .>+ �� � � �� ° s €aui a u , at � '"A .,� Sb x s�' � $ w�aas',ry ro � n x€w Yx8 L•n �C..a �'. aW - - .C r ...;c �• n y�mnw a rv• "� s n ^x �,. a +', `e Y O Rd RG •ue= mk4 rry.� r �' v^ , � n+"x v a yf � ;'N i v F � &"' +R M ,,c: v-.n 5'✓ vTm+�� e .�L. ""mss yg {a, mw_ v: $ ,.,�.1 '€ft✓ `7 ' m k ire. :+w �."n, x m ro st .., rYF' ,�' � � ^E hSA" h �, '�ar r ��. b+" W� a'+u'' s, nQ lr �k tl} si5 hero i a rfa ' �'' rc Q r� � �... �ti .+45:'.• n -b 0 a• ice .° � 'R. bd p .,�, + €s 5: y ,€ +k. `,.�' J ppr" �. erne P• € a aNs ,.h » •a s e'a 'V , z '° :-. e G y Q (� Q O W W r �Uj �hP; v � y `� r .q'�age ' � Pa.�� �a ,� e ^bd ro•, k �' w wY•� :t `� 2t A [ t .€"n 'p" ^ t. C � '° 'a", rn :.�' ';ros "'yr W. . P: >y «w ,. `�" tai .. a{ M `� „w � 'LYd•�C 'O - ntsr. U'm .w - � �.. � � . �' °° .Z � mw,-,� . ,. .. n.� p; ^�.,,, rG ,rte. •xw« c � m`�m +-' e' � ..a,7 o- p — W �$d r +� , ' r a i Pr m Uj7 G � Y F .'OwC4� 09 W r Wro F :n rro U WL [ d 7 CL 80 O ,ps, ,.C) s; CITY OF SALEM, MASSACHUSETTS Arblicxeatrn BOARD OF Hi;.,u: trt -a�m,•.PP�- 120 WvSIimGTON S11ceFT,4:-FLOOR KINIBERLEY DRISCOLL Tia-(978)741-1800 FAx(978)745-0343 LARRY RAbIDIN,RS/RF;LIS,CHO,CI'-FS MAYOR Iramdina.salem.com HFALPj AGENT Food Establishment Permit Application (Application must be submitted at least 30 days before the planned opening date) 1) Establishment Name: A433 2) Establishment Address: 3) Establishment Mailing Address(if different): Q, ++ 4) Establishment Telephone No: `1 O- c ee4 4 5) Applicant Name&Title: ' 6) Applicant Address: 1 � 7) Applicant Telephone No:gg8' I(XL3 24 Hour Emergency No: Email: 8) Owner Name&Title(if different from applicant): ./vNS , 9) Owner Address(if different from applicant): mak. 10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of officers or partner. An as5ocimtlfaL Name Title Home Address -cicor o _ \ An individual oc, YYv�1� c5 A partnership �+ Other legal entity rn 12 Person Directly Responsible For Daily Operations Owner, Person in Charge, Supervisor,Manager, etc. Name&Title: \ett(,^,\ Address: kv\ 51 Telephone No: q - b�) Fax: Email: bAcra5 L u. Emergency Telephone No: 13) District or Regional Supervisor(if applicable) Name&Title: (bWoo(a Address: Sl Telephone No: -M � l Fax: Email: Check#['t-r�dkd' Date:� _1� Amount44y Food Establishment Information 14) Water Source: 15) Sewage Disposal: DEP Public Water Supply No: (if applicable) 16) Days and Hours of Operation: 17) No. of Food Employees: 16) Name of Person in Charge Certified in Food Protection Management: - ` Required as of 101112001 in accordance with 105 CMR 590.003(A) 19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No 20) Location: 22) Establishment Type(check all that apply) (check one) ❑ Retail( . Sq. Ft) ❑ Caterer Permanent Structure ❑ Food Service-( Seats) ❑ Frozen Dessert Manufacturer Mobile ❑ Food Service-Takeout ❑ Residential Kitchen for Retail Sale ❑ Food Service-Institution ❑ Residential Kitchen for Bed and ( Meals/Day) Breakfast Home ❑ Food Delivery ❑ Residential Kitchen for Bed and 21) Length Of Permit: ___Breakfast-Establishments------...........-...... ------------------ ----------------- (check one) RETAIL STORE RESTAURANT C nu ❑ Less than 1000sq.ft. $70 ess than 25 seats $140 Seasonal/Dates: 0 1000-10,000sq.ft. $280 ❑ Residential Kitchens $140 ❑ More than 10,000sq.ft. $420 ❑25-99 seats $280 ❑ More than 99 seats $420 Temporary/Dates/Time: ------------------------------------------------------------------------------------------------------------------------------ C Bed &Breakfast/Childcare Services/Nursing Home $100 --------------------------------------------------------------------------------------------------------------------------- - - ADDITIONAL PERMITS ❑ MAKE ICE CREAM,YOGURT/SOFT SERVE $25 ❑ PASTURIZATION $25 ❑TOBACCO VENDOR $135 ❑ALL NON-PROFIT $25 (Including, church kitchens, state funded childcare&private clubs 23) Food Operations: Definitions: PHF-potentially hazardous food(time/temperature controls required) Non-PHFs-non-potentially hazardous food(no timeRemperature controls required) check all that apply): - RTE-ready-to-eat foods(Ex.sandwiches,salads,muffins which need no further processing Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held Pre-packaged Non-PHFs for More Than a Single Meal Service Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared For Highly Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill Prepared by Consumer Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance Processed Foods for and/or HACCP Plan(including bare hand Service Within 4 hours contact alternative,time as public health control. Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of Non-PHF and Non- Retail Sale Animal Origin Perishable Foods Only Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered Retail Sale Events or Institutional Food Service Offers RTE PHF in Bulk Quantities To be completed by the Board of Health Retail Sale of Salvage,Out of Date or Reconditioned Food Total Permit Fee: Payment is due with application j I,the undersigned,attest to the accuracy of the information provided in this application and 1 affirm that the food establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have be n instructed by the Board of Health on howto obtain copies of 105 CMR 590.000 and the Federal Food Code.. 24) Signature of Applicant: b44g Pursuant to MGL Ch. 62C, sec.49A, I c rtify under the penalties of perjury that I,to my best knowledge and belief, Have flied all state tax returns and paid state taxes required under law. 25) Social Security Number or Federal ID: 0 2 O J 26) Signature of Individual or Corporate Name: I !`T \ t a CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET 4`"FLOORb�1CH�� > rrzveno.r.omm :r.om . TEL. (978) 741-1800 FAX(978) 745-0343 _ KIMBERLEY DRISCOLL lxamdinngsalemxom LARRY R;ANIDIN,RS/REI-1S,CHO,CP-FS MAYOR : 1, 113',m liAGI?N'1' This Form will be collected during your next Board of Health inspection. QUESTIONAIRE -GREASE TRAPS 2012 1. NAME OF ESTABLISHMENT �n �- C�I )n6 \ Noy-Z�2 2 ` 2. ADDRESS OF ESTABLISHMENT: ` \eM CA40 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? W.S 4. WHAT SIZE GREASE TRAP/DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS Gd f" C) V \- 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS? BY AN IN-HOUSE PERSON OR BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? S. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-critical nem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY I✓ f RAA d Discussion With Person in Charge: Corrective Action Required: o No ❑ Yes have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or , spension/revocation of ❑ Embargo ❑ Emergency closure your food permit. ❑ Voluntary Disposal 0 Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to taw Cooled to Factors(items 1.22) (Cont.) 41°F/45'F Within 4 Hours. '" PROTECTION FROM CHEMICALS 3-501.15 Contour Methods for PHFs Food or Color Additives 19 PHF Hot and Cold Holding lA 3-501.16(B) Cold PIfFs•Maintained at or below 3-202.12 Addtttte�' 590.0040 41`/45°F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHR Maintained at or above 15 Poisonous or Toxic Substances 140°P 7-101.11 Identil'vine Information-Original . 3-501.16(A) Roasts Held at or above 130°F. Containers": 7-10211 Common Name-Workrug Containers* 26 Time as a Public Health Control 7-201.17 Se oration-Stora^ct` 3501.19` Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004h H) Variance Re nirement - 7-203.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203,11 forte Containers Canter Proheroic ns` POPULATIONS(HSP) 7204.11 Sarutizets Criteria Cheaticils,` -- 7.204.12 Chemicals for 1>r a^hine Produce Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 1-204.14 Dt ur .,Vents,Criteria" Beverages with R arum*i.abcls* 3-801.11(B) Use of Pasteurized Ee,sb 7-205.11 Incidental Food f orunct Lubricants* 3-801.1l(D) Raw or Partially Cooked Animal Furl and 7-20611 Restricted Use Pesticides. Criteria* Raw Seed Sprouts Not Served. 7-206.12 Rodent Bait Stations" 3-801.11(C) Unopened Food Package hot Re-served. 7-206.13 'Tracking Powders,Pest Control and Monitorim** CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.I1 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 2atho cm* -"""0' 3-401.17 At I)(<) Eggs- 155'17 15 Sec. Ft,gs-LnmerltateService 145°1715sec* 3-302,13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish, Meats&Game L"s* Animals- 155`17 15 sec. a SPECIAL REQUIREMENTS 3-401.11(13)(1)(2) Pork and Beef Roast-130'F 121 nrin' --- 3-40111(A)(2) Ratites,Injected Meats-155"F 75 590.009(A)-@) Violations of Section 590.009(A)-(D) in sec :,: catering, mobile food,temporary and ,-40111Poultry,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 lthiess 3-401.11(C)(3) Whole muscle, linacr Beef Steaks interventions and risk factors. Other 145`F* 590.009 violations relating to goad retail 3-401.12 Raw Animal Foods Crooked in a practices should be debited under#29- Microwave 1651- * Special Requirements, 3-401A I(Al(1)(b) <Vl Other PHFs-145°F'15 sec. * 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PRFs 165`17 15 sec. fi (Items 23-30) 3-403.11(B) Microwave- 165°1=2 Minute Standine Critical and non-critical violations, which do not relate to the Time" foodborne illness interventions nerd risk firrtors listed obovecan be 3-403.11(C) Connuercialk Processed RTE Food- luund in the following sections of the Food Code and 105 GItR 140°F* 590.000. 3-403.11(E) Remaining Umliced Portions of Beef item Good Retat7 Practices fC 590.@QO Roasts* 23. Management and Personnel FC 2 .003 1g Proper Cooling of PHFs 24._ Food and Food Protection - - FC 3 .004 -1 25, Equipment and Utensils FC 4 .005 3-501.1PILLCooling Cooked PHFs from 140`F to 26. _Water,Pluand Waste FC-5 .006 70°F Within 2 Hours and From 70°P 27 Ph sicai FacilitJFC-6 .007_ _ --- to 41`F/45°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC -7 .008 3-50114(B) Cooling PI IFs Made From Ambient 29 Special Requirements -009 Temperature'Ingredients to 4l`F/45°F 30 Other Within 4 Hours,k ssvom.roe^aa-zo., -�Denote critical item in ilre foderal 1999 Prod Code or 105 CNIR 590.000. 0 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T"FLOOR • MAYOR TEL.(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/RENS,CHO,CP-FS LRAMDIN([ilSALEM.COM HEALTH AGENT COMPLAINT INTAKE FORM Q Date: Time: 9U ) 05 4,N— Received By: L1 Complaint Number: 0275 Complainant 4' ;h 60/hrM 911 Address: Phone: 1zSr r4 6cZ A - ) 3101-454 ' 3 eA- LAnn�2t—Z, OlK< a >na -'r r.rJ� u j • Investigated By: Date: Property Owner/Occupant Name Telephone #: CITY OF SALEM, NtASSAC HUSE'ITS i BOARD or Hf.N1;11 r 120 W ySHINGTQN STRUT,41" Ii NIBERLCY DRISCOLL TO_ 0978)741-1800 FAX (978) 745 0343 MAYOR Icamclin@salem orq LARRY ILVNdDIN, RS/lwlis,cIl(1,cl>....1:s I.,IFAJ,HI AGt:NI' This Form will be collected during your next Board of Plealth inspection. QUESTIONAIRE - GREASE TRAPS 2009 1. NAME OF ESTABLISHMENT: n rt�C2 2. ADDRESS OF ESTABLISHMENT: bl 3. DOES YOUR ESTABLISHMENT HAVE A GREASE TRAP? \j �) . 4. WHAT SIZE GREASE TRAP DOES YOUR ESTABLISHMENT HAVE? CAPACITY IN GALLONS 5. HOW IS THE GREASE TRAP MAINTAINED? ON A DAILY BASIS BY AN IN-HOUSE PERSON R BY AN OUTSIDE CLEANING SERVICE? 6. WHAT IS THE FREQUENCY THAT THE GREASE IS REMOVED FROM THE TRAP? on(e. mot) 7. WHAT IS THE NAME OF THE FIRM WHO REMOVES AND/OR PICKS UP THE GREASE FROM YOUR ESTABLISHMENT? 8. WHAT IS THE DATE OF YOUR LAST INVOICE FROM THE REMOVAL FIRM? '►N kVt Commonwealth of Massachusetts i c � e City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2011 ESTABLISHMENT NAME: North House of Pizza File Number:BHF-2008-000008 134 North Street SALEM MA 01970 LOCATED AT: SALEM,MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2012-0206 Jan 1,2012 Dec 31,2012 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES Oecember 31, 2012 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made, all plans for.such must be submitted to and approved by the Salem Board of Health. . Page 1 CITY OF S.ALEM, IVLASSAC-IUSE`I"I'S { BOARD OF HH.I.LTH 120 WASHINGFON STRENT,4`"FI:,OOH. TEL. (978) 741-1800 KIMI3ERLEY DRISCOLL FAX(978) 745-0343 N .1YOIt L-acnSin(t7salem.com LARRY RANIDIN,RS/RHI IS,t;IIO, HvAi:ni A(:;HNT 201_APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �oS _tie .��e © ��\�; A - _TEL (DID Z3 _ ADDRESS OF ESTABLISHMENT MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAMESa ADDRESS 019±0 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) 5_V\n( CERTIFICATE#(S) (Required in an establishment where potentially hazarrlo , isihwJ prepared) EMERGENCY RESPONSE PERSON HOME TEL# 06Y,SOFOPERATI0N_ Mond Tuesda �Wedttes Thursda =r= r.:Frid Saturda Sunda HOURS OF OPERATION \ - t_} I _ Please write in tene of day. (Forexamplellam-ilpm) TYPE OF ESTABLISHMENT FEE (check onivl RETAIL STORE YES NO less than 1000sq.ft. =$ 70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 RESTAURANTY S NO ess than 25 seats (Outdoor Stationary Food Cart$2 25-99 seats ---=T-2-80 more than 99 seats =$420 ------------------- - -- -- - - ---- - BED/BREAKFAST/ YES NO $100 CHILDCARE SERVItrES/tdtJRSING HOME ADDITIONAL ERMITS - •• -.- -----••.......--- ................. ...... ----.. -----_ ------ ...... ...... - ........... P MAKE(riot just serve)ICE CREAM,YOGURT/SOFT SERVE YES O $25 TOBACCO VENDOR YES $135 ALL NON•PROFFr(such as church kitchens) YES $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,1 certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed an state tax returns and paid all state t required under the law. -1 1St>n ate Social Seeunty or Federal Identification Number. Updated523/1I FOODAP201lAdrn Check#&Date �- �� 5 WO Massachusetts Departmep t.,of , Public; Health Salem Board of Health 120 Washington Street,4t'Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name 'r Dat T of O aration s Type of In 12 1 Food Service ❑ Routine Address I�Y Rik Retail PRe-inspection Level ❑ Residential Kitchen Previous Inspection Telephone 2 i y 77 ❑ Mobile Date: Owner El Temporary ElPre-operationHACCP YM ❑ Caterer ❑ Suspect Illness Person in Char§e(PIC) _ Ti e El Bed 8 Breakfast El General Complaint El HACCP Inspector In� � ) Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: - Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. .FOOD PROTECTION MANAGEMENT _,,�.� d" ❑ 12. Prevention of Contamination from Hands 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH .. PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC �-� El 14.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded [:115.Toxic Chemicals FOO D FROM APPROVED SOURCE.. _. .. . .. -- - _--- TIME/TEMPERATURE CONTROLS _ __ ❑ 4. Food and Water from Approved Source _ (Potenpany Nazardoua Fooda) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION -_ x,: ❑ 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 SUSCEP.TIBLE_POPULATIONS.(HSP) El21. Food and Food Preparation for HSP ' ❑ 10. Proper Adequate Handwashing ❑ 11.Good Hygienic Practices CONSUMER,AOVISORY . � ❑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. � c x p 9 590.000/federal Food Code.This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (Fc a)(sso.00s) 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:SBOIny,eetYFwmSl4.tla - � Inspector's Signature: Print: PIC's Signature: L,�y ,Z 1 Print: r '0 t-./ E Page of�Pages TTT w. Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(I) Raw Animal Foods Separated from 1 590.003(A) Assignment of Responsibility* Caked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw ingredients 2-103.11. Person in charge--duties 3-30111(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) Food Protection* require reporting by food employees and 3-30215 WashingFruits and Vegetables _ applicants* 3-304.1 t Food Contact with Equipment and 590.003(F) Responsibility Of A Foul Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 590.003 G) Re ortin b Person in Charge* 3-306.14(A)(B) Returned Food and aced orReseryC of mint Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Reserictions* Food 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fad* 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 Hermeticall•Sealed Container* Sani6ration Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eons* Sanitization Temperatures* " 3-202.14 E*as and Milk Producis.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 fee Made From Potable Drinking Water* concentration and hardness. * 5-101.11 Drinking Water from an Approved System* 4-601,11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Watcr* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0" 4-602.11 Cleaning Frequency of Equipment Food- Shellfish 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 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 Came and Wild Mushrooms Approved by Re ulatoAuthorlt 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* 3-201.1.7 Game Animals* 11 Good Hygienic Practices. S Reeelving/Condidon 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11 PRFs 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:Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstnck Identification* 590.004(E) Preventing Contarnination from 3-203.12 Shellstock Identification Maintained* Em 7o ees* 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` 5-2G4.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 -Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. S ecialized Processing Methods* Devices 3-502.12 Reduced oxv en pacRaging,criteria* 6-301.11 Handwaihing Cleanser,.Availabilit 8-103.12 Conformance with A . roved Procedures* 6-301.1.2 HandD Provision ''Denotes critical item in the federal 1999 Foots Code or 105 CMR 590.000. Massachusetts'Department of Public Health°ti+i 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 l7r J �Z Da ( T e of O eration s Tvoe of Inspection litFood Service Routine Address 12 R sk ❑ Retail ❑ Re-inspection Telephone 7 Level ❑ Residential Kitchen Previous Inspection P Cl ❑ Mobile Date: OwnerHACCP YM 11Temporary ElPre-operationJ ( / "Q, ❑ Caterer ❑Suspect Illness Person in Chale(PIC) C Time ,t1 ❑ Bed&Breakfast ❑General Complaint HACCP Inspector Inc :"Z 4 Permit No. ❑Other Out: S=4 O El Other Each violation checked requires and explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance 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'-' '`�" - PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC �ti 11 ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded FOOD FROM APPROVED SOURCE M_, s's ❑ 15.Toxic Chemicals ❑ 4 Food and Water from Approved SOurcek TIME/TEMPERATURE CONTROLS(Potentially Hazardous Fo_oda) ❑ 5 Receiving/ConditionFF` ' ❑ 16.Cooking Temperatures F F ❑ 17. Reeat hin El 6. Tags/Records/Accuracy of Ingredient Statements g �!li' ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing [REQUIREMENTS FOR.HIGHLY SUSCEPTIBLE POPULATIONS(HSP) „fir" W,}.'k ❑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): of Health. Non-critical (N)violations.must be corrected immediately or within 90 days as determined by the Board Official Order for Correction: Based on an inspection today, the items checked indicate violations of 105 CMR of Health. , C x 590.000/federal Food Code. This report,when signed below s 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or itil%gent constitutes an order of the Board of Health. Failu'�re to correct violations �4. Food and Food Protection (Fc;3)(sso.00a) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (F04)(590.005) the food establishment permit an cessation of food 6. Water,Plumbing and Waste (FC•5)(590.006) R pf establishment operations. If agrgneved by this order, you 27APhysical Facility (FC-6)(590.007) have a right to a hearing. YoFprequest must be in writing 28.Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board di Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this Ybrder. 30. Other DATE OF RE-INSPECTION: S:SWII.Pe F.m 14.E Inspector's Signature: Print:,-� Y C v PIC's Signature: (l Print'---'C- 9' Q �,1 �' Page of -Pages V � I G . /7 Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION $ Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assi=*tment of Responsibility* Cooked and RTE Foods* 590.003(B) Demonst anon of Knowled e"' Contamination from Rawingredents 2-103.11 Per on in charge-dut es 3-302.11(02) Raw Annual 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) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In - Contamination from the Consumer Charge* 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated 3 590.003(D) Exclusions and Rsstrictions* Food 590.003(E) Removal of Exclusions and Res r ct ons 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 1Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water - 3-201.1.2 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3.20113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.7.3 Shell Eons* Sanitization Temperatures* 114 Chemical Sanitization-temH, 3-202.14 Eggs and Milk Products,Pasteurized* 4-501. concentration and hardnessP'" p 3-202.16 Ice Made From Potable Drinking Water* 5-101.11 Drinking Water from an Approved Systeme 4-601f I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- SheiKrsh and Fish From an Approved Source Contact Surfaces and Utcnsils* 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 MethtdsofSanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulato Authorit 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 g Receiving/Condition 2.401.1'1 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 Irate rit y Mouth* 3-101.11. Food Safe and Unadulterated* 3-30t12 Preventing Contamination When Tasting* 6 Tags/Records:Shelistock L12 Prevention of Contamination from Hands 3-202.18 Shellstook Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstoek Identification Midntained* Employees,* Tags/Records: Fish Products I13 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(1) Labeling of Ingredients` 5-204.11 Location and Placement* Conformance with Approved Procedures 5-2(15.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* fi-301.11 Handwashin Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6 301.12 Hand Drying Provision Denotes critical imm in the federal 1999 Food Code or 105 CMR 596.000. J CITY OF SALEM BOARD OF HEALTH Establishment Name: U,) r J-4 14)' .5c, Date: r Page: of 3 — Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF COR \CTION Date No. Reference R-Red Item verified PLEASE PRINT CLEARLY II vc-r 0/.vrt •tA. JP 11 Grp e w D C U c yrezex I�) rumr,' Q /' .4— V.r , (1 C 44 r C. 4 I` 61 iZ ' C,M ;, S �lO /1 � r , S/-)4 r ;f2i oc l CQL&yr ov&- ) i Discussion With Person in Charge: Corrective Action Required: ❑ No Yes i I have read this report, have had the opportunity to ask questions and agree to correct all ❑ voluntary Compliance ❑ Employeilf Restriction ' Exclusion violations before the next ins ection, to observe all conditions`as described, and to k p �q Re-inspection Scheduled ❑ Emergency Suspension t comply with all mandates of the Mass/Federal Food Code. I understand that ttl 111 noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. i f u 0 Voluntary Disposal 0 Other: f 3-501,14(C) P?iFe Received at Temperatures Violations Related to Foodborne fflnesa Infer✓ent/ons and Risk According to Law Cooled to Factors(Items 1-22) {Cont.) 41'-145°F Within 4 Hoam FROM CHEMICALS 3-50 1.15 Coohne Methods for PHFs PROTECTION 14 - MCH or CA Additives 19 PHF Hot and Cold Holding 3-50L16(13) Cold PRFs Maintained at or below 3_202.12 1 Additives* 590.004(F) 410145'F* 3-302.14 Protection from Unapproved Addhivas* 15 Poisonous or Toxic Substances 3-SOI,ib(A) Hoc PHFs Maintained at or above 140°F. 7-101,11 Identifying Information-Original 3_,SOl.f6(A) Roasts Held at or above 230°F. * Containers* 20 Time as a Public Health Control 7-102.11. Common Name-Workmg Containers* 3-501.19 Time as a Public Health Control* 7 201.11 Sion-Storag& 7-202.11 .Restriction-Presence and Use* F590 004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 'Toxic Containers-Prohibitions* REQUIREM NNS FOR FIIGFILX SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals' PAI(A)OPU TONS HSP 7-204.12 Chemicals for WashingProduce,Criteria* 21 3-801AI(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria' :Beverages with vv-arnin*labels* Incidental Food Contact 3-801.11(B) Use of Pasteurized Bias* 7-205,11 7-206.11 Restricted Use Pesticides,Criteria* 3-801-II(D) Raw or Partially Cooked Animal Food and Ran Seed Sprouts Not Served. * 7-206.12 Radent'Bait Stations* 3-801-II(C) Unopened Food Pac Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monienrin " CONSUMER ADVISORY - TIMEITEMPERATURE CONTROLS 22 3-603.11 1 Consutner Advisory Posted for Consumption of fl6 Proper Cooking Temperatures far Animal Foods That are Rau.Undercooked or PHFs Not Otherwise Processed to Eliminate Pathogens.* 3-40i.IIA(1)(2) Eggs- 155`F 15 Sec- Egos- ecB os-Immediate.Service 145*F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell E Y 3401.11(A)(2) Comminuted Fish.Meats&Game Animals-155°F 15 ser:. 3.40L11(B)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS of Section 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.004(A)-{D) Violations of Section 54(1.609{A)-T))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-165'17 15 sec. * above if related to foodborne illness 3401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to good retail 3-401.12 Raw Animal Frxxts Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other Plls- 145"F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3-403.1 I(A)&(D) PHFs 165-T 15 sec.* (Items 23-30) 3403.11(B) Microwave 165`F 2 Minute Standing Critical and non-critical violations, which do not relam to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CIM 140°F* 590.000. 3403.11(E) Remaining Unsticed Portions of Beef Item Good Retail Practices FC 690000 Roasts* 23. 1 Managament and Personnel FC-2 003 18 Proper Cooling of PHPs 24. t Food and Foal Protection IFC 3 .004 1 25, 1 Equipment and Utensils i FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140`Fto ! 26, ! Water.Plumbinq and Waste i FC-5 .006 i 700F Within 2 Hours and From 70°F 27. i Physical Favi' FC--6 .007 J to 4171450F Alithin 4 Hours.* i 28. ' Poisonous or Toxic Materials ' FC-7 .008 3-501.14(,B) Cooling PHFs Made From Ambient 29. --Special R uirements - .009 Temperature ingredients to 410171450F 30. j Other Within 4 Hours* lknorea cribs:mmin the federal 1499 Food Cale ut'105 CMR 590.000. CITY OF SALEM f BOARD OF HEALTH Establishment Name: r Jn I { N u.lX Date: Page: Z of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified i� PLEASE PRINT CLEARLY - I�PrNr✓ (� r �e1 In 11 � ,o s f / - r // ii � Pr rQ1_CCA 6ek/A ' 2 /// /fi r r •S °� V r� •+� rn � ,� N Q o ,r n I' b i 1 - > 3� _120 U, I- U- i 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 Re§tgi ion i Exclusion violations before the next inspection, to observe all conditions as described, and to / p -<Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. ('understand that noncompliance may result in daily fines of twenty-five dollars-or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. JJ` ❑ Voluntary Disposal ❑ Other: - V 3-501.14(0) PHFs Received at Temperatures Violations Related to Foodborne 111nesa Interventlons and Risk According to Law Cooled to Factors Moms 1-22) (Cont.) 41"Fi45°FWithin 4How& PROTECTION FROM CHEMICALS3-501,15 Cooling Methods for PHFs 14 Food or Color Additives 19 ?HF Not and Cold Holding 541..16{B} Cold P11Fs Maintained at or below 3,242.12 Addirives* 590.004(F) 41'!45'F* 3-342.14 Protection from Unapproved Additives'u 3-501.15(,0) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 7-101,11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 1300F. Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storap* .3-501.19 Time as it Public He?ltb Control* 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use+ 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS(HSP) FOR HIGHLY SUSCEPTIBLE POPUONS 7-204.11. Sanitizers.Criteria-Chemicals* - LATI 7-204.12 Chemicals for Washin Produce,Criteria* 21 3-801.1)(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria° .Beverages with Warning Labels* 7-205.11 Incidental Food Contact.Lubticants* 3-&01.11(B) Use of Pasteurized Eggs` 7-206.11 -Restricted Use Pesticides;Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Rax Seed S its Not Served. 7-206.12 Rodent Bait Stations* 7-206.13 Tracking Powders, Pest Control and 3-841.ll(C) Unopened Fled Pac Not Re-served. Monitoring* CONSUMER ADVISORY TIMEtE EMPERATURE CONTROLS 22 3-603.11 Consumer Adiisary Posted for Consumption of 16 Proper Conking Temperatures for Animal Foods That are Rax,Undercooked or PHFs rop Not OtherwiseTrocessed to Eliminate Polito ens*Frr«ew,n, i 3-401.11A(i)(2) Eggs- 155"F 15 Sec. Eggs-immediate Servicc 145°Fi5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.1I(A)(2) Comminuted Fish,Meats R Game E 22. Animals-155°F 15 see. 3-441AI(B)(1)(2) Pori:and Beef Roast- 130°F 121 nun* SPECIAL REQUIREMENTS 3.401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)1n sec. * catering, mobile Fuld,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-I65OF 15 sec * above if related to foodborne 'illness 3-401.11(0(,3) Whole-muscle,intact Beef Steaks interventions and Tisk-factors. Other 145°F* 590,009 violations relating to good retail 3-441.12 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 3403AI(A)&(D) PHFs 165"F 15 see. * (items 23-30) 3403.11(6) Microwave 165`F 2 Minute Standing Critical,and non-critical violations,which do not relate to the Time* foodborne Illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code acrd 105 CASR 1400F* 590.000. 3403.11(E) Remaining Unsticed Portions of Beef {%tem = Good Retail Practices FC 591.QD0 j Roasts* ,?3. i_Mam ement and Personnel I FO-2 .003 131 Proper Coding of PHFs 1 24. 1 Food and Food Protection I FC-3 .004 125. 1 Equipment and Utensils i FG-4 .005 3-50LM(A) Cooling Cooked PHFs from 140°F to 26. ; Water.Plumbing and Waste ` FC-5 .006 1 70*F Within 2 Hours and From 70`F 27. - Physical Facility FC-8- .607 to 41`F/45°F lT.rthin 4 Hous. * X26. ' Poisonous or Toxic Materials =. FC-7 .008 3-501.14(6) Cooling PHFs Made From Ambient 129. SpeciaS Requirements .608 I Temperature Ingredients to 41017145°F i 30. j Other Within 4 Hours* Demtes co ical item in the federal V>)9 Foci Calc or 105 CMR 590.000. Commonwealth of Massachusetts ` City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 FooWRetail Establishment Permit DATE PRINTED: 07/15/2011 ESTABLISHMENT NAME: North House of Pizza File Number:BHF-2008-000008 134 North Street SALEM MA 01970 LOCATED AT: SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0528 Jul 5,2011 Dec 31,2011 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES Oecember3l, 2011 Board of Health g € 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 r s CITY OF SALEM, MASSACHUSETTS lIr BOARD OF HEALTH 120 WASHINGTON STREET,41°FLOOR TEL. (978) 741-1800 KINfBLRLEY DRISCOLL FAX(978) 745-0343 NLIYOR Iramdin@salem.com LARRY RAMI)IN,RSR 1N,CI10,CP-FS H I3r\]a'FI AG LNT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT N©CAh \ ^W5Q, `071� TEL# 9-4 8 _�4 - o 1333 ADDRESS OF ESTABLISHMENT C1 I IO� V1 �� 15 �YYI YYI�IOF # MAILING ADDRESS(if different) .7 EMAIL-Business': D O Website: OWNER'S NAMEKJL1�Qkf)Qk L m n Le ly TEL# Q�f b &2?) '-C?)1`R ADDRESS 124 i rnov� c5T ")fi\2\C" my mWo STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) C \ \k3f' \eClc7 CERTIFICATE#(S) (Required in an establishment where potentially hazardouslood is prepared) ...p EMERGENCY RESPONSE PERSON Q� V_'`-) HOME TEL# DAYS OF OPERATION' Monday Tuesday Wedhesda Thursda Friday ! Saturday Sunda HOURS OF OPERATION Please write in time of day. t0— E{ 'tOflfrl-��('t Iofln-9Pt11\oA�i-1�Ptl' \13P& oe(A \o- t0 \\- ?rt. For example Ilam-11 pm) i 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 - --------------------------------------------- -- -------------------------------------------------------------------------- -- RESTAUnAid "�� NO less than 25 seats ,., (OutdoorSt35onary Food Cart$2 25-99 seats =C2_80 more than 99 seats =$420 -- ----------------------------------------------------------- ------------------- --------- BED/BREAKFAST/ YES O - $100 CHILDCARE -- ASERVICES/NURSING HOM----------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES <N9� $25 TOBACCO VENDOR YES CIRD $135 ALL NON-PROFIT(such as church kitchens) YES O $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 accordarce 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 MGLatpter 62C,Section 49A, I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax returns and paid al ate taxes required under the law. �6- � Sign ure Date Social Security or Federal Identification Number ----------------------------------------------------T' .---------- ------- Updated 523/11 FOODAP201 Ladm Check#&Date / $ � PiS a,( an c�,(sm,co rn CITY OF SALEM BOARD OF HEALTH Establishment Name: ` � � pl?:2 i Date: ? 1 1 Page:--L— of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified ' PLEASE PRINT CLEARLY CLQ k l s U 44 O -ftt f Q� j( 1 0 1. , Discussion With Person in Charge: Corrective Action Required: ❑ No o 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 noncompliance may result in daily fines of twenty-five dollars or spension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ' ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to law Cooled to Factors(Hems 1-22) (Cant.) 41°F145°F Within 4 Hoots. PROTECTION FROM CHEMICALS3-501.15 Cooling Methods for PHFs Food or Calor Additives 19 PHF Hot and Cold Holding 3-50L16(B) Cold PI-IFs Maintained at or below 3-202.12 Additives* 590.004(F) 41°145°F* ` 3-302.14 Protection from caved Additives" 3-501.16(A) Hot PHFs Maintained at or above gg Poisonous or Toxic Substances 140°F. 7-10111 identifying Information-Original 3.501.16(A Roasts Held at or above 130'F. Containers* Time as a Public Health Control 7-102.11, Common Name-Working Containers* 20 * 3-501:4 Time as a euir Health Contras* 7-201.11 Separation-Storage 7-202..11 ,Restriction-Presenceand Use* - 5590.0040Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203-11 Toxic Containers-Prohibitions* POPUt ATiONS HSP i 7-204J I Sanitize".Criteria-Chemicals* 7-204.12 Chemicals for Washin Produce,Criteria* 21 3-801.11(A). Unpasteurized Pre-pacltnged!users and ,. .Beverages with Warning Labels* 7-204.14 encs.Criteria* 3-901AI(B) Use of Pasteurized E 7-205.11 Incidental Food Contact Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Foci and k 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served, 7-206.22 Rodent Bait Stations* 3-801-II(C) Unopened Food Package Na Re-served. 7-206.13 Tracking Powders, Pest Control and Monitorin * CONSUMER ADVISORY TiMEffEMPERATURE CONTROLS 22 3-603.11 1 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw,Undercooked or l PHFs Not Otherwise Processed to Eliminate 3-401.IIA(1)(2) Eggs- 155'F 15 Sec Pathogens.' r� l E es-Immediate.Service 1450F15sec* 3-302.13. Pastcuri.zcd Eggs Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game E gW Animals-155'F 15 sec. SPECIAL REQUIREMENTS 3 461.2I(B)(1)(2) Pork and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-40LI I(A)(2) Ratites,injected Meats-155°F 15 sec.* catering,mobile food,temporary and r 3403.11(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 E 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F Y' 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 Requiretncnts, 3-401a(A)(1)(b) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLA77ONS RELATED TO GOOD RETAIL PRACTICES 3403:11(A)&(D) PHFs 165-F 15 sec. * (Itetns 23-30) 3-403.11(B) Microwave- I65'F 2 Minute Standing Critical.and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sectionsofthe Food Code and 105 CMR 1400F* 590.000. 3-403.11(E) - Remaining Unsliced Portions of Beef Pham 1 Good Retail Practices FC 590.0W 1 Roasts* 23._ _Martaoement and Personnel '. FG-2 :003 lg Proper Cooling of PHFs 24. Food and Food Protection ! FC-3 .004 25. Equipment and Utensils I FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140`F to ! 26. Water.Plumbing and Waste i FC-5 006 70°F Within 2 Hours and From 70'F 27. ( D sicai Facility to 41'F/45'F Within 4 Hours. * 128_ Poisonous or Toxic Materials FC-7 .048 3-501.14(13) Cooling FHFs Made From Ambient X29. S rose!R uiremams .009 Temperature lagtedients to 41°F/456F 30 I Other Within 4 Hours" s_�nr,nmac�c: I I "Denotes critical iwin in the federil 1999 Fc*d Cale o 105 CMR:90.000. 0 i R—Red Item --_� . �. +�� • • . yd.W2 0 —_ FEW ,► • . . , •TOM�2 -_a •.0 \�s��GJ ii i� _ r. _� �_ i� ��i. i_ I�'I�L�_ �h' AIll. 1_OMWEn= n WO 11 MMMI A also 0 . . . . �. r 3-501A4(C) PHFs Received at Temperatures - t Violaftons Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Hems 1-22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS3-501.15 CoclmE Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cale!Holding 3-202.12 Additives* 3-50L W(B) Cold PRFs'v3aintained at or below 4{171 41-501. 3-302.14 Protection from Unapproved Additives" 3-50 L JAS'F 15 Poisonous or Toxic Substances 316(A) Hot PHFs Maintained of or above 140°17. 7-i 01.11 Identifying Information-Original 3501.16(A) Roasts Held at or above 130'F. " Containers* 7-102.11. Common Name-Working20 Containers* Time as a Public Health Control f3-501.19 - Time as a Public Health Control* 7-20202.11 Restriction-Presence and Use*72 .lI raiin-Stora ` _ - 590.004(A) VariatucRequirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS HSP 7-204.11 Sanitizers.Criteria-Chemicals* 7-204.12 Chemicals for Washing Prodbee,Criteria' 21 3-f407..17(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drying Agents.Criteria* Beverages with Wanting Labels* 3-801.11(B) Use of Pasteurized$ * 7-205,11 Incidental Food Contact.Lubricants* 3-801..11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served 7-206.12 - Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served. K 7-206.13 Tracking Powders, Pest Control and Monitor4n " CONSUMER ADVISORY 22 3-603.11 ConsumerAdvisory Posted for Consumption of 7IMEITEMPERATURE CONTROLS i 16 - Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs - Not Otherwise.Processed to Eliminate Patho 3-401.11A(l)(2) Eggs- 155'F 15 Sec. 'Frx>re,n;znar Hees-Immediate.Service 145°FiSsec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell E a 3401.11(A)(2) Comminuted Fish.Meats&Game Animals-155°F 15 sec. * SPECIAL REQUIREMENTS 3.401.11(B)(1)(2) Pots;and Beef Roast- 130°F 121 min* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites, Injected Meats-155°F 15 sec.* catering,"mobile food,temporary and 3401.1 I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'17 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165F* Special Requirements. 3-401A l(A)(1)(b) All Other PHFs-145`1715 sec. Ary Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES 3-403,41(.4)&(D) PHFs 16ST 15 see. * (Itents 23-30) 3-403.11(B) Microwave-165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the foodborne illness interventions and risk factors listed above, can be 3403,t i(C) Commercially Processed RTE Food- found in the following sections.of the Food Code and 105 CMR 140°17* 590.000. 1 3-4031l(E) Remaining Unsliced Portions of Beef " item ! Good Retail Practices .fC silo.000 Roasts* - L_ I Management and Personnel { FC-2 .403 1-- Proper Cooling of PHFs 1 24. 1 Food and Food Protection FC-3 .004 125. { E ui ment and Utensils _! FC-A A05 1 3-50L14(A) Cooling Cooked PHrs from 140'F m i 26. Water.Plumbinq and Waste FG-5 .066 r 70'F Within 2 Hours and From 70°17 27. I Physical Faci6n� FC-6 407 4 to 41`F/45°F Within 4 Hours. * 1-28- Poisonous or Toxic Materials ! FC-7 .008 i 3-501.14(.@) Coolttng PHFs Made From Ambient 1 29. Special Requirements .403 1 Temperature Ingredients to 41°F/45°F ' 34 3 Other __ Within 4 Hours* "Denotes critical mmx in the fed ral 1999 FwJ Cate or 105 CMR 590.000. i CITY OF SALEM (�\ BOARD OF HEALTH Establishment Name: J V Com( � Le��C 3-i P,V C4 Date: G I Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item verified PLEASE PRINT CLEARLY C�4Ir ✓ n,C� Jle Ylk � 'u, IV1<, � �i 1 'D CSC (9J111C�� <PPgizf) TA C rr , DS n71N1 T1Y1)�r'Y _ o 0 ICT ' :5G 'Drn TI-IQ v I (P '1 C c li(4,t w .�} rcx r ,1 —(-o cNii i' ck I orj s,^nom `o 1 r r�/1; t ). C In PGt� I Pr-rto owk o,rs - T - I nest -) JqIQ i r t 1 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/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension ,comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance,may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. �•'��� � r � r '���--- ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures VicWtons Related to Foodborne Illness.Interventions and Risk According to taw Cooled to Factors Otems 1-22) (Cont.) 41'F145F Withia 4 Hams. PROTECTION FROM CHEMICALS3-501.15 Coolinp Methods for PHFs 14 - Food or Color Additives 19 PHF Not and Gold Holding 3-202.12 Additives* 3-501.16(B) Cold PRFs Maintained at or below _ ' 3-302.14 Protection from Unapproved Additicesie 390.004(M 410145'F* 1g Poisonous or Toxic Substances 3-50116(A) Hot PHFs Maintained at or above 140 . 7-101,11 Identifying Information-Orignal 3-501.16(A) Roasts Held at or above, OWE Containers* Time as a Public Health Control 7-102.11. Common Name-Working Containers* 20 * - 3-501.19 Tire as a Public Health Crwtrrzl* 7-201.11 Separation-Stora 590.004(Fl) Varian 7-202.11 .Restriction-PresenceandUse* Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.14 Toxic Containers-Prohibitions* POPULATIONS NSP 7-204.11 Sanitizers.Criteria-Chemicals* 21 3-801.1](A) Unpastctuizzd Pre-packaged Juices and 7-204.12 Chemicals few Washi Prcrdmx,Criteria' packag 7-204.14 Drying Agents,Criteria' Beverages with Warning Labels* 3-83 01.11(B) Use ofPasteurized Bus* 7-245.11 Incidental Food Ct-tacL Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served '-206.12 - Rodent Bait Stations* 3-801.11(0) Unopened Ford Pack Not Ru-served ` 7-206A3 Tracking Powders,Pest Control and Moraltorbilf CONSUMER ADVISORY__ _ TIMEIPEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 26 Proper Gooidrtg Temperatures for Animal Foods That are Raw.Undercooked or Not Otherwise Processed to Eliminate _ PHFs 3401.1IA(1)(2) Eggs- 155°F 15 Sec. Eggs-Immediate Service 145'F15see, 3-302.13. 1 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) - Comminuted Fish.Meats&Game E * Animals-155'F 15 sec.* SPECIAL REQUIREMENTS 3-401.11(B)(1)(2) Pork and Beef Roast- 130'F 121 mio* 3401.11(A)(2) Ratites Injected Meats-155°F 15 590.00%A)-(D) Violations of Section-590.009(A)-(D)in sec.* catering,.mobile food,temporary and 31401.11(.A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Pouluv or Ratites-165'F 15 sec. * above if related to foodborne illness 3-401.11(0)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 1450F* 590.009 violations relating to goal retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Micmwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-903AI(A)&(D) PHFs 165-F 15 sec.* (Itelms;23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing -Criticat and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above,can he 3-103.11(Q Commercially Processed RTE Food- found in the following sections of the Food Code and J05 CMR 1400F* 590.000. 3403.11(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 540.UD0 23.Roasts1c Manattsment and Personrrei FG-2 .003 1g Proper Cooling of PHFs 1 24. Food and Foal Protection FC-3 .004 1 25. i Equipment and Utensils I FC-4 .005 i 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 a Toxic Materials FC-7 .008 ' 3-501.74(6) Cooling PFfFs Made From Ambient 20 `_Special R uiremenis .009 j Temperature lagredients to 41'F/4 'F i 30' i Oma +--- - Within 4 Hours"` "Denotes critical ia:m in the federal 1999 Foal Code or 10 C411t 390.040. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item VerI ied PLEASE PRINT CLEARLY 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 noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures ViolatfonS Related to Foodborne Illness lntementlons and Risk A=)rdmg to Law Cooled to Factors(items 1-22) (Cont,) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 CoolingMethods for PRFs 14 Food or Calor Additives .._ 19 PHF Not and Cold Holding " --••••--• - 3-501.16(B) Cold PHFs Maintained at or below 3-202;12Additives* _ 590.004(0 41'145°F* 3-302.14 Protection from Unapproved Additives" 3-501.16(A) Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances _ - * 7-101.11 Identifying Information-Original 140 3-501.16(A) Roasts Held at or above, 130°F. Containers* 7-102.11. Common Name-Working Containers* 20 Time as a Pubc Health Control ' 7-201.tl S *'on-Stora 3-SQ1.19 'tithe as a Publlic Health Control* 7-202.11 ,Restriction-Presence and Use* 590.U04(H) VarianceR Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanidzers.Criteria-Chemicals* POPULATIONS NSP � 21 3-801.I I(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals fear Washing Produce,Criteria* :Beverages with Warning labels* } 7-204.14 Drying Agents.Criteria* 3-801Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 7-206.11 -Restricted Use Pesticides,Criteria* 3-801.1A I(B)(D) Raw or Partially Cooked .al Food and Raw Seed Sprams Not Served. 7-206.12 - Rodent:Bait Stations* 3-801.11(C) Unopened Food Pack Not Re-served. " 7-206.73 Tracking Powders,Pest Control and Monitcuin * CONSUMER ADVISORY TIMEf6 EMPERATURE CONTROLS 22 3-603.11 I Consumer Advisory Posted for Cansumptian of F6 PAnimal Foods That are Raw.Undercooked or Proper Cooking Temperatures for F6 PPropHFs - - Not Otherwise"P6zssodtoEliminate Pathogens.*� ` 1 3401.IIA(1)(2) Eggs- 155°F 15 Sec. n E Immediate Service 145°F15sec* 3-30213 Pasteuri7xd Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155'F 15 sec.* SPECIAL REQUIREMENTS . 3-461.11(B)(1)(2) Port:and Beef Rpt- 130°F 121 min* 590.009(.0}-{D7 Violations of Section 590.009(A)-(D)in 3-401.11(A)(2) Ratites, Injected Meats-155°F 15 see.* entering,"mobile food,temporary and 3401.1.1(.0X3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165*F 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail I 3-401.12 Raw Animal Fonds Cooked in a practices should be debited under#29- Microwave 165F* Special Requireirtents. I 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hut Holding VIOLATIONS RELATED TO GOOD RETAIL PRAC77CES t 3-103A I(A)&(D) PHFs 165T 15 sec. * (Items 23-30) 3-403.11(B) Microwave 165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk_factors listed above, can be 3403.11(C) Commercially Processed RTE Food- }'bund in the following sections"of the Food Code and 105 CMR 1400t'* 590.000. 3403-11(E) Remaining Unsiiced Portions of Beef !term 11 Good Retail Prectlees .FC $90.000 ^, Roasts': L23. ! Management and Personnel -i FG-2 .003 18 Proper Cooling of PHFs 24.. i Foal and Food Protection FC 3 .004 25. 1 Equipment and Utensils 1 FC-4 .005 3-501.14(A) Cooling Cooked PHFsfrom i40`Fto ! 26. Water.Plumbing and Waste 1 FC-5 .W6 7(rF Within 2 Hours and From 70°F 27. PhYs cal Faoii iy i FC-6 007 4 to 41°F/45°F Within 4 Hours. * i 28. # Poisonous or TOXIC Materials FC-7 .008 3-501.)4(B) Cooling PRFs Made From Ambient ~2� -g_..�i. i�Re uiremems - ,009 Temperature Ingredients to 41°F/45°F 1 OTher Within 4 Haurs* sscrr mta.a llenotm critical iwm in the federal 1999 Foal Calera IOi CIMR 90.000, r CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Item Verified PLEASE PRINT CLEARLY Discussion With Person in Charge: Corrective Action Required: o No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all o Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension =comply with all mandates of the Mass/Federal Food Code. I understand that ' noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne Illnesut lntementlons and Risk According to Law Cooled to Factors(henna Y-22) (Cont.) 41'F145°F Within 4 Hous.' PROTECTION FROM CHEMICALS 3-50t.15 CoolinR Methods for PHFs 14 Food or Calor Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(B) Cold PIIFs Maintained at or below 3-302.14 Protection from Unapproved Additives* 590.004(F) 410145°F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 7-101.11 Identifying Information-Original 140°P. Containers* 3-501.16(A) Roasts Held at or above 1300F. ° 7-102.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501,19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* - 590.W4(H) Variance Requirement 7-202.12 Conditions of Use" 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizem.Criteria-Chemicals* POPULATION$ HSP 7-204.12 Chemicals for WashingProduce,Criteriar 21 3-80-1.11(A) Unpasteurized Pre-packaged Juices slid 7-204.14 Drying Agents.Criteria* .Beverages with NVart»ng Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-EOl.il(B) Use of Pasteurized Eggs* 7-206.11 -Restricted Use Pesticides;Criteria* 3-801-II(D) Raw or Partially Co�.ed Animal Food and 7-206.12 - Rodent Bait Statists° Raw Seed S uts Not Served * 3-801.11(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY _ TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures far Animal.Foods That are Raw,Undercooked or PHFs _ Not Otherwise Processed to Eliminate 3 40i.IlA(1)(2} Eggs- I55`F 15 Sec. Eggs-immediate Service 145°F15sec^ 3-302.13. Pasteurized Eggs Substitute for Raw Shell 31401.11(A)(2) Comminuted Fish.Meats&Creme E Animals-155'F 15 sec:. " SPECIAL REQUIREMENTS 3.40LI VB)(1)(z) Pork and BeefRoastM -130'F 221 mit* 590 009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.1 itA}(2) Ratites,Injected Meats-155°F 15 sec.* catering,mobile food,temporary and 3-401.1.I(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-I65'F 15 sec. * above if related to foodborne illness 3-401-II(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. tither 145°F* 590,009 violations relating to good retail 3-101.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 340LII(A)(1)(b) All Other PItFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-103:11(A)&(D) PIIFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-'165'P 2 Minute Standing Cri2icai,acrd non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- found in the following sections-of the Food Code and 105 CMR 1400F* 590.000. 34003.11(E) Remaining Unsliced Portions of Beef - ttem 1 Good Retail Practices 1 FC 59D,tJ1J0 Roasts* i 23. 1 Management and Personnel 1 FC-2 .003 .I lt3 Proper Cooling of PHFs i-24- ii Food and Food Protection FC-3 .004 i 25. I Equipment and Utensiis _ FC-4 ,005 3-501.14(A) Curling Cooked PHFs from 140°F to 26. Water.Plumbinq and Waste i FC-5 .006 1 70'F Within 2 Hours and From 70'F 27, Physical Facility l FC-6 .007 to 41 F/45'1'Within 4 Hous. * 128. - Poisonous or Toxic Materials ! FC-7 .008 - 3-501.14(6) Cooling PHFs Made From Ambient Specie Requirements 009 Temperature Ingredients to 41'Ft45°F i Other ;_- Within 4 Hours* "Denotes critical ivm in the federal 1999 Food Cate a'105 CMR 590.000.