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PEST•END EXTERMINATING
15 PELHAM STREET
METHUEN,MA 01844 ,
978-7943321
JUN 0 2 2D06 1109761 1109751
EMEMMUM
PIZZA VENTURES 05/31/06.
33 SO.COMMERCIAL STREET
MANCHESTER,NH 03101
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RETURN THIS PORTION WITH PAYS
DATEORDER •ICE DEscRip,rjoN AMOUNT BALANCE INVOIck--
Service Addre w PAPA JOHN'S 233 10 ASHINGTON STREET.SALEM,MA 1970
05/23/06 240857 240857 GENERAL PEST CONTROL 25.00 25.00 240857 25,00
I
CURRENT 30
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DAYS 6 r DAYS OVER • TOTAL
AMOUNT25.00
25.00 0.00 0.00- 0.00 2500- DUE
CHECK ITEMS BEING R
PAYMENT DUE NET 30
AMOUNT
0 Copyrlghr 2005 Marathon Dem Syolonm,Ina,•A0 RiGhm RoaomW REMITTED
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR -
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
Kimberley Driscoll WWW.SALEM.COM
Mayor JOANNE SCOTT, MPH, HIS, CHO
HEALTH AGENT
2007 APPLICATION FOR PERMIT TO OPERATE A FOOD(ESTABLISHMENT
NAME OF ESTABLISHMENT � J(IW) Z21� TEL# f`7 / r
�� 6 +�'/$ff/AA �( '�33yf
ADDRESS OF ESTABLISHMENT
yy (( GdjQfS� �JR �: / f7
MAILING ADDRESS (if different) S8 LX101B (�r )nM,e_RU1 -LV- RdntPj 3k, YUP-[ 310/
EMAIL--Business': Owner's:
OWNER'S NAME h2-2Q V, nl`1"I 4,6;:5 :R:_ LJP TEL#
ADDRESS 34S S0117M 6OV1Ri'I9oW l -e_ s-r /Od,ne,he_<IA" Yl w 031621
STREET CITY STATE `J ZIP
CERTIFIED FOOD MANAGER'S NAME(S) Y jAAC.(o 6A 71 . (r4 CERTIFICATE#(S) +28 ZS 7y`
v
(Required in an establishment where potentiallyh/azardous food is prepared)
EMERGENCY RESPONSE PERSON yaSt+15L HOME TEL# Q
�� i ` ✓7rtZ
OATS OF OPERATION Monday _ Tuesday Wednesday Thursday _ Friday Saturday Sunday
HOURS OEeintim of `3Pm-&M. Pril-)0Pei PM-lOPpt 4M I?�trT �1 ^12Pnt . (tRytt- 12�
Please writelndmea(fiay. '�;8(� SNI��,,
(Forexamplellam-11pm1
i
TYPE OF ESTABLISHMENT FEE (check only)
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sci t. =$100
more than 10,000sq.ft. =$250
- -- ......-..._ ------- -------- -------_... - ------... - -------- -----.,-.. _---
-
RESTAURANT YES NO less than 25 seats G$400r
25-99 seats =$150
more than 99 seats =$200
-
BED/BR-EAKFAS_`ST YES--- , -NO----- ...-- .--* - -.._..---- -----
__...-..__......$100_..-------- ----
.- ----- ---- ----....--
-.-_ - -- ---------- - .------..........--..._......__. - ------ ---- . ......_ __._ ........... ...... ...... ..
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
`Please pay total with one check payable to the City of Salem.
This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a
prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are
made, all plans for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and belief,
have filed all s e taxturns and paid all state/axep required under the law.
12. D �1 � �
Sig lure Date Social Security or Federal Identification Number
- ------- ------------------- i -- -
------------ - - - -- ---- -- ..-------------------- ------
j - ------------------------------------
Revised 11/13/06 FOODAP2007.adm Check#&Date _f0 &-I `,. � s � �.
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'� '"Z',is • � . • � '- `�ta+.t s,•-.+x5 BOard Of Health r r y,�'�.,�- �t �,�a�,'ro&t r r�>�`ev,,��'�, � -"i`"�; " '�"#^'��'' :
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SALEM,MA ,01970
Food/Retail Establishment Permit
DATE PRINTED: 12/20/2006
ESTABLISHMENT NAME: Papa Johns Pizza
File Number:BHF-2003-000018 Pizza Ventures II Inc.
33 S.Commercial Street
MANCHESTER NH 03101
LOCATED AT:
SALEM, MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2007-0161 Dec 20,2006 Dec 31,2007 $100.00
ESTABLISHMENT
Total Fees: $100.00
PERMIT EXPIRES IDecember3l, 2007
Board of Health
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code,beofre any revonations, improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 13 of 16
Pizza Ventures II Inc. Papa Johns Pizza
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: FOOD PROTECTION MANAGEMENT
_744-9777 PIC Assigned/Knowledgeable/Duties PASS RED
Owner: Comments:All Certified food manager certifications to be faxed over to the Board of Health. Also displayed on wall next to food
Pizza Ventures II Inc. permit. Establishment to have completed within one month.
PIC: PROTECTION FROM CONTAMINATION
_Nicholas Copadis Food Contact Surfaces Cleaning and Sanitizing PASS ❑Q RED
Inspector: Comments:Sanitizing solution reading low. Sanitizing solution to be avilable at each work station with proper concentration.
John Gehan
Date Inspected:Correct By: Violations Related to Good Retail Practices (Blue Items)
11/22/2006 j Equipment and Utensils PASS BLUE
Risk Level:
Comments:Victory three door refrigerator requires general cleaning.
-Permit Same unit has no visible thermometer. Provide visible and accurate thermometer.
BHP-2006-0333 Walk in refrigerator requires thermometer inside.
Status:
Open Sanitizing log not up to date. Log to be maintained daily with proper concentration.
#of Critical Violations: Top of oven requires general cleaning.
0 Physical Facility PASS BLUE
Time IN: Time OUT:
Comments: Ceiling tiles missing above washing machine. Replace tiles.
Urgency Description(s): GENERAL COMMENTS:
BLUE:
Violations Related to Good All violations from 11/22/2006 have been corrected.
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 ) Page/ of
Item Status Violation Critical Urgency
RED:
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 29,2006 ) Page 2 oft
Y'7
Commonwealth of Massachusetts
City of Salem
Kimberley Driscoll
Board of Health
Mayor
120 Washington Street,4th Floor
SALEM,MA 01970
Food/Retail Establishment Permit
DATE PRINTED: 01/11/2006
WHO'S PLACE OF BUSINESS IS: Papa Johns Pizza
File Number:BHF-2003-0018 Pizza Ventures II Inc.
33 S.Commercial Street
MANCHESTER NH 03101
LOCATED AT:
SALEM,MA 01970
Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes
FOOD SERVICE BHP-2006-0333 Jan 11,2006 Dec 31,2006 $100.00
ESTABLISHMENT
Total Fees: $100.00
PERMIT EXPIRES December 31, 2006
Board of Healthx xC,
This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in
a prominent location in the Establishment.
In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made,all
plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1
CITY OF SALEM, MASSACHUSETTS ��y
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01 970
.� TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR 610019 HEALTH AGENT
2985 APPLICATION IF�OR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT l � T06`�'1J 5 1 Iz7-4 TEL# / ? 7qY Q777
70
ADDRESS OF ESTABLISHMENT 13 3 UJt9 sF1•,r�7 S+ S'gZo�.., �� (W70
aw
�1 Ste, 201
MAILING ADDRESS (ifdifferent)/ 93 3- 0� l.Dt� -age„h S'4 M1st&t.� 0 3(Of
OWNER'S NAME r17ZA Vt#A-Iv64c IT LL-e- TEL# b” 232- 9907
ADDRESS 33 'S• Comm-{2c,At
CITY II/(I¢N(.48c-flc STATE N, ZIP 1310
CERTIFIED FOOD MANAGER'S NAME(S) FY N FyipJ ST-Lovq CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON J"45 1714lLl4 HOME TEL# 1003 232 -9`Y7
HOURS OF OPERATION: Mon.I1-11 Tue.tl-Il Wed. 11-II ThuA/-// Fri. //-/ Sat. /1- 1 Sun. //-//
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$_0
more t 0,000 ,000
more than 10,000sq.ft. =$250
i
RESTAURANT YES NO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
2 03 81 �, `f23
Signature _046--lie
' Date (� 2��Si Social Security or Federal Identification Number
1�1�!1
Revised 11/0 03 FOODAP2.adm Check#8 Dale i2f °/ 11-A9-e�e
ao
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Massachusetts DepartMent Of Public Health Salem Board of Health
a 120 Washington Street,41h Floor
Division of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name 1/ ` Date T e of 0 eration s Tvoe of Inspection
/rte Il O 9 ofa Food Service ❑ Routine
Address I I ' I Risk [3 Retail /Pj-Re-inspection
w I�CLevel [] Residential Kitchen Previous Inspection
7
Telephone r ,� , q-441- 7 EI Mobile Date:Previous
o 6
Owner �F HACCP YIN El Temporary ElPre-operation
\(p -}"j-- Caterer❑ El Suspect Illness
Person in Charge(PIC) Time
gg ❑ Bed&Breakfast El General Complaint
E] HACCP
Inspector 1/ OuY �({ Permit No. ❑Other
Each violation c ecked r quires 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.
FO PROTECTION MANAGEMENT- �:"_r .,, ,r`,, ❑ 12. Prevention of Contamination from Hands
1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities
EMPLOYEE HEALTH
FPROTECTIQN FROMCHEMICALB
�r
❑ 2. Reporting of biseases by Food'Employee and PIC A_, A. 4s
El 14. Approved Food or Color Additives
E] 3. Personnel with Infections Restricted/Excluded
�� � a
rFOQD FROM APPROVED SOURCE El 15.Toxic Chemicals a..�, .a, ,-�,--m�,„, , �
❑ 4. Food and Water from Approved Source ',"TIMEREMPERATURE CQNTROLS(PbtcMlally Hazardous Foods)
iE 1n'.a .t=- .r..c iai a
E] 5. Receiving/Condition [j16.Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling
'PROTECTION FROM CONTAMINATION = ff ."71 ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR- 'HIHLY SUSCEPTIBLE POPULATIONS(HSP)'
❑21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
�CONSUMEI?ADVISORYc,,,"', i., M'°y"';,,.�ga,'��"�
❑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 ofA05 CMR
of Health. 590.000/federal Food Code. This report, when signed below
23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an
24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of
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:
5:5901nspeclFarm614 tlx _
Inspector's Signature: ' Print:
PIC's Signature: Print: v Page_of-�pges
_ a
Violations Related to Foodborne Illness
Interventions and Risk Factors(Items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590.003(A) I Assignment of Responsibility' 3-302.11(A)(]) Raw Animal Foods Separated from
590.001(B) Demonstration of Knowledge* - Cooked and RTE Foods*
2-103.11 Person in charge-duties Contamination from Raw ingredients
3-302.11(A)(2) Raw AniuulFoods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.lt(A) Food Protection*
applicants* 3-302.15 Washin Fruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11, Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge* Contamination from the Consumer
590.003(G) Reporting by Person in Charge* 3-306.14(1'}(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003{E) Removal of 6xciusions and Restrictions Food
3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.1.11. Manual Warewashing-Hot Water
3-201.1.2 Poai in a Henneticaliy Sealed Container*
Sanitization Temperatures*
3-201..13 Fluid Milk and Milk Products* 4-501.112 MechanicalWarewashino I-lot Water
3-202.13 Shell En s* Sanitization Temperatures*
3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,PH,
3-202.16 Ice Made From Potable Drinking Water`
concentration and hardness.
5-101.11 Drinking Water from an Approved System 4-601.11(A) Equipment Food Contact Surfaces and
Utensils Clean*
590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food-
590.0(f6(B) Water Meets Standards in 310 CMR 220
Contact Surfaces and Utensils*
ShelNish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui ment*
Shellfish* 4-703.11 Methods ofSanidzatioa-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Reitulatray Authority 2-301.1 I. 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
Receiving/Condition 2401..11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Packa a Lite it * Mouth*
3-101.11 food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Etuto ecs*
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) 1 Labeling of Ingredients' 5-204.11 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 -Accessibility,Operation and Maintenance
lHACCP Pians - Supplied with Soap and Hand Drying
3-502.1Specialized Methods* Devices
3-502.12 Redued oxygen
x packaging,gen criteria* 6-301.11 Handwashing Clanser, Availability
8-103.12 Clonformance with Approved Procedures* 6-301..12 Hand-DrnR Provision
*Denotes cri8cad item in the federal 1999 Food Code 01 105 C1Mft 590-W0. -
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: o �Z Date: � Page: � of
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item "'_ Verified
? - --PLEASE PRINT CLEARLY.
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Discussion With Person in Charge: Corrective Action Required: ❑ No
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ volunta y Compliance ❑ "Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
Ir 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:-
;.. I '
y 3-501.14(C) PHRe Received at Temperatures
Violations Related to Foodborne fitness Interventions and Risk According to Law Cooled to '
Factors(items 1.22) (Cont.) 4I''F/45'F Within 4 Homs.
PROTECTION FROM CHEMICALS I9 3-501.15 Coolin"Methods for PHFs
Id Food or Color Additives PHF Hot and Cold Holding
3-501.16(B) Cold PI-IFs Maintained at or below
3-202.12 Additives* 590.004(F) 41`145°F*
r
3-302.14 Protection from Una roved Additives* 3-501 16(A) Hot PHFs
IS Poisonous or Toxic Substances Maintained at or above
14WF. �
7-101.11 Identifying Information-Original 3-501.16(A) _Roasts Held at or above 1300F.
Containers` 20
Time as a Public Health Control
7-102-I l Common Name-Workirn, Containers*
7-201.11 Separation-Stora e* 3-501.39 Time as a Public Health Control*
7-202.11 Restriction-Presence mid Use's 519;0.004(11) Variance Re ulrement
7-202.12 Conditions of Use"
7.203.ll Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 SainLets,Criteria Chemicals* POPULATIONS(HSP)
n
3-R01.
'll(A) U
7-2W.12 Chemicals for Washin E Produce.Criteria* 21 npasteurized Pre-packaged Juicesd
an
7-204.14 Divide Agents.Criteria* „_Beier rte.with"arsine I. bels*
3-50LII(B) Use ofPtsteutizedFZ*
7-205.11 Incidental Food Contact,Lubricants* 3_g01.11(D} .Raw or Parially Cooked Anitn
7-206.11 Restricted Use Pesticides, Criteria* Fixxl and
Raw Seed Partially
goats Not Served.a7 it
7-206.12 Rodent Bait Stations"' 3-80 L 11(C) Unopened Fotxi Package Not Re-served.
7-206.13 Tracking Powders,Pest Control and
Monitoring*
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3 603-ll Consumer Advis<ay Posted for Consumption of
16 Proper Cooking Temperatures for
Animal Foods That are Raw, Undercooked or
_ PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2)� Eggs- 155'F 7.5 Sec.
Pathooens* .Hecn�c r anar
Eggs-hrvnediate Service 145'F15sec* 2.13 Pasteurized Eggs Substitute for Raw Shell
3-401-11(A)(2) Comminuted Fish,Meats&Game 3-30Eyes*
Aninmis- 155'F 15 sec. *-
3-401.11(13)(1)(2) Pork and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS _
3-401.11(A)(2) Ratites,Injected Meats-155"F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec * catering, mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game; Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish, Meat, debited under the appropriate sections
Poultry or Ratites-165"F 15 sec. * 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
3-401-12 Raw Animal Foods Cooked in a practices should be debited under#29-
Microwave 165'F* Special Requirements.
3-401,11(A)(1)(b) All Other PHFs-- 145'F 15 sec.
I7 Reheating for Hot Holding OOLAT/ONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PHFs 165'F 15 sea "' (Items 23-30)
3-403.11(B) Microwave- 165'F 2 Minute Standine Critical and non-critical violations, which do not relate to the
Time" teodtorne illness intervenoons and risk factors listed above, can be
'3 403.11(C) Commercially Processed RTE Food- ,found in the following seeeions of the Food Code and 105(MR
140'P* 590.000,
3-40311(E) Remaining Unsliced Portions of Beef Mem Good Retail Practices FC 590.000
----- ---
Roasts* 23. Masa ement and Personnel FC-2 .003
Ig Proper Cooling of PHFs 24. Food and Food Protection__ FC_3 .004
25 __Equipment and Utensils _ _FC 4
3-501.14(A) Cooling Cooked PHFs from 140'F to 26 W ater Plumbin and Waste FC 5
.F
70'F Within 2 flours and From 70" 27. Physical I Facility FC-6 .00
to 4l'F/45'F Within 4 Hours. * 28 Poisonous or Toxic Materials FC 7 .008
3-501.14(3) Cooling PHFs Made From Ambient 29 Special Requirements _ .009
Temperature Ingredients to 4I'F/45'F 30 _Other
Within 4 Hours* ssvormr1,.,ar-2411c
''Deniz.,critical item in the Iodate] 1999 Foixt Code or 105 ChiR 590,000.
Massachusetts Department oft Public Health Salem,Board of Health
Division of Food and Drugs )' 120 Washington
Oton St35234'h Floor
SalFOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343
Name Dat Type of Operation(s) Type of Inspection
(( 2 /o/
Food Service ❑ Routine
Address Rik Retail I.Re-inspection
Level El Residential Kitchen Previous Inspection
Telephone ❑ Mobile Date:
Owner , / HACCP Y/N El Temporary ElPre-operation
r ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
In:lq ❑ HACCP
Inspector Out: /J. 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.
�Lr,FOOD PROTECTION MANAGEMENT 2",.W.0 r�,'?.,-74 El12. Prevention of Contamination from Hands
❑ 1 PICA signed/Knowledgeable/Duties
a ❑ 13. Handwash Facilities
rEMPLOYEE HEALTH .:.a u- ..« �
PROTECTION FROM CHEMICALS ' , F-7, -
ases by ti
❑ 2� Reporting of DiseFood Employee and PIC = _ -�� � a. �, ww =4 ��. . P
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
no FOOD FROM APPROVED SOURCE„�''' "'' g""� ' " "
❑ 4. Food and Water from Approved Source �TIMFJTEMPERATURE CONTROLS(Potentially 118zardaus footle) -.
, L,,t. A'?a
❑ 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.' :"! „ a».j, F''"` El 19. Hot and Cold Holding
❑ 8 Separation/Segregation/Protection ❑ 20.Time As a Public Health Control 1
❑ 9. Food Contact Surfaces Cleaning and Sanitizing ; REQOIREMENTS FOR HIGHLY SUSCEPTI8Lt POPULATIGNS(HSP)
El21. Food and Food Preparation for HSP
El 10. Proper Adequate Handwashing
❑ 11.Good Hygienic Practices
CONSUNIERADVISORYI`�K`„„„;,�„ .� � 4W
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(e90.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-a)(sso.004)) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
5:590MSXCIFO 14.Ooc P
Inspector's Signature: Print:
PIC's Signature. "'-' - Print: / Pages of,rPages
( 'i n .1 'i
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from
�590.003(B) Demonstration of Knowledget Cooked and RTE Foods*
- 2-103.11. Person in charge-duties Contamination from Raw ingredients
3-302A I(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other*
2 590.003(C) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.1.1(A) Food Protection*
applicants* 3-302.15 Washing Fruits and Vegetables
590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge' Contamination from the Consumer
590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Resttietions Food
3-701.1.1 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Food*
$ 1 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501..1.1 I. Manual Warewashing-Hot Water
3-201.12 Food in a Hermetically Scaled Container* Sanitization Tem eratures*
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Hot Water
Sanitization Temperatures*
3-202.13 Shell E- s* Water** 4-501.114 Chemical Sanitization-temp.,pH,
3-202.14 E =s and Milk Products.Pasteurized concentration and hardness. .,
3-202.16 Ice Made From Potable Drinking
5-101.11 DrinkingWater from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled DrinkingWater* Utensils Clean"
590.006(B) Water Meets Standards in 310 CMR 22.0 4-602.11. Cleaning Frequency of Equipment Food-
` *
Contact Surfaces and Utensils
Shellfish and Fish Froman Approved Source 4-702.11. Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Meth<dsofSanitization-HotWaterand
3-201.15 Molluscan Shellfish from NSSP Listed ChemicaPk
Sources* t0 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority 2-301.11. Clean Condition-Hands and Anns*
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* 1.1 Good Hygienic Practices
g Receiving/Condition 2401.11. Eating,Drinking or Using Tobacco*
3-202.11 - PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and
3-202.15 Package Integrity* - Mouth*
12
3-101.11. Food Safe and Unadulterated* 3-301.12Preventing Contamination When Tastin *
6 TagslRecords:Shellstock Prevention of Contamination from Hands
3-202.18 Shellstock Identitication* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Employees*
Tags/Records;Fish Products 1 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
5-203.11 Numbers and Capacities*
3-402.12 Records.Creation and Retention* 5-204.11 Location and Placement*
590.004(J) - Laabelingg of Ingredients' -
ry Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
fHACCP Plans Supplied with Soap and Hand Drying
-3-502.11. S ecialized Proeessin Methods*
Devices
3-502.12 Reduced ox en packaging.criteria* 6-301.11 Handwasihing Cleanser,Availability
' 8-103.12 Conformance with Approved Procedures*
6-301.12 Hand Dr 'ng P ov sion
*Denotes critical item in the federal 1999 Foal Code or 105 CMR 590.094. -
CIT OF SALEM
BOARD OF HEALTH
L Establishment Name: Loa lhn_� y2o. Date: & Page: r of
Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLA O CORRECTION Defeo
No. Reference R—Red Item Verified
E - PLEASE PRINT.CLEARLY -
T 4 Y
41
!Q
1 � � t '� AD -
�T J
a
'i
3
r
zS
4
+C
i�
e
r
Y
l
't
;+t
tE Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
! ❑ Voluntary Compliance LI Employee Restriction/
I have read this report, have had the opportunity to ask questions and agree to correct all Exclusion
violations before the next inspecYon, 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 ollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. /�/
�_ ,�,�— ❑ Voluntary Disposal ❑ Other:
3-50J,14(C) PHFs Received at Temperatures
Violations Related to Foodborne Illness Interventions and Risk According to LaW Cooled to
Factors(items 1-22) (Cont) 4 F:F/45`F Within 4 Hours.
3-SOL!- -5 1 Cooling Merbod's for PHFs
s
PROTECTION FROM CHEMICALS
F-14 Food or Color Additives Lj_9 PHF Hot and Cold Holding
3-202.12 Additives i 3-501.16(B) Cold Kips Maintained at or below
590.0049 41'145° F*
3-302.14 Protection lines Una p2roved Additives*
L-15 Rofsonous or Toxic Substances 3-501,16(A) Hot PHFsMaintained at or above
140'17. *
7-101.1 I Identifying Information-Original 3-501.16(0) Rousts Held at or above 130'F,
Containers*
20bile Health Control
-FI02 It Common Name--Workha.�,Containers* Time as a Pu
7-201.11 -.Separation-Storage* 3-5UL19- Time as a Public Heald)Control-
7-202,11 Restriction-Presence and Use* 590.004(H) Vaxiance Re uirc[n ent
7-202.12 ConifiTions-id Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-20111 Toxic Containers-Prohibitions`
POPULATIONS(FISP)
7-204.11 Sanitizers,Criteria-Chemicals*
7-204.1.2 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
Beverages with Warning babel;"
_6ryin�-Agents.Criteria* a
-,-801,11(B) Use of Pasteurized Less*
7-2(15.11 Incidentid Food Contact,Lubricants* - 3-&01 A I(D) Raw Sr Partially Cooked Animal Food a
7-206.11 Restricted Use Pesticides.Criteria* - nd
Raw Seed Sprouts Net Served.
,206A2 Rodent Bail Stations"
7-206,13 Tracking Powders,Pest Control and -1-8() (C)
Monitarrifl8* CONSUMER ADVISORY
TIMErrEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods'lliat are Raw.Undercooked or
Proper Cooking Temperatures for
PHFs ,N
of()tber,iSe Processed to Eliminate
3-401.1.1 A(1)(2) Eggs- 155'F 15 Sec.. Path s
'�)"Cas
Eggs-Immediate Service 145"F15sec, 3-302.13 Pasteurized Eggs Substitute for Raw Shell
3-401.,11(A)(2) Comminuted Fish, Meats&Game Eggs*
Animals- 155°T 15 sec. *
3-401.11(13)([)(2) Poricand Beef Roast - 130'F 121 min* SPECIAL REQUIREMENTS
'3-401.11(A)(2) Ratites, Injected Meats- 155'F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
see. * catering, mobile food,temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-165°P15see, 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 165°F- Special Requirements.
3-40 1.11(A)(1)(b) All Other PHFs-145'F'15 see.
F-17 - Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&Q)) PHFs 165-F 15 sec. * (Items 23-30)
3-403.11(B) Microwave- 165°F 2 Minute Standing Critical and non-crithad violations, n-hich do not relate to the
Time': foodborne illness interventions and risk factors listed above, can be
,403.11(C) Commercially Processed RTE Food- found at rhe follow sections o/the Food Code and 105 CMI?
14WF* 590.000-
3-403.1.1(E) Remaining Un.Qiced Portions of Beef Item Good RetainPractices _-Fic-T-5,g000d-
Roasts' 23. Marra ement and Personnel FC-2 1 .003
lA Proper Coo- -TC-3�1004
l 24. Food and Food Prolection
Cooling of PHFs
25._ __Equipment and Utensils FC-4 1 .005
3-501.14(A) Cooling Cooked PHFs from NOT ir) 26, Water, Plumbinit and Waste Fc-_5 Fa
70+'Within 2 flours and From 70+ 27. Physical Facilitv FC-6 I .007
1 to41'-F/45°FWithin 4Hours. 28. Poisonous or Toxic Materials FC-7 1 .008
--
3-501J4U800 Cooling PHFs MadeFrom Ambient 29 §22ctal R uirements 000
Timsperature hi&redients to 4 I'F/45'F _30o Other
I Within 4 flouri;'
Denotes critical ilon in Ih,loderal 1999 Food('ode or 105 CNIR 590000.
Massachusetts De artment of. Public Health Salel},Board of Health
rp d 120 Washington Street,4" Floor
Division°of Food and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name Dat Tvoe of Ooeration(s) Tvoe of Inspection
n L Food Service LkRoutine
Address ' Ri ( ❑ Retail ElRe-inspection
jec L el El Residential Kitchen Previous Inspection
Telephone - ❑ Mobile Date:
OwnerHACCP YM El Temporary ElPre-operation
:V It �' ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint
El HACCP
Inspector In:o�'(4 Permit No. ElO herr
c Q Out:
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) ❑ 59o.00g(F) ❑
action as determined by the Board of Health.
�FOOD gROTECTION MANAGEMENTS - � .p=,m.n"„mom T .,g ,a;a'-" ❑ 12. Prevention of Contamination from Hands
PIC Assigned/Knowledgeable/Duties
❑
EMPLOYEE HEALTH """" -r • riamg«• a p�• s"i • 13 HandwashFacilibes
�a.m.�..a �..,. ,m 91., �', .E,4,'R *Xdr," ai PROTECTION FROM CHEMICALS'
❑�2. Reporting of Diseases by Food Employee and PIC A
❑ 14.Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals
�iFOOD FROM APPROVED SDURCE, . _.,,�
E] 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potemialiy Hazzardoua Food-9I on
❑ J
16. Cooking Temperatures'
em;p�e+�ra.atumr.es
5. Receiving/Condition , +.� eta a,�'�? a a •a18H39 `
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 16.Cooling
�
*� 1PROTECTION FROM CONTAMINATION�E _ •, F P I�w� .� 9. Hot and Cold Holding
❑ 8 Separation/Segregation/Protection ❑20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing 1:RE'OUIREMENTS FOR HIGHLY SUSCEPTIBLE PUPULATIONS'(H§Pj;,;,
El21. Food and Food Preparation for HSP f
El 10. Proper Adequate Handwashing
❑ 11. Good Hygienic Practices
[122. Posting of Consumer Advisories ff
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22):
of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code. This report, when signed below
c by a Board of Health member or its agent constitutes ani"''
24. Food and Food Protection (FC-3)(590
3. Management and Personnel (FC-2)(590.0 4)) order of the Board of Health. Failure to correct violations ,
cited in this report may result in suspension or revocation of
25. Equipment and Utensils (Fc-a)(sso.00 )oos)f 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)(510.0011) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature: J� Print:
PIC'sSignature: Prim: -G /. i u I G PagejofPages
V Ir
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 9-22)
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT 8 Cross-contamination
1 59b.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from
-590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
2-103.11 Person in charge-duties Contamination from Raw Ingredients
3-302.1.1(A,)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other-
2 590.003(0) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.11(A) Food Protection*
applicants*, 3-302.15 Washingits and Vegetables
590.003(F) Responsibility Of A}rood Employee Or An 3-304.11 Food Contact with Equipment and
Applicant To Report To The Person In Utensils*
Charge* Contamination from the Consumer
590,003(6) Re ortina by Person in Charge 3-306.14(A)(B) Returned Food gid Reservice of Foal*
3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions Food
3-701.1'1 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCEFord*
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590A04(A-B) Compliance with Food Law* 4-501_t l Manual Warewashing-Hot Wates
3-201.12 Food in a Henneticall•Sealed Container* Sanitization Ten eratures* -
3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water
3-202.13 Shell Egs* Sanitization Tem eratures*
3-202.14 roducts.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.
5-101.11 DrinkingWater from an Approved System, 4-601.11(A) Equipment Food Contact Surfaces and
590.006(A) Bottled DrinkingWater* Utensils Clean*
590.006(B) Water Meets Standards in 310 CMR 22.0"` 4-602.11 Cleaning Frequency of Equipment Food--
Surfaces and Utensils
Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* 1p Proper,Adequate Handwashing
Regulatory Authority Game and Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arias*
Aut
3-202.18 ShcllstockIdentification Present* 2-301.12 Cleaning Procedure*
590.004(0) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* 1.1 Good Hygienic Practices
5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco*
3-202.11 PHFs Received at Proper Temperatures* 2401.12 Discharges From the Eyes, Nose and
3-20115 Package Inteit * Mouth*
3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.1.2 Shellstock Identification Maintained* Em to 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(J) Labeling of Ingredients' 5-204.11 Location and Placement*
q Conformance with Approved Procedures 5-205.1] Accessibility, Operation and Maintenance
/HACCP Pians Supplied with Soap and Hand Drying
Devices
3-502.11 Serialized L) Methods*
<�
Processing jvledto6301.11 Handwashin Cleanser,Availability
3-502.12 Reduced oxygen
en racka 'n ,criteria*
8-103.12 Conformance with Approved Procedures* 6301.12 Hand Drying Provision
r
*Denotes critical item in the fedend 1999 Fail Cale or 105 CMR 590.000. -
' r y
F Y rat '
CITY O,F-SALEM As 1 m
t BOARD OF HEALTH
Establishment Name: c aDate: '7 of
Page:-
Item
i
Code C-Critical Item DESCRIPTION OF VIOLATION/PL NOF CORRECTION Date
f No. Reference R-Red ItemVerified
n {' PLEASE PRINT CLEARLY..
, oar t- '90 UaCln '
-ter. sri Cd-
iU "• 1P e s 1F
F '
t ,
n
f)ojjNffc -ins �in c� erOAA , r,
FI L n M I—q�3— ITa? �kc e
k 3 0, tend H z 3a °1= w� � fh
c oJM�nn e/s4740, li efl CGti rc- .,.e -q4
t
fi
t
k
4 Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
i Voluntary Compliance ❑ Employee Restriction
/
C I have read this report, have had the opportunity to ask questions and agree to correct all VoExclusion
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
4 noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of Embargo ❑ Emergency Closure
`4 your food permit. = /
, . ❑ Voluntary Disposal ❑ Other:
4 �
Y
3-501,14(C) F41
HFS Received at'I'entperatures
Violations Related to Foodborne Illness Interventions and Risk ccording to Law Cooled to
Factors(items 1-22) (Cont) 'F/�45'F Within 4 Hours.
PROTECTION FROM CHEMICALS 3-501.15 1 Coolim,Methods for PHFS
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additives 3-501.16(B) Cold PHFs Maintained at or below
590.004(F) 41°/45' F"
3-302.'14 Protection from Una roved Additives* 3-SO1.16(A) Hot PHFc Maintained at or above
15 Poisonous or Toxic Substances
140"F. *
7-101.11 Identifying tnfonnation-Orifi not 3-501.16(A) Roasts Held at or above 130'F.
Containers*
7-1.0211 Common Name-Warkini Containers* 20 Time as a Public Health Control
7-201.7 7 Se.enation-Storage" 3-301-19 Time as a Public Health Control*
7-202.11 Resttictipn-PresenceattdtJse*
590004('H) Varianec Re Trement
7-202.12 Conditions of Ilse"
7-203-11 Toxic Container,-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criterin-Chemicals* POPULATIONS(HSP) _
7-204.12 Chemicals for Washiin,Produce,Criteria* 21 3-301.1 I(A) Unpasteurized Pre-packaged juices arid
7-204.14
Beverages with Warning I..abets*
Drina, ents,Criteria* '*
3-801_11(B) Use of Paste
7-205.11 Incidental Food Contact,Lobricants* 11lly C Ekes*
3-801.1
7-206.11. Restricted Use Pesticides. Criteria* .1(D) Raw or Partla7lyCaaketl Animal Food and
Raw Seed Sprouts Not Served. ,r
7-206.12 Rodent Bait Stations` 3.801.1I(C Unopened Food Packs<�
e Not Re-served.
7-206.13 'tracking Powders,Pest Control and
Monitorinv*
CONSUMER ADVISORY
TIMETTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw,Undercooked or
16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate
PHFS enx�s. rirsda�
3-401.1.1 A(l)(2) 1„gs- 155 F 1.5 Sec. Pathe em
Eves-binnediarc Service 145°F15sw 3-302.13 Pasteurized Fggs Sute Lihrte for Raw Shell
3401.11(A)(2) Comminuted Fish,Meats S.Game
E s*
Annuals 15-5'F I7 sec * SPECIAL REQUIREMENTS
3-401.11(B)(1)(2) Pork and Beef Roast 130E 121 min*
3-401.11(A)(2) Rana;s,Injected Meats- 155'F 1.5 5900009(A)-(D) Violations of Section 590.009(A)-(D)in
sec. * catering, mobile food, temporary and
3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFS, residential kitchen operations should be
Stuffing Containing Fish, Meat, debited ander the appropriate sections
Poultr or Ratites-165�F 15.sec. " above if related to foodborne illness
3-401,11(C)(3) Whole-muscle,Intact Beet Steaks intetwentions and risk factors. Other
45°1`* 590.009 violations relating to good retail.
3-401.12 Raw Animal Foody Cooked in a practices should be debited under#29--
_Microwave 165`F* Special Requirements.
3-401.1l(A)(1)(b) All Other PHFS-145'F 15 sea
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3403.11(A)&(D) PHI``+s 165'F 15 sec. '^ (Items 23-30)
3-403.11(B) Microwave- 165'F2 Minute St'andine Citieal and non-critical violations, which do not relate to the
Tice* foodborne illness intetventions and risk fo(lors listedabove, can be
-T--403 1 I(C) Commercially.Processed R'PE Faxl- ,found in the following sections of the Food Code and 105 CMR
1.40°F* 590.000.
3-403 JI(E) Remaining Unsliced Portions'of Beef Item Good Retail Practices_ FC 580.000
Roasts' 23. Mans emeni and Personn_el__ FC-2 .003
ig Proper Cooling of PHFS 24. Food and Food Protection - __ FC-3 .004
___
25. __Equipment and Utensils _FC_-4_ _005 _
3-501.14(A) Cooling Cooked PHFS from 14W to 26,
Water Plurn[Ang and Waste FC-a 1 .006
70'1-Within 2 Hours and From 70'F 27. Ph foal Facility_ _ FC-6 007
to 41'F/45'F Within 4 Homs. * 28. Poisonous or Toxic Materials FC-7 ' .008
3-501.1487 Cooling PRFs Made From Ambient -2q-
S ,sial Re uirements __ ._009
Ternperatnre Ingredients to 41'F/45`F Other
Within 4 Efours:` rI-A, z do,
'Denotes vt'itical i[e,�n in the tedexztl 1999 Pood Code or 1 OS C'MR 590-000.
p
{ CITY OF SALEM
�_ BOARD OF HEALTH
Establishment Name: hn s ,7--7c-, Date: r-r 0(o Pager of 7
i Item Code C-Critical Item DESCRIPTION'OF VIOLATION/PLAN OF CORRECTION Date
;! No. Reference R-Red Item y. Verified
PLEASE PRINT CLEARLY
A J t-5
�t 11 ``''-- I
!r - 37S l G n G �t�l -r S -/�.
S7) r 76Pe
tr
t q ( j
r _ ,
i
y II
if
l
Y
¢ M,
Discussion With Person in Charge: Corrective Action Required: .❑ No Yes
have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employer 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 Ll Embargo L) Emergency Closure
your food permit.
—Voluntary Disposal ❑ Other:
A
3-501.14(0 PHFs Received at'lemperatures
Violations Related to Foodborne Illness Interventions and Risk According to Iaw Cooled to
Factors(Items 1.22) (Cont.) 4l'F/45'F Within 4 H)urs.
PROTECTION FROM CHEMICALS 3-501.15 Coolim,Methods forPHFs
14 Food or Color Additives 19 PHF Hot and Cold Holding
3-202.12 Additites 3-501.16(B) Cold PHFs Maintained at or below
3-3()2.14 ProtectionU
�framnaproved Additives'' 590.004(17) 41'745°F*
1g Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above
7-101.11 Identlforig information-Original 140°F.
3-50L16(A) Roasts Held at or above 130`F
Containers* .
7-102.11 Common Name- Workint,Containers'" 20 Time as a Public Health Control
7-201.11 Separation-Stonacre4` 3-501.19 Time as a Public Health Control*
590.004(H) Variance Re uirement
7-20211 Restriction-Presence and Use'"
7-202.12 Conditi ons of Use*
720311 Toxic Containers-Pmh3bitiono REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204.11 Sanitizers.Criterias-Chemicals" POPULATIONS(HSP)
7-204.12 Chemicals for Washing Produce. Criteria* 21 3-801.I I(A) Unpasteurized Pre-packaged Juices and
Beverages with War ninel.abels*
7-204.14 Dr�in�r eats,Criteria* -
7-205.1.1 Incidental Food Contact,Lubricants" 3-SO1.11(B) Use of Pasteurized Eaasl
7-206.11 Restricted Use Pesticides, Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and
Raw Seed Sprouts Not Served. ,w
7-206.12 Rodent Bait Stations* 3$01.11 tC Uno anal Food Package Not Re-served. *
7 06.13 Traeking Powdc,rs,Pest C::onaol and )
4lonitorin
CONSUMER ADVISORY
TIME/TEMPERATURE CONTROLS 22 3-6ffi.1 i Consumer Advisory Posted for Consumption of
1fi Proper Cooking Temperatures for Animal Foods'I'bat are Raw. Undercooked or
PHFs Not Otherwise Processed to Eliminate
3-407.1 I A(1)(2) F gs- 155'F 15 Sec.
Pathogons.* Ea,,Iv,uraoor
E gs-Iunncdrate Service 145°F15see* 3-302.13 Pasteurized Eggs Substitute for Raw,Shell
3-401.11(A)(2) Comminuted Fish,bleats&Geon E s*
Animals- 155-'F 15 sec. *
3-401.11.(8)(1)(2) pork and Beef Roast-130`F 121 nein* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites, injected Meats- 155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in
sec. ' catering. mobile food,temporary and
3-40L11(A)('3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Poultry or Ratites-1651F 15 sec. „ above if related to foodborne illness
3-401.1 I(C)(3) Whole-muscle,Intact Beef Steaks Interventions and risk factors. Other
145-F It 590.009 violations relating to good retail.
3-401.12 Raw Animal Foods Cooked in a practices should be debited under 129-
Microwave 165'F - Special Requirements,
3-401.11(.A)(I)(b) All OtherPHFs- 145'F 15 sec
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(AWD) PHFs 165°F 15 sea. ' (Items 23-30)
3403.1 IB) Microwave-165°F 2 Minnie Standing Critical and non-erilical vic lalions, which do not oclare to file
Timex` ,foodborne illness into vennons and risk factors listed above, can be
1-403.11(C) Commercially Processed RTE Food- ,found in the following sections of the Food Code sad 105 CMR
140°F* 590.000.
3-403.11(E) Remaining Unsliced Portions orlteef Item Good Retail Practices ( FC 580.000
Ronsts'I 23. Manaement and PersonnelFC-2 .003
L.
1g Proper Cooling of PHFs 24._ Food and Food ProtectionFC-3_ 004
25. E ui ment and Utensils FC 4 .005
3-501.1A(A) Cooling __Cooked PHFs from 140`F to 26 Water.Plumbin and Waste FC S .006
70°F Within 2 Hours and From 70°F 27. Ph sical Facility FC- 6 .007
to 41'F/45°F Within 4 Hours. ` 28. Poisonous or Toxic Materials FC-7 .008
3-501.'14B) Cooling PHFc Made From Ambien 29 S acts Re ulremants A09
Temperature Ingredients to 41017(451F 30 Other L
Within 4 Hours" so�0r°iba"�a.m
Denotes critical item in the fieral 1999 Food Code or 105 CMR 590900.
co CITY OF SALEM, MASSACHUSETTS
gr.
�. BOARD OF HEALTH
3 120 WASHINGTON STREET, 4TH FLOOR
e SALEM, MA 01970
TEL. 978-74 1-1 800
FAX 978-745-0343
STANLEY USOVICZ. JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter
94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate
a Food Establishment in the City of Salem is hereby granted to:
Owner' s Name : Constantine G. Saivanos
Name of Establishment : Papa Johns Pizza
Address of Establishment : 233 Washington Street
Type of Establishment : FOOD SERVICE
Application Date : 12/30/2002
Restrictions :
Permit for Food Establishment 160-03
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2003
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
F
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 GE0 2 0 2002
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR, JOANNE SCOTT, MPH, CHO
MAYOR , RBOARD F hEALTH
HEALTH AGENT
2003 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT_eUa 30h �S PliZI TEL# q]j
7
ADDRESS OF ESTABLISHMENT jnt 1&0
MAILING ADDRESS (if different) 6A I' 'int A
OWNER'S NAMEan5f� b7r vaA o TEL
r)?, r-j .6" #A1--—6m —
60,
ADDRESS 5 1 PPAJoAQ.
CITYa
-LakJ--KJJL_ ZIP
CERTIFIED FOOD MANAGER'S NAME(S) STATE CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared,)
HMERGENCYRESPONSEPERSON�
kn T-P /ta
OURS OF OPERATION: M04ue,
TYPE OF ESTABLISHN FEE check only
RETAIL STORE YES NO G3 less than 1000sq.ft, 0,
0
1000-10,000sq,ft 0
more than 10,000sq.ft. =!25050
RESTAURANT ',YES NO less than 25 seats =$100
25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL tJON-PROAIT(such as church lrltc."ncl YES A0 025
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made,all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 620, Section 49A, I certify under the pains and penalties of perjury that 1, to my
best I nowledge and belief, have filed allstate x returns and M all state taxes required under the law.
-? wgoel
gn a(JuAr e Dafe Social Security or Federal Identification Number
Revised 11125/02 FOODAP2.8din Check#&Date
- - - -- V I
THE COMMONWEALTH OF MASSACHUSETTS
CITY OF SALEM Address: 120 Washington Street, 4th Floor
BOARD OF HEALTH Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel: (978) 741-1800 Fax: (978) 745-0343
Nam r` Date Type of Ooeration(s) T In I n
(J/f/2,+ LI o)fJtl f f l22 !( tJ f Z!Food Sem rvice Routine
Address Risw ❑ Retail ❑ Re-inspection
Level ❑ Residential Kitchen Previous Inspection
Telephone23,z V451'lal Nfi-i'd's s,r- El Mobile Date:
Owner HACCP YIN ❑ Temporary ❑ Pre-operation
C tpNs(A 1 t; 6 _34I P ❑ Caterer ❑ Suspect Illness
Person In Charge(PIC) ,,,I/� )r Lt_��1 Time ❑ Bed 8 Breakfast ❑ General Complaint
In: ❑ HACCP
Inspector V1 Out: Permit No. LlOther
Each violation checked requires an expl nation on the narrative page(s) and a citation of specific provision(s)
violated. Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors (Red Items) Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health. Local Law ❑
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/ Duties
❑ 13. Handwash Facilities
EMPLOYEE HEALTH
El 2, Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS
113. Personnel with Infections Restricted/ Excluded El 14. Approved Food or Color Additives
❑ 15. Toxic Chemicals
FOOD FROM APPROVED SOURCE
El 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)
El 16. Cooking Temperatures
L1 5. Receiving/Condition
[16. Tags/ Records/Accuracy of Ingredient Statements El 17. Reheating
' ❑ 18. Cooling
❑ 7. Conformance with Approved Procedures/ HACCP Plans
El 19. Hot and Cold Holding
PROTECTION FROM CONTAMINATION
❑ 20. Time as a Public Health Control
❑ 8. Separation/Segregation/ Protection
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
❑ 9. Food Contact Surfaces Cleaning and Sanitizing
❑ 21. Food and Food Preparation for HSP
❑ 10. Proper Adequate Handwashing
CONSUMER ADVISORY
❑ 11. Good Hygienic Practices ❑ 22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/Federal Food Code.This report, when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing
28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
Inspector's Signature: A Print:
PIC's Signature:
Print- Page-cof�Pages
/ /r/iC IVAO1 4�./.k--f
FORM 734A HOBBS a WARREN -BOSTON
Violations Related to Foodborne Illness
Interventions and Risk Factors (Red Items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from
1x 590.003(A) Assi nment of Res onsibilit * Cooked and RTE Foods*
590.003(8) Demonstration of Knowledge* Contamination from Raw Ingredients
2-103.11 Person in Charge-Duties 3-302.11(A)(2) Raw Animal Foods Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the Person in Charge to 3-302.11(A) I Food Protection*
require reporting by Food Employees and 3-302.15 Washing Fruits and Vegetables
Applicants* 3.304.11 Food Contact with Equipment and
590.003(F) Responsibility of a Food Employee or an Utensils*
Applicant to Report to the Person in
Charge* Contamination from the Consumer
3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(G) Reporting by Person in Charge* Disposition of Adulterated or Contaminated
«3 590.003(D) Exclusions and Restrictions* Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
Food*
FOOD FROM APPROVED SOURCE 9 Food Contact Surfaces
4* Food and Water From Regulated Sources 4-501.111 Manual Warewashing-Hot Water
590.004(A-B) Compliance with Food Law* Sanitization Temperatures*
3-201.12 Food in a Hermetically Sealed Container* 4-501.112 Mechanical Warewashing-Hot Water
3-201.13 Fluid Milk and Milk Products* Sanitization Temperatures*
3-202.13 Shell Eggs* 4-501.114 Chemical Sanitization-tem H,
3-202.14 Eggs and Milk Products,Pasteurized* p'P
88 Concentration and Hardness
3-202.16 Ice Made from Potable Drinking Water* 4-601.1 I(A) Equipment Food Contact Surfaces and
5-101.11 Drinking Water from an Approved System* Utensils Clean*
590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food-
590.006(B) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source 4.702.11 Frequency of Sanitization of Utensils and
3.201.14 Fish and Recreationally caught Molluscan Food Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization- Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources*
"1R. Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by
Regulatory Authority 2-301.11 Clean Condition-Hands and Arms*
2-301.12 Cleaning Procedure*
3.202.18 Shellstock Identification Present* 2-301.14 When to Wash*
590.004(C) Wild Mushrooms* 11 Good Hygienic Practices
3-201.17 Game Animals* 2-401.11 Eating,Drinking or Using Tobacco*
5 Receiving/Condition 2-401.12 Discharges From the Eyes,Nose and
3-202.11 PHFs Received at Proper Temperatures* Mouth*
3-202.15 Package Integrity* 3-301.12 Preventing Contamination When Tasting*
3-101.11 Food Safe and Unadulterated* ''12, Prevention of Contamination from Hands
6> Tags/Records:Shellstock 590.004(E) Preventing Contamination from
3-202.18 Shellstock Identification* Employees*
3-203.12 Shellstock Identification Maintained* 13 Handwash Facilities
Tags/Records: Fish Products Conveniently Located and Accessible
3-402.11 Parasite Destruction* 5-203.11 Numbers and Capacities*
3-402.12 Records,Creation and Retention* 5-204.11 Location and Placement*
590.004(J) Labeling of Ingredients* 5-205.11 Accessibility,Operation and Maintenance
7.+ Conformance with Approved Procedures Supplied with Soap and Hand Drying
/HACCP Plans Devices
3-502.11 Specialized Processing Methods* 6-301.1 I Handwashing Cleanser,Availability
3-502.12 Reduced Oxygen Packaging,Criteria* 6-301.12 Hand Drying Provision
8-103.12 Conformance with Approved Procedures*
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
'r CITY OF SALEM
BOARD OF HEALTH
Establishment Name: P'4" /�ws / -/� Date: e Page: 2 of 2
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R—Red Item Verified
PLEASE PRINT CLEARLY
CL "-WJ^4.5L. o 'LC3v*— dl L
✓.//�iEL AG.,_ G ✓t r tft QzJ c> = � �,S' No cJ
C,,4FC r r-tlm (�Ctzi
h
`r ✓ I 00LI
r
Discussion With Person in Charge: Corrective Action Required: Ll No ❑ Yes
have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
P ❑ Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twen - e Bolla suspension/revocation of ❑ Embargo ❑ Emergency Closure
your food permit. .
L3Voluntary Disposal Ll Other:
I
3-501,14(C) PHFs ReceivedatTerriperitures
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(items 1-22) (Cont.) 41'17/45'F Within 4 Hours,
PROTECTION FROM CHEMICALS Cooling Methods for PHFs
L14 Food or Color Additives 19 PHF Hot and Cold Holding
3-501,16(B) Cold I'liFs, Maintained at or below
3-202.12 Additives* 590.004(F) 4 l'i45'F1'o-o- 3-302,14 Protection frortriLtLinspEroved Additives -3-501,16(A) Hot PI1Fs Maintained at or above
LIS Poisonous or Toxic Substances 1400F.. '
7101-1] Identifying—Inforniation-Original 3-501.16(.0) Roasts Held at(it above 130°F.
Containers;, 20 Time as a Public Health Control
7-102.11 Coulawn Name I-Working Containers*
7-201,11 Separation-Stot aEO 3-501,19 Time as a Public Health Control*
7-202,11 Restriction-Presence and Use" 590.004(H) VarianseRecuiretnent
7-20112 Conditions of Use, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-204,11 toxic Containers-Prohibitions*
7-204.11 SanftiCcrs.Crincria-Chernicals* POPULATIONS(HSP)
7-204.'12 Chemicals for NVashin, Produce,Criteria" 21 3-801.11(A) Unpasteurized Pre.packagedJuices and
7-A14A4 DrLing Agents Quena' Bevejages with Warning Labels*
3-801.1)(13) -tt—�);1-tteu'1l7CdEggS�
7-205.11 Incidental Food Contact,Lubricants*
3-801.11(D) Raw or Partially Cooked Animal Food and
1-2106.11 Restricted Use Pesticides,Criteria* Raw Seed SprOL119 Not Served. 4:
7-206,12 Rodent Ban Stations* 3-801.11(C) Unopened Food Package Not Re-served.
7-206,13 ,o
ing'ackPowders,Pest Control arid —
TN4",taring"
.....g" CONSUMER ADVISORY
TIM ErrEMPERATURE CONTROLS 22 3-603,11 Consumer Advisory Posted for Consumption of
16 A Proper Cooking Temperatures for Annual Food-,That are Raw, Undcrcoo)ked or
PHFs erw
Not Otherwise Processed to Eliminate
1�1',001
3-40 1.11 A�1)(2) Eggs- 155'F 15 Sec. Pathogens,* F""',
E. s-Immediate Service 145'FlSwc* 3-302,13 1 Pasieurvccl Eggs Substitute for Raw Shell
3-401.1—(A)(-,) Comminuted Fish.Meats &Game
i'uninah,- 155T 15 sec. *
3-401.1 t(B)(1)(2) Pork and Beef Roast- 1307121 min;' SPECIAL REQUIREMENTS
3-401.11.(A)(2) Ratites, Injected Meats- 155-F 15 59(t009(A)-(I)) Violations of Section 590.009(A)-(D)in
Sec * catering, mobile food, temporary and
- Poultry Wild Game:..Stuffed PHFs, residential kitchen operations should be
3-40 1.11(A)(3) i
Staffim,Containing Fish,Meat, debited under the appropriate sections
Poultiv or Ratites-165°F 15 sec. above if related to foodborne illness
3-401.11(C)(3) Whole-runwie,Intact Beef Steaks interventions and risk factors. Other
145'F* 590.009 violations relating to good retail
3-401.12 Raw Annual Foods Cooked in a practices should be,debited under#29 -
--- Microwave 1651, Special Requirements.
3-401.1 1 6)0(1)(b) At I Other PHFs- 145'F 15 see.
1
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-403.11(A)&(D) PI Ii 165'F 15 sec. (items 23-30)
3-403.11(B) Microwave- 165'F 2 Minute Standi,.,, Critical and non-critical violations, which do not relate to the
Tittle* foodborne illness naerventions and risk factors listed above, can be
3-40111(C) Commercially Processed RTE Food found in the following sections rf ihe Food Code and 105 CMR
14WF1 590.000.
3-403.11(E) Remaining Unsliced Portions of Beef Item 1: Good Retail Pi 590.000
poasta* 23. 'i I'danarpentiont and Personnel FC-2 ,003
24. Food and Food Protection -3 .004
Proper Cooling of PHFs
— 25. up 1 2C_4
Tent and Utensils 005
3-501.14(A) Cooling Cooked PHFs from 140'F to -- --- -------------
A. Water.Plumbing FC-5 _,006
70"F Within 2 Hours and Fronl7WF 2-7 Rh—ysical Facility FC-6 007
to 4 I'F/45'F Within 4 Hours, 213. Poisonous or Toxic Materials FC-7 _208
3-501.114(13) Cooling PHFs Madc.Front Ambient 29. SE
Temperature Ingredients to 41'F/45'F 30. off
Within 4 Hours*
I>nole,critical item in the tederil 1999 F(x)d 000 or 10�CMR 590.000.
.M'" 3�yN'„F''�'"�"��� ;���a y.� +�,Sr �, '.41 �• 'iii x �,ur�'�c � �k'# ir��s' �+}«o� �::»,
t
�', r � �'`"-... .Yr"'�.'-"k. Tye r f ". • r.� r
CITY OF SALEM MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET;4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Papa Johns Pizza
Address of Establishment: 233 Washington Street
Owner's Name: Constantine G. Saivanos
Restrictions:
Application Date: 12/6/2004
Permit for Food Establishment 164-05
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2005
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
' ! CITY OF SALEM, MASSACHUSETrza j
�! BOARD OF HEALTH C rg B'V/
120 WASHINGTON STREET, 4TH FLOOR Illiii��� �J�II IdJIj
a SALEM, MA 01970 �7 A
TEL. 978-741-1800 DEC — 12004
FAX 978-745-0343
CITY OF SALE
JOANNE SCOTT, MPH, RS, SALEM
J. USOVICZ, JR. -
MAYOR HEALTH AGENT BOARD OF HEALTH
2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT Aapp, 'S Ll-C_ / / /T�E/L#
ADDRESS OF ESTABLISHMENT lkd- 0 /'?/0
i
MAILING ADDRESS (if different) /me, leo &' uaZ4 � c�—0/d 3 5-
OWNERS
OWNER'S NAME (20hi- -dw7, up 6. f&4'Z;"0S TEL# %76?fd% `moi-.
ADDRESS IYA/ -k- ejje. led-
CITY �� STATE MeL - ZIP e2/F3
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON HOME TEL#
HOURS OF OPERATION: Mon.—Tue.—Wed.—Thu.—Fri.—Sat.—Sun.
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
more than 10,000sq.ft. =$250
RESTAURANT (::Y�ES NO / less than 25 seats =$100
ItQ 25-99 seats =$150
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Signature Dat Social S cunt r FdI Identification Number
elm Revised 11/03/03 F0ODAP2. dm Check#&Date
�/b G
O1Y
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
. a® 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745.0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter 94,
Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food
Establishment in the City of Salem is hereby granted to:
Type of Establishment: FOOD SERVICE
Name of Establishment: Papa Johns Pizza
Address of Establishment: 233 Washington Street
Owner's Name: Constantine G. Saivanos
Restrictions:
Application Date: 12/2/2003
Permit for Food Establishment 63-04
Frozen Desserts/Ice Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2004
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment,
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
• u CITY OF SALEM, MASSACHUSETTS {��'I�',ggq11`►(((1� �` R U
BOARD OF HEALTH IAV
3
120 WASHINGTON STREET, 4TH FLOOR I/ NOV 212003
1 SALEM, MA 01970
TEL. 978-741-1800 ( j( ( OF SALEM
FAX 978-745-0343
STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO L30AR
D OF HEALTH
MAYOR HEALTH AGENT -
2004 APPLICATION `FOOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
`
NAME OF ESTABLISHMENT 1J 0t 42IS L/ /C / TEL# ,-_��T 9��7rI
ADDRESS OF ESTABLISHMENT �3 LUuSLi/nes S� , Sa1�`e/vu /vim 919'70
MAILING ADDRESS (if different) my 3 s
OWNER'S NAME � 6-S7R��i - JnnWV'q-Wds TEL#
ADDRESS %f 1' 4 -/�,r L6, leBL
CITY STATE ZIP o/P 3 5
CERTIFIED FOOD MANAGER'S NAME(S) Wt1Lt+AT%--F-kLm-& CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON MtCr*-- 1Mlt*vL-tt HOME TEL# �78 301 %f o G
HOURS OF OPERATION: Mon.11"/ Tue.(I-�Wedll-12A-Thu.tt-114-Fri. fl-MSat. It-Z4-Sun. It -12k
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO less than 1000sq.ft. =$ 50
1000-10,000sq.ft. =$100
y/ more than 10,000sq.ft. =$250
RESTAURANT NO �6/ less than 25 seats =$100
25-99 seats X50
more than 99 seats =$200
BED/BREAKFAST YES NO $100
ADDITIONAL PERMITS
MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO $50
ALL NON-PROFIT(such as church kitchens) YES NO $25
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sanitary Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
Signatur Date Social Secur'ty or Federal Identification Number
----------------------/1'%'�_r_77�--}P 3 D .s $y
Revised 11/03/03 FOODAP2.adm Cheek#8Dat 6.d%�(�1�776 ` ��`��
r
_ _
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street, 4`" Floor
Division of Food'and Drugs Salem, MA 01970-3523
FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343
Name Date jTvpeAf Operations) Type of Inspection
JO /%L e R Food Service {] Routine
Address '23 Risk ❑ Retail ❑ Re-inspection
TelephoneLevel , ElResidential Kitchen Previous Inspection
.7 YV-9777 f4 ❑ Mobile Date:
Owner HACCP WN ❑ Temporary ❑ Pre-operation
Sej t Q tr Ap ❑ Caterer ❑ Suspect Illness
Person in Charge(PIC) Time ❑ Bed& Breakfast ❑ General Complaint
Inspector In: F-1 HACCP
,42-0 1019 er7t4 E I r tf4 If 1J,01A Out: Permit No. ❑Other
Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco
Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑
action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ❑ revention of Contamination from Hands
El1. PIC Assigned/Knowledgeable/Duties 12.
andwash Facilities
EMPLOYEE HEALTH I "
PROTECTION FROM CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14 Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
❑ 15.Toxic Chemicals
FOOD FROM APPROVED SOURCE
❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods) -
❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION `" ` ` ❑ 19. Hot and Cold Holding
❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control
❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP).;.
El 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER ADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices Number of Violated Provisions Related
Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions 1
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 p
of Health. today, the items checked indicate violations of 105 CMR
'r c N 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
t2 Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
cited in this report may result in suspension or revocation of
5. Equipment and Utensils (Fc-a)(sso.005) the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you
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:5MnSp ClForm-14AX
Inspector's Signatu Print.
PIC's Signature: /� � �� print; Page-of -Pages
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22)
f
PROTECTION FROM CONTAMINATION
FOOD PROTECTION MANAGEMENT S Cross-contamination
2 590.003(A) Assignment of Responsibility" 3-302.11(A)(1) Raw Animal Foods Separated from
590.003(B) Demonstration of Knowledge* Cooked and RTE Foods*
LI-103.11 Person in charge-duties Contamination from Raw ingredients
3-302.11(A)(2) Raw Animal Foods Separated from Each
EMPLOYEE HEALTH Other-
2 590.003(0) Responsibility of the person in charge to Contamination from the Environment
require reporting by food employees and 3-302.1 t(A) Food Protection*
3-30215 Washin Fruits and Vegetables
590,003(F) Responsibility Of'A Food Employee Or An 3-304.11. Food Contact with Equipment and
Applicant To Report To The Person In :Utensils*
Charge' Containlnation from the Consumer
590.003(G) Reporting by Person in Change* 3-306A4(A)(B) Returned Food and Reservice of Food*
3 590.003(I)) Exclusions and Restrictions* Disposition of Adulterated or Contaminated
590,003(3) Removal of Exclusions and Re-strictions Food
3-701.11 Discarding or Reconditioning unsafe
FOOD FROM APPROVED SOURCE --
Foodt
q Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law"� 4-561.111 Manual Warewash ne-Hot Water
3-201.12 Fcwd in a Hermetically Sealed Container* Sanitization Tem e,ratares*
3-201.13 Fluid Milk and Milk Products* 4-501.112 MechanicalWarewashina Hot Water
3-202.13 Shell E-ns'' Sanitization Temperatures*
3-202.1.4 P r rs and Milk Products_Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH,
3202.16 Ice Made From Potable Drin'kino Water* concentration and hardness. ;'
4-601.11(A) Equipment Food Contact Surfac�cs and
5-101.11 Drinkin Water from an Approved System'
Utensils Clear"
590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency ofEquipment Food-
590.006(73) Water Meets Standards in 310 CMR 22.0* Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source
4-702.11 Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan ,Food Contact Surfaces of E ui in
Shellfish'" 4-70)3.11 Methods of Sanitization-Hot Water and
3-201.15 Molluscan Shellfish from NSSP Listed Chemical*
Sources* Ifl Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms"
Regufaforl,Author((
3-202.18 Shellstock ldentification Present* 2-301.12 Cleaninn,Procedare*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.1.7 Game Animals* tl Good Hygienic Practices
g Receiving/Condition 2-401.11 Satin ,DriakinR m'Usht Tobaceo*
3-202.11 PHF's Received at Pioper Temperatures* 3401.12 Discharges From the Eyes, Nose-and
3-202.15 Package Integrity* Mouth"
3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination LYhen Fastin.,`
Tags/Records:Shellstock 12 Prevention of Contamination from Hands
3-202.1$ Shellsta=k Ideneitication* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Em toees*
Tags/Records: Fish Products LL3 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*
7 Conformance with Approved Procedures
5-205.1.1 Accessibility, Operation andMaintenanec
/HACCP Pians Supplied with Soap and Hand Drying
3-502.11 S ecializedProcessingMethods*
Devices
3-50112 Reduced ox gen racka ria<*.criteria" 6-301.51. Handwashiug Cleanser, Availability
8-103.12 Conformance with Approved Procedures" 6-301.12Hand Dryiu?Provision
"'Denotes critical item in the ceders! 1999. Fwd Cate or 105 CNIR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: �/f/e/f Jetfrff Date: Page: 2-1 of 2
Item code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Red Item - - Verified
PLEASE PRINT CLEARLY
OF
IF 36L G rlcrrc d�aK N s•1-t e /"I i 7 A.s kr: ter Ram 0- rvw,f4t
to odc 9 rN PC(41C e/k'� //& c 17 e
e4 A-1711 kV-J4%. 17` ^ 600S r G� p4e.4 Att
Y
U �4 tat �n10
J .fej17Z&A_ Ar 4-A(W 61ao40' r
An ray 2
rn re�K at
�r c
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 n Restriction/
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
YO food permit. f�x% "i���
❑ Voluntary Disposal ❑ Other:
A
3-5U1,14(C) 'PHFsReceiggdat'I'emperainres
Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to
Factors(Items 1-22) (Cont.) 41`�F/45F Witthm 4 flours. *
PROTECTION FROM CHEMICALS ]9 3-.0L15 t.00lim Methods for PHFs
14 Food or Color Additives PHF Hot and Cold Holding
3-501.16(B) Cold PRFs Maintained at or below
3-202.12 Addivses'x 590.004(17) 41'/45°F*
3-302.14 Protection from Una oeed Additives*
r3-501,16'(A) Hof PHFs Maintained at or above
15 Poisonous or Toxic Substances
14WF.
7-101.11 Identifying Information-Original
3-501,16(A) Roasts Held at or above 130°F.
Containers`
1-102"11 Common Name-Workinn Containers* Time as a Public Health Control
7-201.11 Separation-Storacc" 3-001.19 Time as a Public Health Control*
7-20211 Restriction-Presence and Use* 590.004(H) variance Rc uirement
7-202.12 Conditions ofUsc* � REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP)
7-204.11 Smtitizers.Criteria-Chemicals"'
7-204.12 Chemicals for Washine Produce,Criteria* 21 3-801,11(A) Unpasteurized Pre-packaged Juices and
7-204.14 Dr•hra. ants.Cataria* P.,everages with 1�nninC Iabels*
7-205.11 Incidental Food Contact, Lubricants* 3-801"11(B) Use of Pasteurized B>,zs*
7-206.11 Restricted Use Pesticides.Cri cora* 3-801.I I(D) Raw or Partially Booked Animal Food and
Raw Seed Sprouts Not Served. *
7-206.14 cBait Stations` 3-801.I (C) Uno ened Food Packa>e Not Re-served" *
7-306.13 Tracking ra<tcking Powders,Pest Control and
Monitoring*
CONSUMER ADVISORY
TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of
----
Proper Cooking Temperatures for Annual Fax1s That are Raw, Undercooked or
16
PHFs Not Otherwise Processed to Eliminate
3-401.11A(1)(2) Eggs- 155'F 15 Sec.
Patna ns eo,ccve,t-zoai
1; s-hmnedrate Service 145".Fl5sec* 3-302.13 Pasteunyed Eggs Substitute for Raw Shell
3-401,11(A)(2) Comminuted Fish,Meats&Game E s*
Animals- 155°F 15 see. ^"
3-401.11(13)(1)(2) Pork and Beef Roast- 130'F 121 min* SPECIAL REQUIREMENTS
3-401.11(A)(2) Ratites, Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590,009(A)-(D)in
sec * catering, mobile food, temporary and
3-40L11(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be
Stuffing Containing Fish,Meat, debited under the appropriate sections
Pouloy 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 retai'1
3-401.12 Raw Animal Foods Cooked in a practices should be debited under 1{29-
Microwave 165"F* Special Requirements.
3-401A I(A)(1)(b) All Other PHFs- 1450F'15see.
17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
,403.11(A)&(D) RUIN 165'F 15 sec. " (Items 23-30)
_ 3-403.11(B) Microwave- 165°F 2 Minute Standing Eritrea]and nun-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 RTP Foal- found in the fallowing.sections of the Food Code and 105 CMR
14WF* 590.600.
3-403.11(L) Renstinu,Uri Portions of Beef Item Good Retail Practices FC 590.Q1t0
Roasts* 23. Mena ement and Personnel_ FC-2 .003
lA Proper Cooling of PHFs 24. _ Food and Food Protection FC-3 .004
25 Egugment and Utensils FC 4 .005
3-501.14(A) Cooling Cooked PHFs from 140'F to -" _{
26 Water, Plumbing and Waste FCC 5 OOS
Phys-- 00
70`1'Withfn'2€Tours and From 70°F ?7 Physical Facility_ FG B _ .007
to 41°F145°F Within 4 Hours. * 28. Poisonous or To: Materials FC-7 .008
3-501.14(13) Cootie,PRFs Made From Ambient 29. S aural R uiremeats __ .009
Temperature Ingredients to 41°F145°F 30 _ Other
Within 4 Ilours'r c=wm„-�sa.emm„
°Denotes txitical iter)in the tuleral 1999 Food Code or 105 CMR 590.600.
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
3
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
COMMONWEALTH OF MASSACHUSETTS
PERMIT TO OPERATE A FOOD ESTABLISHMENT
In accordance with regulations promulgated under authority of Chapter
94 , Section 305A and Chapter III , Section 5 of the General Laws, to operate
a Food Establishment in the City of Salem is hereby granted to:
Owner' s Name: Papas LLC
Name of Establishment : Papa Johns Pizza
Address of Establishment : 233 Washington Street
Type of Establishment : FOOD SERVICE
Application Date : 09/27/2002
Restrictions:
Permit for Food Establishment 318-02
Frozen Desserts/Ice .Cream
Permit for the Sale of Tobacco Products
These Permits Expire December 31, 2002
This permit is not transferable and must be reissued upon change of
ownership or location. The permit must be posted in a prominent location
in the Establishment.
In accordance with the State Sanitary Code, before any renovations,
improvements, or equipment changes are made, all plans for such must be
submitted to and approved by the Salem Board of Health.
HEALTH AGENT
f
OF SALEM,y°MASSACHUSETTS
vg BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR y »
SALEM, MA 01970
4 TEL. 978-741-1800
_ FAX 978-745-0343
"R
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO SEP 2 6 2002
MAYOR HEALTH AGENT
CITY OF SALEM
BOARD OF HEALTH
2002 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT
NAME OF ESTABLISHMENT 7 A jorh1
nS 112-+-A TEL# 979 14-q-` 777
ADDRESS OF ESTABLISHMENT 233 bvlSI4Itj(rTtln) Sa S/ evsl1IJIq 007o
MAILING ADDRESS (il different) /5- DGr (NI�+L✓1 i4l°- , "A 0 ds! '
OWNER'S NAME TA-VA-s LLC TEL# `P7 ? 521 `t''�;L
ADDRESS IS ?RrKKft1DG-E ?j
CITY W 1 ILL STATE 07/9 ZIP I,)
CERTIFIED FOOD MANAGER'S NAME(S) CERTIFICATE#(s)
(required in an establishment where potentially hazardous food is prepared.)
EMERGENCY RESPONSE PERSON MIKE h4` L4WL fit,/►`I HOME TEL# 9*7K A,O N4
DAYS/ HOURS OF OPERATION: Mon. ✓ Tue. ✓ Wed. — Thu. Fri. � Sat. �Sun.
/F 75-2 ll-i1,1 11 a/J !/-29 /1-29 /%/7!1
TYPE OF ESTABLISHMENT FEE check only
RETAIL STORE YES NO
RESTAURANT YES NO /�f'O�. $40
BED & BREAKFAST YES NO $40
ADDITIONAL PERMITS
,MAKE ICE CREAM,YOGURT
SOFT SERVE YES NO $5
TOBACCO VENDOR YES NO 10
NO CHARGE FOR NON-PROFIT(such as church kitchens) PLEASE INCLUDE COPY OF TAX
EXEMPTFORM
Please pay total with one check
payable to the City of Salem
This Permit is not transferable and must be reissued upon change of ownership. The Permit must
be posted in a prominent location in the Establishment.
In accordance with the State Sapitary'Code, before any renovations, improvements, or equipment
changes are made, all plans for such must be submitted to and approved by the Salem Board of
Health.
Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my
best knowledge and belief, have filed all state tax returns and paid all state taxes required under the law.
G.-.JK k ` �/<' ld2 01yk 3 c'-4 W'7?
Signature 11 Date Social Security or Federal Identification number
---------------------------------------------------------------
-----------------------------------------------------------------
Revised 11/1/01 foodapladm Check#&Date I's
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i�tta.turezza
10 12
THE WORKS'M- " .=r� ' ` "999 ' 412,99 ` 1399 16.99`
PEPPERONI,HAM,ONIONS,SPICY ITALIAN x
SAUSAGE,BABYPORTABELLA'MUSHROOMS"
GREEN PEPPERS.AND BLACK OLIVES
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ALGTHE MEATS ' .',, Rr 9.99x r 12.99 13.99 x,16.991`.
PEPPERONI,HAM;BACONAND SAUSAGE ` k
SPINACH ALF10.99 11.9% -14;99`
CREAMY ALFREDO'AND SPINACH SAUCE
GRILLED CHICKEN ACFREDO Z:99 , 10:99 -,. ' 11.99u-_'141.99
GRILLED ALL-WHITE CHICKEN AND CREAMY «' ' r
`WHITE ALFREDO•SAUCE
^,: s ° • 'v i r « ..qfl r J.:• t ,"r • ': � x«:�.• xr 2 <"= �. 3...,
GARDEN FRESH 9.99e` 12 99 13 99 `1
. 16 99
BABY-PORTABELLA MUSHROOM$,:BLACK OLIVES;:
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GREEN PEPPERS,SLICED TOMATOES AND ONIONS
SPINACH ALFREDO CHICKEN TOMATO_, 9.99 l2 99 13 99 „ 16 99.E
TOPPED WITH;A CREAMY SPINACH AND GARLIC PARMESAN' s'"
ALFRE60 SAUCE,GRILLED ALL-WHITE CHICKEN,FRESH!-
SLICED
RESH SLICED ROMA'TOMATOES AND 100%REAL CHEESE
B60 CHICKEN'AND,BACON . 9.99, -`12,991, 13.99 16.99;`
BARBEQUE SAUCE TOPPED WITH GRILLED y . M , y.- w +> p f _
ALL-WHITE CHICKEN,BACON AND ONION
HAWAIIAN BBQ CHICKEN' a_ .;« 49.99 12.99 ;13.99 16.99
BARBEQUE SAUCE TOPPED WITH GRILLED a
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ALL-WHITE CHICKEN,BACON,ONION AHD PINEAPPLE
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John sch-liattet
An Founder
u�cr 0 I
j\s t 11MI' pool student.my first job was al a pizzeria in Jeffc�'somrillc,Jndialna
In 1978 I gir•t aced from vvilshill dishes to making pizzas. I don't know if 1 its just
erred of ha Jing pots mrd piens or if it was my calling,but from the get-go I fell ill J.ovc
with nt ikut}; a°I soon realized thin there epics something missing from nationid pizza
charm I supu5ur quality nadtnoni pizza delivered to the customer's door My dream
f flr � ' A
was to one i4t}open it pizza resl sur int that would fill that void.
In 1984 m}%the ten c une`hue L knocked out a broom closet located in the hitck of
nrvfather's t.mern sold mi%Iii veil 147'1Z28( mtaro,pw chased$1.600 worth of used
equipment,and be,m selling pvi a to t.derii customers I took reat pude.in in', ung
the pings and the customers loved them°I was soon able to exp Ind moi ai tdjo'ung' t
space,eventually leading to Ole opening of the fml Papit lobo s'restam int itI`J85 t '
To thus d ty nudwtg quality pizza using better ut"rcthents is the foundation of Papa lobits.
;-
I We know pir.'r,.t calci~evenmhere wool lits of delicious loppmei and cheese in even bite -
our conunitnicut is to provide you suint the glial6'pizza you expect°At Papa John's,we '
lu'e dedicated to being better tomorrow than we iu'e totLnt lou hii�c nry commitment that
Pap I Johns will not stray from the foundation of quality A super ioi-ity upon which the
company was built We will idw.us strive to be vour 'Bette Para l omp.mv
Family Special,„ Papa's Meal Deal
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Manchester Medford(E.of 93)
' 223 South Willow Street 1 Highland Avenue
° 1 (6031629-0060 (781)324=9772
Somerville/Cambridge/ Salem/Marblehead/
Manchester,. Medford(West of 93) Peabody
' 1015 Elm Street 622 Somerville Avenue233 Washington
(6031645-7676 1617)627-9100 (87e)744-9777
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CHEESE s 599`=` 799` . 9.99-7tX11'99,
OKE*TOPPING ' .' a 6 99 -'' 9 39 ` 1,1 49,1174
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.:y
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ANCHOVIES /.GRILLED ALL-WHITE CHICKEN_
a
15-Parkridge Road Papa Johns Pizza
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE REINSPECTION Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: '- z FOOD PROTECTION MANAGEMENT
744-9777 PIC Assigned/Knowledgeable/Duties FAIL ❑Q RED _
Owner."
Comments: No Certified food manager on hand at time of reispection.Owner is set to send Kirk Carson to CFM training. copy of
Constantine G. Saivanos certification to be posted and a copy to be sent to the board of health for our records.
PIC: Non-compliance with:
Kirk Carson Anti-Choking PASS
Inspector '; - &
Tobacco PASS
Janet Dionne
Date Inspected: Correct By: f EMPLOYEE HEALTH
12/8/2005 Reporting of Diseases by Food Employee and PIC PASS RED
Risk Level:
- Personnel with Infections Restricted/Excluded PASS RED
Permit NUmber, "s , FOOD FROM APPROVED SOURCE
64-2005-0256 Food and Water from Approved Source PASS 0 RED
Status: IM '
SIGNED OFF Receiving/Condition PASS ❑J RED
#Of Critical Violations _ Tags/Records/Accuracy of Ingredient Statements PASS RED
2 4
Time IN: _ Time OUT Conformance with Approved Procedures/HACCP Plans PASS RED
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days) c ,
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 09,2005 ) Page 1 of
Item Status Violation Critical Urgency
RED. PROTECTION FROM CONTAMINATION
Violations Related t0 °E Separation/Segregation/Protection PASS 0 RED
Foodborne Illness Interventions
and Risk Factors(Requires. Food Contact Surfaces Cleaning and Sanitizing FAIL ❑J RED
immediate corrective action),, Comments:cutting board on order and to be replaced.Kirk said by end of week cutting board should be delivered.
Proper Adequate Handwashing PASS ❑J RED
Good Hygienic Practices PASS ❑d RED
Prevention of Contamination from Hands PASS RED
Handwash Facilities PASS ❑J RED
PROTECTION FROM CHEMICALS
Approved Food or Color Additives PASS RED
Toxic Chemicals PASS RED
TIMEtTEMPERATURE CONTROLS(Potentially Hazardous Foods)
Cooking Temperatures PASS Q RED
Reheating PASSd❑ RED
Cooling PASS �/❑ RED
Hot and Cold Holding PASS RED
Time As a Public Health Control PASS ❑d RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food and Food Preparation for HSP PASS ❑Q RED
CONSUMER ADVISORY
Posting of Consumer Advisories PASS RED
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 09,2005 ) Page 2 of
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection PASS BLUE
Equipment and Utensils PASS BLUE
Water, Plumbing and Waste PASS BLUE
Physical Facility PASS BLUE
Management and Personnel PASS BLUE
Poisonous or Toxic Materials PASS BLUE
Special Requirements PASS BLUE
Other-See Notes PASS BLUE
GENERAL COMMENTS:
399:
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 09,2005 ) Page 3 of
15 Parkridge Road Papa Johns Pizza
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: " FOOD PROTECTION MANAGEMENT
.744-9777_ - PIC Assigned/Knowledgeable/Duties FAIL ❑J RED
Owner: Comments: no certified food manager on hand at time of inspection.
Constantine G. Slivanos .. Non-compliance with:
PIC:, - °= T = Anti-Choking N/A
Mike McLaughlin
Inspector: Tobacco PASS
JanetDlOnne EMPLOYEE HEALTH
Date Inspected: Correct By: Reporting of Diseases by Food Employee and PIC PASS ❑� RED
11/30/2005
Risk Level: Personnel with Infections Restricted/Excluded PASS ❑d RED
-Permit Number* FOOD FROM APPROVED SOURCE
BHP-2005-0256, n Food and Water from Approved Source PASS RED
Status: = ''- Receiving/Condition PASS ❑v RED
Open .,
#of Critical Violations Tags/Records/Accuracy of Ingredient Statements PASS ❑/ RED
4
Conformance with Approved Procedures/HACCP Plans PASS RED
Time IN: I..Time OUT:
Urgency Description(s):` A.
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 05,2005 ) Page 1 of
_ Item Status Violation Critical Urgency
RED: •- PROTECTION FROM CONTAMINATION
Violations Related to Separation/Segregation/Protection PASS ❑d RED
Foodborne Illness Interventions
and Risk Factors (Require Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED
immediate corrective acti&h)' Comments: cutting board near three bay sink stained and scored. replace cutting board.
Proper Adequate Handwashing PASS ❑d RED
Good Hygienic Practices PASS RED
Prevention of Contamination from Hands PASS RED
Handwaash Facilities FAIL �/❑ RED
Comments: mens restroom, paper towels to be placed in paper towel dispenser.
PROTECTION FROM CHEMICALS
Approved Food or Color Additives PASS RED
Toxic Chemicals PASS ❑d RED
TIME(TEMPERATURE CONTROLS(Potentially Hazardous Foods)
Cooking Temperatures PASS ❑d RED
Reheating PASS ❑d RED
Cooling PASS ❑d RED
Hot and Cold Holding PASS ❑d RED
Time As a Public Health Control PASS ❑J RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)
Food and Food Preparation for HSP PASS RED
CONSUMER ADVISORY
Posting of Consumer Advisories N/A RED
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeOTMSO 2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 05,2005 ) Page 2 of
Item Status Violation Critical Urgency
Violations Related to Good Retail Practices (Blue Items)
Food and Food Protection FAIL BLUE
Comments:sauce on line uncovered at time of inspection.all food to be covered.
Equipment a Utensils FAIL Critical BLUE
omments: pizza cutter had accumulation of food debris and not being cleaned and sanitized between uses. Clean and sanitize
utensils between uses to help prevent cross contamination.
V1 an opener had accumulation of dried food debris.thoroughly clean and sanitize can opener daily to prevent buildup of food debris.
''v§1-11
log not being maintained. log to be maintained daily.
Water, Plumbing and Waste FAIL BLUE
1,�omments:Toilet in women's restroom was not flushing properly at time of inspection.Repair toilet.
Physical Fac ty FAIL BLUE
Comments: back exterior door has gap at bottom of door.provide door sweep.
anagement and Personnel PASS BLUE
Poisonous or Toxic Materials PASS BLUE
Special Requirements PASS BLUE
Other-See Notes PASS BLUE
Vol"Comments: There was a pizza dough proofer being stored in mens restroom.food equipment to be stored in proper areas. remove
from restroom and relocate.
Iso there was a purell wall hung dispenser that employees were using to clean hands.Purell not approved substitute for proper
handwashing with soap and water.Owner to teach and enforce proper handwashing techniques with all employees to help in the
prevention of contamination from hands.
GENERAL COMMENTS:
384:
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMSO 2005 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 05,2005 ) Page 3 of
CITY OF SALEM
BOARD OF HEALTH
Name of Establishment: Papa John's Pizza
Address: 233 Washington Street
Owner(s): Pizza Ventures II LLC
Manager: James Astarita
Phone: 978-744-9777
Date: November 29, 2005
The current and proposed Directors of Operation of this establishment presented;
Mike McLaughlin and James Astarita presented a Floor Plan and Menu for
review in accordance with the State Food Code.
FLOOR PLAN
Hand Sinks are located next to the opening to the oven and across from
the three-bay sink. Hand sinks must have wall hung soap and paper towel
dispensers. These must be stocked at all times. Hand sinks must be used for
hand washing only.
A food prep sink is available for washing vegetables, etc.
All floors, walls, and ceilings where food, utensils, paper products, etc, are
stored, prepared or served must be intact, impervious, and easily cleanable.
MENU/FOOD PREP
All food must be purchased from a wholesaler licensed by the State.
All food must be held at 41°F or lower, or 140°F or higher, at all times.
Salad items, such as vegetables, must be held cold.
Food may not be added to containers in vegetable unit. Instead, a
sanitized container with new product may replace the existing container and the
old product may be placed on top of the new product.
There may be no bare hand contact of ready-to-eat foods. Gloves, tongs,
or tissues must be used when handling such food.
CERTIFICATION
There must be a Certified Food Manager working at this establishment full
time. Information regarding upcoming classes was given to the owner. The
Manager of the establishment will be the Certified Food Manager.
When a CFM is not onsite there must be a Person-in-Charge (PIC) who is
fully trained in sanitation techniques and has a thorough understanding of the
operation.
UNDERCOOKEDFOODS
No undercooked items will be served at this establishment. A notice
saying this will be placed on the menu.
EXTERMINATION
Monthly services of a Licensed Pest Control Operator are required.
Please keep receipts for inspections.
SANITIZING SOLUTION
Sanitizing Solution must be accessible at each prep station and-fefthe
patreas'-tablea.
Test strips corresponding to the kind of sanitizer, must be on hand to
check concentration of solution. Solution must be made daily, tested, and the
results recorded on a log sheet for examination by Board of Health inspectors.
Solution may be prepared in the 3`d bay of the 3-bay sink and spray
bottles and/or wiping pails may be filled there. Spray bottles with clean paper
towels may be used, as well as wiping pails with wiping clothes always held in
the solution in the pail. Spray bottles and wiping pails must be clearly marked
"sanitizes".
Outside area of premises, including the dumpster area, must be kept clean and
sanitary.
The application and check were submitted.
An opening inspection is scheduled for November 30, 2005 at 2 pm.
Joanne Date
Health Agent"�� qla�.
I ' Zi oS
Jame Astarita Date
Director of Operations
I
21 1
RESTROOM ; { Nit
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THE COMMONWEALTH OF MASSACHUSETTS
i
Establishment Name p Date
Address Page / of
3 3 U JQ s h ->y �! ! z• 7VV- 9777
Item No. In the space below describe all violations checked on front page. /
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"" � ,A ....,4, � /",7f. ..M'7�s D ,ls✓J �r�/(�� /7AlA1f I9�'1T✓
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15 Parkridge Road Papa Johns Pizza
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Telephone: Item Status Violation Critical Urgency Nature of problem or correction
744-9777 Non-compliance with: Not Done
Owner: Anti-Choking PASS ❑
m
Constantine G. Saivanos Tobacco PASS ❑
PIC: ,
= u- = •rr' FOOD PROTECTION MANAGEMENT Not Done
Carmine Mongiello PIC Assigned/Knowledgeable/Duties PASSd❑ RED
Inspector:
!David Greenbaum;. - EMPLOYEE HEALTH Not Done
Date Inspected. Correct By', Reporting of Diseases by Food Employee and PIC PASS RED
6/23/2005 _ Personnel with Infections Restricted/Excluded PASS ❑d RED
Risk Level:
•F FOOD FROM APPROVED SOURCE Not Done
Permit Number Food and Water from Approved Source PASS ❑d RED
BHP-2005-0256 Receiving/Condition PASS RED
Status. Tags/Records/Accuracy of Ingredient Statements PASS RED
SIGNED OFF
#of Critical Violations Conformance with Approved Procedures/HACCP. PASS RED
Plans
2a !:. PROTECTION FROM CONTAMINATION Not Done
Time IN: Time OUT: Separation/Segregation/Protection PASS ❑d RED
Notes' L> s°., Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑J RED Cutting board by 3 bay sink is stained and
•r* - - scored. Resurface or replace cutting board.
r
250: Proper Adequate Handwashing PASS RED
Urgency Description(s): Good Hygienic Practices PASSd❑ RED
BLUE: 4 Q
'`6
Violations Related to Good Prevention of Contamination from Hands PASS Q RED
Retail Practices (Critical Handwash Facilities FAIL Critical ❑Q RED Hot water in restrooms was only warm.
violations must be corrected Restore hot water to restrooms
immediately or within 10 th ` a immediately.
days)(Non-critical violations
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 23,2005 ) PaQe 1 oft
4
15 Parkridge Road Papa Johns Pizza
must be corrected Immediately PROTECTION FROM CHEMICALS Not Done
or.within 90 days) Approved Food or Color Additives PASS RED
RED W a
Violations Related to Toxic chemicals PASS ❑D RED
Foodborne Illness Interventions, TIME/TEMPERATURE CONTROLS(Potentially Haz Not Done
and Risk Factors (Require. - Cooking Temperatures PASS RED
immediate corrective action)
Reheating PASS ❑/ RED
Cooling PASS ❑Q RED
Hot and Cold Holding PASS RED
Time As a Public Health Control PASS RED
REQUIREMENTS FOR HIGHLY SUSCEPTIBLE PO Not Done
Food and Food Preparation for HSP PASS RED
CONSUMER ADVISORY Not Done
Posting of Consumer Advisories PASS RED
Violations Related to Good Retail Practices (Blue Not Done
Management and Personnel PASS ❑ BLUE
Food and Food Protection PASS ❑ BLUE
Equipment and Utensils FAIL Non-Critical ❑ BLUE Relable 3 bay sink"wash-rinse-sanitize.
Water, Plumbing and Waste PASS ❑ BLUE
Physical Facility PASS ❑ BLUE
Poisonous or Toxic Materials PASS ❑ BLUE
Special Requirements PASS ❑ BLUE
Other-See Notes PASS ❑ BLUE
GeOTMS®2005 Des Lauriers Municipal Solutions, Inc. ( Rev. Aug 23,2005 ) Page 2 oft
Pizza Ventures II Inc. Papa Johns Pizza
City of Salem
FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection
HACCP: ❑
Item Status Violation Critical Urgency
Telephone: FOOD PROTECTION MANAGEMENT
744-9777 i PIC Assigned/Knowledgeable/Duties FAIL .❑ RED
Owner: ✓ Comment:All Certified food manager certifications to be faxed over to the Board of Health. Also displayed on wall next to food
Pizza Ventures II Inc. permit. Establishment to have completed within one month.
PIC: PROTECTION FROM CONTAMINATION
Kerrie Mosher Food Contact Surfaces Cleaning and Sanitizing FAIL RED
Inspector:
i omment:Sanitizing solution reading low. Sanitizing solution to be avilable at each work station with proper concentration.
John Gehan
Date Inspected:Correct By: 11 Violations Related to Good Retail Practices (Blue Items)
11/22/2006 Equipment and Uten ils'- FAIL BLUE
Risk Level
ment:Victory three door refrigerator requires general cleaning.
Permit Number: ame unit has no visible thermometer. Provide visible and accurate thermometer.
BHP-2006-0333 amefrigerator requires thermometer inside.
Status:
Open nitizing log-tiot up to date. Log to be maintained daily with proper concentration.
#of Critical Violations: of oven requires general cleaning.
2 Physical Fa ility FAIL BLUE
Time IN: Time OUT:
Comment: Ceiling tiles missing above washing machine. Replace tiles.
Urgency Description(s):
BLUE:
Violations Related to Good
Retail Practices (Critical
violations must be corrected
immediately or within 10
days)(Non-critical violations
must be corrected immediately
or within 90 days)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 21,2006 ) Page I oft
Item Status Violation Critical Urgency
RED:
Violations Related to
Foodborne Illness Interventions
and Risk Factors (Require
immediate corrective action)
City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741.1800
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