AMANO ITALIAN KITCHEN - ESTABLISHMENTS A 1^ti klo rm u r4j xrr�NaN
L2 W.4nIR F ST
Lniversal one,,
www.myuniversalop.com
phone: 1-800-756-4676
UNV16162
MADE IN USA
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Massachusetts Department of Public Health Salem Board of Health
Divisloq of Food and Drugs 120 Washington Street,0 Floor
Salem, MA 01970-3523
Tel. (978) 741-1800 Fax(978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
Name D t Type of Operations) Type of Inspection
(4--Food Service Routine
Address RIs E] Retail Re-inspection
Telephone Level ❑ Residential Kitchen Previous I spe ion
�� 6 ❑ Mobile Date:
Owner HACCP YIN ❑ Temporary ❑ Pre-Ooopp�rati
I ❑ Caterer El Suspect Illness
Person-in-Charge PI 01 c` Time ElBed&Breakfast E] General Complaint
Inspector In Permit No. ElOtherCP
Ou ❑.
Each violation checked requires an explanation on the narrative age(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti-Choking 590.009(E) ❑
Tobacco 590.009(F) E],.
Violations marked may pose an imminent health hazard and require immediate Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities
'EMPLOYEE HEALTH
❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTIOM¢ROM'CHEMICACS
El3. Personnel with Infections Restricted/Excluded [114.Approved Food or Color Additives
fOOO'FROMAPPROVED SOURCE El 15. Toxic Chemicals
❑ 4. Food and Water from Approved Source TIMEITEMPERATURE:CONTROLS.(Potentlalty 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=$U$CEP.TI6[E=POPULATIONS(HSp)
❑ 10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER ADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices (Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical (N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of CeaNh. 590.000/federal Food Code.This report,when signed below
23. Management and Personnel (FC-2X590.003) by a Board of Health member or its agent constitutes an
4. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations
12
25. Equipment and Utensils (FC-4X590.005) 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-6X590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:
s. iJs,a�
Inspector's Signature: Prin
PICS -- Print .✓/p G✓�C4� Page 0f--,Pnes
Violations Related to Foodborne Illness
interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from
1 59(1.003{q) Asst�r ment of R�onsibility* Cooked and RTE Foods
590.003(8) Demonstration of Knowles"' Contamination from Raw ingredients
2-103.11 1 Person in charge-duties 3-30211(A)(2) Raw Animal Foods Separated from}Each
Other'
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(C) Responsibility of the person in charge to 3302.11(A) Food Protection*
require reporting by forKI 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'ro The Person In Contamination from the Consumer
Chin m.* 3-306.14(A)(B) Returned Food and Reservice of Food*
590.(k3(G} Re ortin b�Person in C'har+e* Disposition of Adulterated or Contaminated
3 59,0.003(D) Exclusions and Rcstriclions* Food
590.003(F) Removal of ExulusIons and Restrictions 3-701.1 1 Disc aiding or Reconditioning Unsafe
Food*
FOOD FROM APPROVED SOURCE
4 Food and Water From Regulated Sources 9 - Food Contact Surfaces
590.004(A-B) Compliance with Food Law 4-501.111 Manual Warewashmg-Hot Water
3-201.12 Food in.a Hermetically Sealed Container* Sanitization 1'entperatures*
320113 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewastiirig-Hot Water
3-202.13 Shell E s* Sanitization Temperatures*
3-202.14 Eggs and Milk Products,Pasteurized" 4-501.114 Chemical Saniiizarion-temp.,pH,
3-202.16 Ice Made From Potable Drinkiu�Water* concentration and hardness. *
5-'101.11 DrinkingWater from an Approved System" 4-601.11(A) Equipment Food Contact Surfaces and
Utensils Clean*
590.006 A) Bottled Drinking Water*
590.006(B)
l Cleaning Frequency of Equipment Food-
Contact Nater Meets Standards in 310 C,MR 22.01' Contact Surfaces and Utensils"
Shellfish and Fish From an Approved Source 4.701,11 Frequency ot:Sanitization of Utensils and
3-20114 Fish and Recreationally Caught Molluscan Poi Contact Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitizatiion-Flut Water and
3-201.'15 Molluscan Shellfish from NSSP Listed i Chemical*
Sources* 10 1 Proper,Adequate Handwashing
-Game and Wild Mushrooms Approved by 2-301.11 C(ean Condition-Hands and Ann;"
Re ulator Author@
3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure*
590.004(C) Wild Mushrooms* 2-30114 When to Wash*
3-201.17 Game Animals* 11 Good Hygienic Practices
g Receiving/Conditlon 2.401.11 Eating,Drinking or UsingTobacco*
3-202.11 PHFs Received at Pro er'reui ranves'" 2-101.12 Discharges From the Eyes,Nose and
Month*
3-202.15 Package integrity*
3-101.11 Food Safe and Unadulterated"` 3-301.12 PreventingContamination When 9' *
6 TagsfRecords:Shellstock 12 Preventionn Han of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(1;) EmployPreventees Contamination from
3-203.12 Shellstock Identification Maintained* Employees*
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(1) Labeling ofingredlents• 5-204.1.1 Location and Placement*
Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
Supplied with Soap and Hand Drying
/HACCP Plans Devices
3-502.17. Specialized Processing Methods* 6-301.11. Handwashing Cleanser,Availability
3-502.12 Reduced ox eu 2ackaging,criteria* 6.301.1.2 Hand Drying'Provision
8-103.12 Conformance with Approved Procedures*
a Denotes critical¢em in the federal 1990 Fax1 Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Page:�— of
Rem Code C-Cdticat Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Dere
No. Reterenee R-Red Rem Verified
L E PRI T LEARLV
11
Discussion With Person in Charge: Corrective Action Required: ❑ No es
I have read this report, have had the opportunity to ask questions and agree to correct all luntary Compliance ❑ Employee Restriction/
Exclusion
violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension
corimply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of ertty five dollars or suspension re tion of ❑ Embargo ❑ Emergency Closure
your food permit.
❑ Voluntary Disposal ❑ Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors(Items 1.22) (Cont.) 3-501.15 Cooling Methods for PHFs
19 PHF Hot and Cold Holding
PROTECTION FROM CHEMICALS 3-501.16(13) Cold PHFs Maintained at or below
14 Food or Color Additives 590.004(F) 410/450 F*
3-202.12 Additives* 3-501.16(A) Hot PHFs Maintained at or above
3-302.14 Protection front Unapproved Additives* 140°F *
15 Poisonous or Toxic Substances 3-501.16(A) Roasts Held at or above 130°F.
7-101.11 Identifying Information-Original 20 Time as a Public Health Control
Containers* 3-Sp1.19 Time as a Public Health Control*
7-102.11 Common Name-Working Containers* 3-501.19Variance Requirement
7-201.11 Separation-Stour e* 590.004(11)
7-202.11 Restriction-Presence and Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-202.12 Conditions of Use* POPULATIONS HSP
7-203.11 "Toxic Containers-Prohibitions* 21 3-801.11(A) Unpasteurized Pre-packaged.luices and
7-204.11 Sanitizers,Criteria-Chemicals* Beverages with Warning Labels*
7-204.12 Chemicals for Washing Produce,Criteria* 3-801.11(B) Use of Pasteurized Eggs*
7-204.14 D in A gents,Criteria* 3-801.11(1)) Raw or Partially Cooked Animal Food and
7-205.11 Incidental Food Contact, Lubricants* Raw Seed Sprouts Not Served. *
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(C) Unopened Food Package Not Re-served.
7-206.12 Rodent Bait Stations*
7-206.13frocking Powders,Pest Control and CONSUMER ADVISORY
'Monitoring* 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw,Undercooked or
TIME/TEMPERATURE CONTROLS Not Otherwise Processed to Eliminate
16 Proper Cooking Temperatures for Pathogens.*E"°"112001
PHFs 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs*
3-401.1 IA(1)(2) Eggs- 155°F 15 See.
Eggs-Immediate Service 145°I715sec* SPECIAL REQUIREMENTS
3-401.1 I(A)(2) Comminuted Fish,Meats&Game 590.009(A)-(D) Violations of Section 590.009(A)-(D) in
Animals- 155°F 15 sec.
catering,mobile food,temporary and
3-401.11(6)(1)(2) Pork and Beef Roast- 130°F 121 mut* residential kitchen operations should be
3-401.11(A)(2) Ratites, Injected Meats-155°F 15 sec. debited undie tappropriate sections
' «
3-401.11(A)(3) Poultry,Wild Game,Stuffed PIIFs, above if related to foodborne illness
Stuffing Containing Fish,Meat, interventions and risk factors. Otter
r
Poultry or Ratites-165°F 15 sec. * 590.009 violations relating to good retail
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks practices should be debited under#29-
145°I'* Special Requirements.
3-401.12 Raw Animal Foods Cooked in a
Microwave 165°F* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-401.11(A)(1)(b) All Other PRFs- 145°F 15 sec. * (Items 23-30)
17 Reheating for Hot Holding Critical and non-critical violations, which do not relate to the
foodborne illness interventions and risk factory listed above, can be
3-403.11(A)&(1)) PI-IPs 165°F 15 sec. * found in the following sections of dre food Code and 105 CMR
3-403.11(13) Microwave- 165°F 2 Minute Standing 590.000.
Tunic* Item Good Retail Practices FC 590.000
3-403.11(C) Commercially Processed RTE Food- 23. Management and Personnel FC-2 .003
14001'* 24. Food and Food Protection FC-3 .004
3-403.1](1-) Remaining Unsliced Portions of Beef 25. Equipment and Utensils FC-4 .005
Roasts* 26. Water,Plumbing and Waste FC-5 .006
18 Proper Cooling of PHFs 27. Physical Facility FC-6 .007
R28. Poisonous or Toxic Materials FC-7 .008
3-501.14(A) Cooling Cooked PRFs from 140°F In 29. Special Requirements .009
e
t 70°F Within 2 Hours and From 700P l0 30. Other
t 41°1745°F Within 4 l lours. *
3-501.14(B) Cooling PRFs Made Front Ambient
"temperature Ingredients to 41'17/45'17
Within 4 Hours*
3-501.14(C) PRFs Received at-Temperatures
Accordine to Law Cooled to
41°F/45°F Within 4 Hours. "
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
*
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,4a'Floor
Division of Food and Drugs Salem, MA 01970-3523
Q n//1/ Tel. (978) 741-1600 Fax (978) 745-0343
City/Town of X 4 Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
NameD Type of Operation(s) Type of inspection
J i ti Food Service ❑Routine
AddressRik ❑ Retail IFFRe-inspection
Level ❑ Residential Kitchen Previous inspection
Telephone El Mobile HACCP YIN [IElPre-bDate: //
Owner Temporary {1er 1
0 Caterer 0 Suspect Illness
Person-in-Charge(PIC) Time - [I Bed 8 Breakfast El General Complaint
In: 55�� ElHACCP
Inspector IOU S Permit No. ❑.Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-compliance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009(F) ❑
q Allergen Awareness 590.009(G) ❑
corrective action as determined by the Board of Health.
FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13. Handwash Facilities
'EMPLOYEE HEALTH
PROTECTIONIFROM'CHEMICALS
❑ 2. Reporting of Diseases by Food Employee and PIC
❑ 14.Approved Food or Color Additives
❑ 3. Personnel Wth Infections Restricted/Excluded
❑ 15. Toxic Chemicals
FOOD-FROM APPROVED SOURCE
171 4. Food and Water from Approved Source TIMEREMPERATURE: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 [118. Cooling
PROTECTION FROM CONTAMINATION ❑19. Hot and Cold Holding
❑ 8.Separation/Segregation/Protection ❑ 20.Time as a Public Health Control
156 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY.SUSCEPTIBLE-POPULAtfONS.(iiSP).
❑10. Proper Adequate Handwashing ❑21. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER ADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
\!tems) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
mediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
r 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-2X590.0 order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-4X590.0044)) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (Fc-axsso.00s> the food establishment permit and cessation of food
26. Water, Plumbing and Waste (FC-5)(590.o06) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-5)(590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7x590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION:`-r
s: o-radw l ntv �/ O( V
Inspector's Signature: Pri
PICS Signature: Print: ageA-of Pages
Violations Related to Foodborne illness
interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION
8 Cross-contamination
FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(]) Raw Animal Foods Separated from
1 590.003(A Assn*tment of Responsibility* Cooked and RTE Ftxxls*
590.003(6) Demonsh�ation of Kttowled_ge* Contamination from Raw Ingredients
2-103.11. Person in charge-duties 3-302.11(.4
)(2) Raw Aniutxl Fails,Separated from Each
Other*
EMPLOYEE HEALTH Contamination from the Environment
2 590.003(0) Responsibility of the person in charge to 3302.1 I(A) Food Protection*
require reporting by food employees and 3-302.15 Washing Fruits and Vegetables
applicants* 3-304.11 Fait Contact with Equipment and
590003(F) Responsibility Of A Fond Employee Or An Utensils*
Applicant To Report To The person In Contamination from the Consumer
Charge* 3-306.14(A)(B Returned Foal and Resetvice of Foal*
590.003 G) Re atrn hPerson in Charge* =
Disposition of Adulterated or Contaminated
31 590.003(D) Exclusions and Restrictions" Food
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROMFood*_
APPROVED SOURCE
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Fuad law* 4-501.1 T1 Manual Warewashing-Hot Water
3-201.t2 Food in a Hermetically Scaled Container* - __ Sanitization Temperatures*
3-201.13 Fluid Milk and MilkProducts* 4-501.112 Mechanical Werewashing-Hot Water
3-202..13 Shell Eggs* Sanitization Tem eratures*
3-202.14 Eggs and Milk Products,Pasteurized" 4-501.114 Chemical Stm lizatiim-temp.,pH,
3-202.16 ice Made F'rmtn Potable Drinking Water"'
concentration and hardness. *
5-101.11 Drinking Water from an Approved System" 4-601..11(A) F.qui.pment Food Contact Surfaces and
590.006(A) Bottled Drinking Water* Utensils Clean*
590.006(,B) Water Meets Standards in 310 CMR 22.04' 4-602'11 Cleaning Frequency of Equipment Food-
Contact and Fish From an Approved Source
Contact Surfaces and Utensils*
4-702.11. Frequency of Sanitization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan - Food Contact.Surfaces of Equipment*
Shellfish* 4-703.11 Methods of Sanitization-HotWaterand
3-201.15 MollascanShellfish from NSSPListed Chemical*
Sources* 10 L Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Anns"
Regulatory Authority
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 2-401,11 Eating,Drinking or Using Tobacco*
3-102.11 PHFs Received at Proper Tem. ratures* 2.401.12 Discharges From the Eyes,Nose and
3-202.15 Package hnetiit * Mouth*
3-101.11 Food Safe and Unadulterated * 3-301.12 preventing Contamination When Tasting"'
6 TagsiRecords:Shellstock t 12 Prevention of Contamination from Hands
3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from
3-203.12 Shellstock Identification Maintained* Em plo ees*
Tags/Records:Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records',Creation and Retention* 5-203.11 Numbers and Capacities*
590.0040) Labeling ofingredlents° 5-204.11 Location and;Placetnent*
Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plans Supplied with Soap and Hand Drying
3-502.1.1 Specialized Methods* Devices
3-502.12 Reued oxygenpacka nom,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Drying Provision
*Denoias critical i enp in the ledar al 1999 Food Code or,105 CNM 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: G Date: Page: of t%
Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAWOF CORRECTION Dam
No. Reference R-Red Item Verlfled
PLEASE PRINT LEARLV
In 1 _ S r
SUt.0 Mcr c 11 1�c P r
� 0 Ll s
1
�.
Y� U
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
p Re-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twe y-ive-d6ll5r9 or suspen vocation of ❑ Embargo ❑ Emergency Closure
your food permit.
`� '� _ 0 Voluntary Disposal ❑ Other:
r
i
Violations Related to Foodborne Illness Interventions and Risk
Factors(Items 1-22) (Cont.) 3-501.15 Cooling Methods for PHFs
'i
19 PHF Hot and Cold Holding
PROTECTION FROM CHEMICALS 3-501.16(13) Cold Pill's Maintained at or below
14 Food or Color Additives 590.004(F) 41°/45°F*
3-202.12 Additives* 3-501.16(A) Hot PHFs Maintained at or above
3-302.14 Protection from Unapproved Additives* 140°F *
15 Poisonous or Toxic Substances 3-501.16(A) Roasts Held at or above 130'F-
7-101.11 Identifying Information-Original 20 Time as a Public Health Control
Containers*
3-501.19 Time as a Public Health Control*
7-102.11 Common Name-Working Containers* 590.004(li) Variance Requirement
7-201.11 Separation-Stora e*
7-202.11 Restriction-Presence and Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-202.12 Conditions of Use* POPULATIONS HSP
t
7203.11 Toxic Containers-Prohibitions* -'
21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.11 Sanitizers,Criteria-Chemicals* Beverages with alantin Labels*
7-204.12 Chemicals for WashingProduce,Criteria* 3-801.1 I Use of Pasteurized Eggs*
7-204.14 Drying Agents,Criteria* 3-801.1](1)) Raw or Partially Cooked Animal Food and
7-205.11 Incidental Food Contact,Lubricants* Raw Seed Sprouts Not Served.
7-206.11 1 Restricted Use Pesticides,Criteria* 3-801.11(C) Unopened Food Package Not Re-served
7-206.12 Rodent Bait Stations*
7-206.13 Tracking Powders,Pest Control and CONSUMER ADVISORY
Monitoring* 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods That are Raw,Undercooked or
TIME/TEMPERATURE CONTROLS Not Otherwise Processed to Eliminate
16 Proper Cooking Temperatures for Pathogens.*ens.*E"°m`°"'
PHFs 3-302.13 Pasteurized Fggs Substitute for Raw Shell Eggs*
3-401.11A(I)(2) Eggs- 155°F 15 Sec.
Eggs-Immediate Service 145°Fl5sec* SPECIAL REQUIREMENTS
3-401.11(A)(2) Comminuted Fish, Meats&Game 590.009(A)-(D) Violations of Section 590.009(A)-(D) in
Animals- 155°F 15 sec.
catering;mobile food, temporary and
3-401.11(13)(1)(2) Pork and Beef Roast- 130'F 121 min* residential kitchen operations should be
-' 3-401.11(A)(2) Ratites, Injected Meats-1550I' 15 sec. debited under the appropriate sections
3-401.11(A)(3) Poultry,Wild Game,Stut ed PRFs, above if related to foodborne illness
'• -Stuffing Containing Fish,Meat, interventions and risk factors. Other
Poultry or Ratites-165°F 15 sec. * 590.009 violations relating to good retail
i 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks practices should be debited under#29-
145°F* Special Requirements.
3-401.12 Raw Animal Foods Cooked in a
Microwave 1650I'* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-401.11(A)(1)(b) All OtherPllFs- 145°F 15 sec. • (items 23-311)
17 Reheating for Hot Holding Critical and non-critical violations, which do tool relaie to the
3-403.11(A)&(D) Plifs 165115 see. * foodborne illness interventions and risk faclors listed above,can be
found in the following seciirms of the Food Code and 105 CMR
r
3-403.1](13) Microwave- 165°F 2 Monne Standing 590.000.
FTime* Item Good Retail Practices FC 590.000
w 3-403.11(C) Commercially Processed RTE Food- 23. Management and Personnel FC-2 .003
140°F* 24. Food and Food Protection FC-3 .004
3-403.1 1(l ) Remaining Unsliced Portions of Beef 25. Equipment and Utensils FC-4 .005
Roasts* 26. Water,Plumbing and Waste FC-5 .006
027. Physical Facility FC-6 .007
18 Proper Cooling of PHFs 28. Poisonous or Toxic Materials FC-7 .008
3-501.14(A) Cooling Cooked PI-IFs from 140°F to 29. Special Requirements .009
I 70°F Within 2 Hours and Front 70°F to 30. Other
C 41°1'/450F Within 4 Hours. da
3-501.14(13) Cooling PI-IFs Made From Ambient
Temperature Ingredients to 41°17/45°F
Within 4 Hours*
3-501.14(C) PHFs Received at Temperatures
According to Law Cooled to
410F/45014'Within 41lours. *
4 'Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
Massachusetts Department of Public Health Salem Board of Health
120 Washington Street,0 Floor
Division of Food and Drugs Salem, MA 01970-3523
Tel. (978) 741-1800 Fax(978) 745-0343
City/Town of Address:
FOOD ESTABLISHMENT INSPECTION REPORT Tel.
NameDat Type of Operaffon(s) Type of Inspection
MW G r 1705/16 Food Service Routine
Address �a Rik Retail g Re-inspection
Telephone Jvr Level El Residential Kitchen Previous Inspection
�O a [:] Mobile Date:
Owner , HACCP YIN ❑ Temporary ElPre-operation
J/ ❑ Caterer ❑Suspect Illness
Person-in-Charge(PIC) i c_ Time . ❑ Bed&Breakfast ❑ General Complaint
In: ❑ HACCP
Inspector Out: Permit No. I ❑.Other
Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated.
Non-complfance with:
Violations Related to Foodborne Illness Interventions and Risk Factors_(Red
Items) Anti-Choking 590.009(E) ❑
Violations marked may pose an imminent health hazard and require immediate Tobacco 590.009 IF) ❑
❑
corrective action as determined by the Board of Health. Allergen Awareness 590.009(G)
FOob PROTECTION MANAGEMENT [112. Prevention of Contamination from Hands
❑ 1. PIC Assigned/Knowledgeable/Duties
❑ 13. Handwash Facilities
'EMPLOYEE HEALTH -+
112. Reporting of Diseases by Food Employee and PIC PROTECTION{ROM'CHEMICAtS
❑ 14. Approved Food or Color Additives
❑ 3. Personnel with Infections Restricted/Excluded
F.00DFROM-APPROVED SOURCE E] 15. Toxic Chemicals
❑ 4. Food and Water from Approved Source TIMEREMPERATURE"CONTROLS.(Potentlaily Hazardous Foods)
[1 5. Receiving/Condition ❑ 16. Cooking Temperatures
❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating
❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling
PROTECTION FROM CONTAMINATION .kM. Hot andof olding
❑ 8. Separation/Segregation/Protection ❑ 20.Time as a Public Health Control
,/9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLYSU$CEPTIBLE-POPULATtONS'(H$P)`
❑ 10. Proper Adequate Handwashing [121. Food and Food Preparation for HSP
❑ 11. Good Hygienic Practices CONSUMER ADVISORY
❑22. Posting of Consumer Advisories
Violations Related to Good Retail Practices_(Blue Number of Violated Provisions Related
Items) Critical(C)violations marked must be corrected To Foodborne Illnesses Interventions
immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22):
of Health. Noncritical(N)violations must be corrected Official Order for Correction: Based on an inspection
immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR
of Health. 590.000/federal Food Code.This report,when signed below
C N by a Board of Health member or its agent constitutes an
23. Management and Personnel (Fc-2X9 ) order of the Board of Health. Failure to correct violations
24. Food and Food Protection (FC-3X590.004)0.004.0oa) cited in this report may result in suspension or revocation of
25. Equipment and Utensils (Fc-4X590.005) the food establishment permit and cessation of food
26.Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you
27. Physical Facility (FC-6X590.007) have a right to a hearing. Your request must be in writing
28. Poisonous or Toxic Materials (FC-7X590.008) and submitted to the Board of Health at the above address
29. Special Requirements (590.009) within 10 days of receipt of this order.
30. Other DATE OF RE-INSPECTION
s: 614.doc I
in
Inspector's Signature: _ Print:
c (�
PICS Si - --- - - Prin • Page of I Pages
oN --�C'c��t•�
l
Violations Related to Foodborne Illness
Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION
g Cross-contamination
FOOD PROTECTION MANAGEMENT 3.302.11(A)(]) Raw Animal F(xdS Separated from
1 590.003(A) I Assignaient ofResponsihilit * Coked and RTE Foods*
590.003(6) Demonstration of Knowledge" Contamination from Raw Ingredients
2.103.11. Pet-son in charge -duties 3-302.'11(A)(2) Raw Animal Funds Separated from Each
Other"
EMPLOYEE HEALTH Cmgamination from the Environment
2 590.003(,C) Responsibility of the person in charge to 3-302.1 l(A) Food Protection*
require reporting by food employees and 3-302.1.5 WashingFruits and Vegetables
a plicauls* 3-304.11. Food Contact with Equipment and
590.003(F) Responsibility Of A Food Employee Or An L7tensils*
Applicant To Report To The Person In - Contamination from the Consumer
Charge* 3-306.14(A)(B) Returned Food and Reservice of Food*
590.003(6) Reporting by Person in Charge*
3 590.003(1)) LAcilist( I and Restrictions* Disposition 8iof Adulterated or Contaminated
590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe
FOOD FROM APPROVED SOURCE Fail.*
__ _
4 Food and Water From Regulated Sources 9 Food Contact Surfaces
590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water
3-201.12 Food in a Henneticall y Seated Container* Sanitization TentperaWres*
3.201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-HerWater
3-202.13Shell Eggs* -- _" Sanitization Temperatures*
3-202.14 Eggs find Milk Products. Pasteurized* 4-.501.114 Chemical Sanitization-temp.,pH,
3-202.16 lee Made From Potable Drinking Water* concentration and hardness.'*
5-101.11 Drinking=.Water Sinn an Approved System* 4-601_1'7(A) Equipment Food Contact Surfaces and
Utensils Clean'k
590.006(A) Bottled Drinking Watcr*
590.006(B) Water Meets Standards in 3l0 CMR 22.0"' 4-602.11 Cleaning Frequency of F,quipment Food-
Contact Surfaces and Utensils*
Shellfish and Fish From an Approved Source
4-702.17. Frequency of Sanirization of Utensils and
3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces ofEquipment*
Shellfish* 4-703.11 Methods of Sanitization-Hot Water
Sources*
Shellfish from listed and
3-201.15 oChemical*
S 10 Proper,Adequate Handwashing
Game and Wild Mushrooms Approved by 2_301.11 Clean Condition-Hands and Arms*
Re ulator Authoril
3-202.18 Shellstock Identification Present* 2`301.12 Cleans Procealore*
590.004(C) Wild Mushrooms* 2-301.14 When to Wash*
3-201.17 Game Animals* it Good Hygienic Practices
$ Receiving/Condition 2-401.11 Eating,Drinkin or Using Tobacco*
3-202.11 PHFs Received at Pra er Temperatures" 2.401.12 Discharges From the Eyes,Nose and
3-202.7.5 Package Integrity* Mouth* -
3-101.17. Food Safe and.Unadulterated* 3-301.12 Preventing Contamination When Tasting*
6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands
3-202.18 Shellsoxk Identification* 590.004(Fi) Preventing Contamination from
3-203.1.2 Shellstock Identification Maintained* Employees*
Tags/Records: Fish Products 13 Handwash Facilities
3-402.11 Parasite Destruction* Conveniently Located and Accessible
3-402.12 Records.Creation and Retention* 5-203.11. Numbers and Capacities*
590.0041.1) Labeling of Ingredients* 5-204.1.1 Location and Placement*
7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance
/HACCP Plane Supplied with Soap and Hand Drying
3-502.71 Specialized 1'rc>Cesein Methods*
Devices
3-502.12 Reduced oxygenpackaging,criteria* 6-301.11 Handwashing Cleanser,Availability
8-103.12 Conformance with Approved Procedures* 6"301.12 linnd.D in g Provision
,�Denoaes critical item in nie federal 1999 Ford Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: ZZ G/n 0 Date: Page: a of
Nem Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R-Rod Rom VeriNed
PLEASE PRINT CLEARLY W
�. i C ,n/
u SIN cc t
170°F 77°C ,/
o � C � KiAl ! vr!
Gr �4 GrN ✓'ry 0 C cI
s,e o IG J '!= ti
Cs
°i� it cIse?
J�h2 Cc, J G I n a 2'9210'A n'/ J 0 Zi
! .
F V rrJ>�J
r s
I Cil✓ JYl 4
(Mc Wv '- Sd r, O S
Z r N
( S -�.✓ CJS
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
p e-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 suspensionlrevocation of ❑ Embargo ❑ Emergency Closure
your food permit.
0 Voluntary Disposal 0 Other:
Violations Related to Foodborne Illness Interventions and Risk
Factors(Items 1-22) (Cont.) 3-501.15 Cooling Methods for PHFs
19 PHF Hot and Cold Holding
PROTECTION FROM CHEMICALS 3-501.16(13) Cold PRFs Maintained at or below
14 Food or Color Additives 590.004(F) 410/450 F*
3-202.12 Additives* 3-501.16(A) Hot PHFs Maintained at or above
3-302.14 Protection from Unapproved Additives* 140°F *
" 15 Poisonous or Toxic Substances 3-501.16(A) Roasts Held at or above 130°F. "
7-101.11 Identifying Information-Original 20Time as a Public Health Control
Containers" 3-501.19 Time as a Public Health Control*
" 7-102.11 Common Name-Working Containers* 590.004(H) Variance R uiiement
' 7-201.11 Separation-Storage*
7-202.11
Restriction and Use" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-202.12 Conditions of Use* POPULATIONS HSP
7-203.11 Toxic Containers-Prohibitions" - 21 3-801 11(A) Unpasteurized Pre-packaged Juices and
7-204.11 Sanitizers,Criteria-Chemicals* Beverages with Wanting labels*
t
7204.12 Chemicals for Washing Produce,Criteria* 3-801.1 113 Use of Pasteurized Eggs*
7-204.14 Drying Agents,Criteria*. 3-801.1 I(D) Raw or Partially Cooked Animal Food and
7-205.11 Incidental Food Contact,Lubricants* Raw Seed Sprouts Not Served. *
7-206.11 Restricted Use Pesticides,Criteria" ,. .., ,
3-801.1 I(C) Unopened Food I acka e Not Re-served.
7-206.12 Rodent Bait Stations*
7-206.13 Tracking Powders,Pest Control and CONSUMER ADVISORY
Monitoring* 22 3.603.11 Consumer Advisory Posted for Consumption of
Animal Foods"rhal are Raw,Undercooked or
TIME/TEMPERATURE CONTROLS Not Otherwise Processed to Eliminate
16 Proper Cooking Temperatures for Patho rens.*E"°,"I
PHFs 3-302.13 Pasteurized Eggs Substitute for Raw Shelf Eggs*
3-401.11A(1)(2) Eggs- 155°F 15 Sec.
Eggs-hnmediate Service 145°1715sec" SPECIAL REQUIREMENTS
3-401.11(A)(2) Comminuted Fish,Meats&Game 590.009(A)-(D) Violations of Section 590.009(A)-(D) in
Animals- 1550P 15 sec. * catering,mobile food, temporary and
3-401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 min* residential kitchen operations should be
3-401.11(A)(2) Ratites, Injected Meats-155°F 15 sec. debited under the appropriate sections
3-401.1 I(A)(3) Poultry,Wild Game,Stalled PI-IFs, _ above if related to foodborne illness
Stuffing Containing Fish,Meal, interventions and risk factors. Other
`
Poultry or Ratites-165°F IS sec. 590.009 violations relating to good retail
*
3-401.1 I(C)(3) Whole-muscle,Intact Beef Steaks practices should be debited under#29-
145°F* I Special Requirements.
3-401.12 Raw Animal Foods Cooked in a
Microwave 165°F* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-401.1 I(A)(1)(b) All Other PIlFs 145°F 15 sec. * (Items 23-30)
17 Reheating for Hot Holding Gdlical and non-crifical violations, which do not relate to the
`. 3-403.11(A)&(D) PHFs 165°F 15 sec. * foodborne ilbress interventions and risk s listed above, can be
found in rhe following sections of the Food Code and 105 CMR
3-403.1](13) Microwave- 165°F 2 Minute Standing 590.000.
Time* Item Good Retail Practices FC 590.000
3-403.11(C) Commercially Processed RTE Food- 23. Management and Personnel FC-2 .003
140°F• 24. Food and Food Protection FC-3 .004
3-403.11(1-) Remaining Unsliced Portions of Beef 25. Equipment and Utensils FC-4 .005
Roasts* 26. Water,Plumbing and Waste FC-5 .006
? 18 Proper Cooling of PHFs 27. Physical Facility FC-6 .007
r 3-501.14 A > 28. Poisonous or Toxic Materials FC-7 .008
O Cooline Cooked I HFs from 140°F to 29, Special Requirements .009
70°F Within 2 Hours and From 70°F to 30. Other
41°F/45°F Within 4 Hours. * s:esoram�n".6_aa -
3-501.14(13) Cooling PRFs Made From Ambient
Temperature Ingredients to 41°F/45°F
16 Within 4 Hours*
3-501.14(C) - PHFs Received al Temperatures
According to Law Cooled to
41°F/45°F Within 4 Flours. °
i
*Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000.
r
CITY OF SALEM
BOARD OF HEALTH
Establishment Name: Date: Page: ` of
Rem Code C-Critical em DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date
No. Reference R–Red Rem Verified
PLEASE PRINT CLEARL
Ligpej . 1.
��? !!fi�n� l
n ,'
rim
v2W,`
' on rk `✓1 lAo We S
2' iS i r✓ /
S'!' J
ri D,�jJl S ✓`22
r _ ,nX
/ / QJOwJJ &a2 14s
n V . J ."i Ili o! ,
Discussion With Person in Charge:G3P(Q rle, Corrective Action Required: ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employe Restriction/
violations before the next inspection, to observe all conditions as described, and to Exclusion
P �—Ra'-inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that iV
noncompliance may result in daily fines of twenty-five dollars or suspension/revocation o Embargo ❑ Emergency Closure
your food permit.
0 Voluntary Disposal 0 Other:
l
Violations Related to Foodborne Illness Interventions and Risk 3-501.15 Cooling Methods for PRFs
Factors(Items 1-22) (Cont.)
19 PHF Hot and Cold Holding
PROTECTION FROM CHEMICALS 3-501.16(13) Cold PHFs Maintained at or below
14 _ Food or Color Additives 590.004(F) 410/450 F*
3-202.12 Additives* 3-50L16(A) Hot PIiPsMaintained atorallote
3-302.14 Protection from Unapproved Addifives* 1400F .'
15 Poisonous or Toxic Substances 3-5O1.I6(A) Roasts I-Idd at or above 130°P.
7-101.11 Identifying Information-Original 20 Time as a Public Health Control
f Containers* 3-501.19 Time as a Public Health Control*
102.11 Common Name-Working Containers* 590.004(li) Variance Re uirentcat
7-201.11 Separation-Storage*
7-202.11 Restriction-Presence and Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-202.12 Conditions of Use* POPULATIONS HSP
i 7-203.11 Toxic Containers-Prohibitions* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and
7-204.11 Sanitizers,Criteria-Chemicals* Beverages with Wanting Labels*
'I 7-204.12 Chemicals for Washing Produce,Criteria"
3-801.11(13) Use of Pasteurized Eggs*
7-204.14 Drying A rents,Cr feria* 3-801.11(D) Raw or Partially Cooked Animal Food and
7-205.1 I Incidental Food Contact;Lubricants* Raw Seed Sprouts Not Served. *
7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(C) Unopened Food Package Not Re-served"
7-206.12 Rodent Bail Stations*
7-206.13 Tracking Powders, Pest Control and CONSUMER ADVISORY
Monitoring* 22 3-603.1 I Consumer Advisory Polled for Consumption of
Animal Foods That are Raw,Undercooked or
TIME/TEMPERATURE CONTROLS Not Otherwise Processed to Eliminate
1G Proper Cooking Temperatures for Pathogens.*ef".""
PHFs 3-302.13 Pasteurized Eggs Substitute for Raw Shell L' s*
'r 3-401.11A(I)(2) Eggs- 155°F 15 Sec
E s-Immediate Service 145°PI Ssec• SPECIAL REQUIREMENTS
3-401.11(A)(2) Comminuted Fish,Meats&Game 590.009(A)-(D) Violations of Section 590.009(A)-(D) in
Animals- 155°F 15 sec. * catering,mobile-food, temporary and
3-401.11(13)(1)(2) Pork and Reef Roast- 1307 121 min* residential kitchen operations should be
3-401.11(A)(2) Ratites, Injected Meats-155°F 15 sec. debited under the appropriate sections
*
3-401.11(A)(3) Poultry,Wild Game,Stuffed PRFs, above if related to foodborne illness
�s Stuffing Containing Fish,Meat, interventions and risk factors. Otter
Poultryor Ratites-1650F 15 sec. * 590.009 violations relating to good retail
3-401.11(C)(3) Whole-muscle,Intact Reef Steaks practices should be debited under#29-
145°F* Special Requirements.
3-401.12 Raw Animal Foods Cooked in a
Microwave 1650F* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-401.11(A)(1)(b) All Other PRFs-145°F 15 sec. * (Items 23-30)
17 Reheating for Not Holding Critical and nor-critical violations,which do not relate to Ore
foodborne illness itnervenlions and rislr facmrs listed above, can be
3-403.1](A)&(])) PHFs 165°F 15 sec. * found in the following sections of the rood Code and 105 CMR
3-403.11(13) Microwave- 1650 F 2 Minute Standing 590.000.
t Time* Item Good Retail Practices FC 590.000
3-403.11(C) Commercially Processed RTE Food- 23. Management and Personnel FC-2 .003
14001'* 24. Food and Food Protection FC-3 .004
3-403.11(E) Remaining Unsliced Portions of Reef 25. Equipment and Utensils FC-4 .005
Roasts* 26. Water,Plumbing and Waste FC-5 .006
27. Physical Facility FC-6 .007
FI 8 Proper Cooling of PHFs
26. Poisonous or Toxic Materials FC-7 .006
3-501.14(A) Cooling Cooked PHFs from 140'F to 29. Special Requirements .009
70°F Within 2 Hours and From 70°F to 1 30. 1 Other
41°F/450F Within flours. * S5%f „n"rasa
3-501.14(8) Cooling PRFs Made From Ambient
Temperature Ingredients to 410F/450F
Within 4 Hours*
3-501.14(C) PRFs Received at Temperatures
1 According to Law Cooled to
-
41°F/450F Within 4 Hours. `
l
*Denotes eritial item in the federal 1999 Food Code or 105 CMR 590.000.
CITY OF SALEM
BOARD OF HEALTH
Establishment Name Date: G Page: of
nem Code c—Crtnc i nem DESCRIPTION OF VIOLATION I PLAN OF CORRECTION Date
No. Reference R—Rednem Verified
PLEASE PRINT CLEARLY
a °;— s= H
)'4
3
sJIU5Q rN r n
Or
f <.)
,} vl
NS ry S (t vew o
v rf
v
Discussion With Person in Charge: Corrective Action Required: ❑ No Yes
I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/
inspection, to observe all conditions as described, and to Exclusion
violations before the next ins
P -inspection Scheduled ❑ Emergency Suspension
comply with all mandates of the Mass/Federal Food Code. I understand that
noncompliance may result in daily fines of twe _ f.ive-dollars or-suspension/r vocation of o Embargo ❑ Emergency Closure
your food permit.
0 Voluntary Disposal ❑ Other:
1
Violations Related to Foodborne Illness Interventions and Risk -
Factors(Items 1-22) (Cont.) 3-501.15 Cooling Methods for PHI's
I - 19 PHF Hot and Cold Holding
PROTECTION FROM CHEMICALS 3-501.16(13) Cold PHFs Maintained at or below
14 Food or Color Additives 590.004(1') 410/450 F*
3-202.13 Additives' 3-501.16(A) Hot PHFs Maintained at or above
3-302.14 Protection from Unapproved Additives* 140017.
j I S Poisonous or Toxic Substances 3-501.16(A) Roasts Held at or above 130°F. "
7-101.11 Identifying Information-Original 20 Time as a Public Health Control
Containers* 3-501.19 Time as a Public Health Control`
7-102.11 Common Name-Working Containers* 590.004(H) Variance Requirement
7-201.11 Separation-Storage*
7-202.11 Restriction-Presence and Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE
7-202:12 Conditions of Use* POPULATIONS HSP
7-203.11 Toxic Containers-Prohibitions*
} 7-204.11 Sauilizers,Criteria-Chemicals* 21 3-R01.11(A) Beverages wrized ith
and
1 Bevera es with Watnin Labels*
I 7-204.12 Chemicals for Washing Produce,Criteria" 3-801.1 I B Use of Pasteurized Eggs*
> 7-204.14 Drying Agents,Criteria'
3-801.11(D) Raw or Partially Cooked Animal Food and
7-205.11 Incidental Food Contact, Lubricants* Raw Seed Sprouts Not Served. `
7-206.11 Restricted Use Pesticides,Crileria* 3-801.11(0) Unopened Food Package Not Re-served.
7-206.12 )'Rodent Bait Stations`
7-206.13 Tracking Powders, Pest Control and CONSUMER ADVISORY
Monitorin g* 22 3-603.11 Consumer Advisory Posted for Consumption of
Animal Foods Thal are Raw,Undercooked or
TIME/TEMPERATURE CONTROLS Not Otherwise Processed to Eliminate
16 Proper Cooking Temperatures for Pathogens.*6"O""O'"20°'
PHFs 3-302.13 Pasteurized Eggs Substitute for Raw Shell E s*
3-401.11A(I)(2) Eggs- 155°F 15 Sec.
!
Eggs-Immediate Service 145°FI Ssec" SPECIAL REQUIREMENTS
° 3-401.1 1(A)(2) Comminuted Fish,Meats&Game
590.009(A)-(D) Violations of Section 590.009(A)-(D) in
Animals- 155°F 15 sec. * catering,mobile food, temporary and
3-401.11(13)(1)(2) Pork and Beef Roast- 130°F 121 mm* residential kitchen operations should be
3-40 1.11(A)(2) Ratites, Injected Meats-155°F 15 sec. debited under the appropriate sections
3-401.11(A)(3) Poultry,Wild Game,SlulTed PHFs, above if related to foodborne illness
Stuffing Containing Fish,Meal, interventions and risk factors. Other
Poultry orRatites-165°F 15 sec. * 590.009 violations relating to good retail
3-401.11(C)(3) Whole-muscle,Intact Beef Steaks practices should be debited under#29-
1459' Special Requirements.
3-401.12 Raw Animal Foods Cooked in a
t Microwave 165°F* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES
3-401.11(A)(1)(b) All Other PHFs- 14501' 15 sec. * (Items 23-30)
17 Reheating for Hot Holding Critical and non-critical violations, which do not relate to the
3-403.1](A)&([)) PHFs 165°F 15 sec. * - foodborne illness interyention.c and risk factors listed above,can be
found in the following sections of the food Code and 105 CMR
3-403.1](13) Microwave- 165°F 2 Minute Standing 590.000.,
Time* Item Good Retail Practices FC 590.000
.r 3-403.1 I(C) Commercially Processed RTL'- Food- 23. Mana ement and Personnel FC-2 .003
1400I'* 24. Food and Food Protection FC-3 .004
3-403.11(1,) Remaining Unsliced Portions of Beef 25. Equipment and Utensils FC-4 .005
Roasts* 26. Water,Plumbing and Waste FC-5 .006
18 Proper Cooling of PHFs 27. Physical Facility FC-6 .007
28. Poisonous or Toxic Materials FC-7 .008
3-501.14(A) Cooling Cooked PI1Fs from 140°F to - 29. Special Requirements .009
70°F Within 2 Hours and From 70°F to 30. Other
41°F/45°F Within 4Hours.
` assom sxxazaa
3-501.14(B) Cooling PRFs Made From Ambient
Temperature Ingredients to 41'17/45'1'
Within 4 Hours*
3-501.14(C) P1114s Received at Temperatures
Accordine to Law Cooled to
4 PF/45°F Within 4 Hours.
'Denotes critical item in the federal 1999 Food Cudc or 105 CMR 590.000.
j
1�1 -7
• , + CITY OF SAI-EM, 1VIASSACHUSETTS I
lu
BOARD OF HEALTH
�0 WASHINGTON STREET,4T" F1.,OOR P11h�1CPromIi@alth
(978) 741-1800 FAx(978) 745-0343
KIMBERLEY DRI IramdinGlsalem.com
MAYOR 3 +C LARRY RAMDIN,RS/REI-]S,01-10,CP-FS
QL� O8 �01'J HEALTI-I AGENT
REMODEL LAN REVIEW APPLICATION FOR CURRENTLY
LICENSED ESTABLISHMENTS
i
REMODEL _CONVERSION Application fee :$90.00
Category: Restaurant " , Institution , Daycare Retail Market , Other
Name of
Establishment: 4�0 �`— a/�� ✓ �',``��e^�
Address: & 9vJG .2` Sf S �c.•t Q
Phone, email if available: � 7 P 7 yy �a
Name of Owner: v��-�
Mailing Address:
Telephone: qT� 7yy vow : 5 � � 39 588
Applicant's Name: eT/c eo a Zf
e.
Title (owner, manager, architect, etc.):
Mailing Address: I& & � L✓h�/z S/r -C,500'
Telephone/email: a , 5 z 3f?
I have submitted plans/applications to the following authorities on the following dates:
Plumbing IX Building Fire Planning Electrical
Conservation Engineering Licensing Historical Commission
City Clerk Public Services Water Assessors
Hours of Operation: Sun 1141"-I Mon -00� Tues 4n Wed
Thurs 1- 54,4 FRI T Sat /Y4ri ' // 't
Number of Seats: Number of Staff: (Maximum per shift)
Maximum Meals to be served: (approximate number): Breakfast &-- Lunch 7 Dinner�7
nnPK04-cc) 7k
, 1
Y
Type of Service: (check all that apply): Sit Down Meals tl� Other Take Outy
Caterer Mobile Vendor
Project Start date: D cf 57 Completion date: Dc l
Please enclose the following documents:
Application Fee $90.00 (Check or Money Order made out to "City of Salem" )
Proposed Menu (including seasonal, off-site and banquet menus)
Manufacturer Specification sheets for each piece of equipment shown on the plan
Site plan showing location of business in building; location of building on site including alleys, streets;
and location of any outside equipment (dumpsters, well, septic system - if applicable)
Plan drawn to scale of food establishment showing location of equipment, plumbing, electrical services
and mechanical ventilation (color coded)
Equipment schedule
FOR OFFICIAL USE ONLY
DATE RECEIVED4 �� FEE AMOUNT (V\
RECEIVED BY DATE APPROVED:
APPROVED BY:
CITY OF SALEM, IV
MASSACHUSETTS PeuacHeatr>1
BOARD OFHFALTFI ".
120 WASHINGTON STREET,4m FLooR
KIMBERLEY DRISCOLL TCI..(978)741-1800 FAx(978)745-0343 LARRY RAMDIN,RS/RF.HS,CHO,CP-FS
MAYOR Iramdin@salem.com - HEAL1'uAGENf -
Food Establishment Permit Application
(Application must be submitted at least 30 days before the planned opening date)
1) Establishment Name: %IJJ Iia4"a../ e,i } X�GYeer �.
2) Establishment Address: ;., a 0)4".k 2 Sf Sot lel" /-('4f
3) Establishment Mailing Address(if different):
4) Establishment Telephone No: 7P- OD rpm
5) Applicant Name&Title: '4�.✓/O r/;o �T/�' ✓C r� kR - d ✓d 2,C_
6) Applicant Address: D,
9�8 a�9 s8�sa
7) Applicant Telephone No: ? a13� ,S'8g=4 Hour Emergency No: Email:
6) Owner Name&Title(if different from applicant):
9) Owner Address(if different from applicant):
10) Establishment Owned by: 11) If a corporation or partnership,give name,title and home address of
officers or partner.
An as ion Name Title Home Address
corporation 7—
An in rvi a ✓�J v c�1E' ✓C' �.t ✓ewe-%.
A partnership
Other legal entity 1/a/e r.`e �Sr�,t2.✓ccs rr� f° 2 TP�r9� 5 . �/o��✓e c
12 Person Directly Res onsible For Daily Operations Owner, Person in Charge, Supervisor,Manager,etc.
Name&Title: /9✓P��✓i0 ��f�� ✓Co u. e yC�r
Address: o?/ 7'7"uS 374. Jeer✓22S (/j
Telephone No: Y78 % -"8'.2-83- Fax:97F 79y i/b-A Email: 4ew
Emergency Telephone No:
13) District or Regional Supervisor(if applicable)
Name&Title:
Address:
Telephone No: Fax: Email:
Check#: Date: Amount:
Food Establishment Information
14) Water Source: 15) Sewage Disposal:
DEP Public Water Supply No: ( if applicable)
16) Days and Hours of Operation: 17) No. of Food Employees:
18) Name of Person in Charge Certified in Food Protection Management:
Required as of 101112001 in accordance with 105 CMR 590.003(A)
19) Person Trained in Anti-Choking Procedures(if 25 seats or more): ❑ Yes No
20) Location: 22) Establishment Type(check all that apply)
(check one) ❑ Retail( Sq. Ft) ❑Caterer
Permanent Structure ❑ Food Service—( Seats) ❑ Frozen Dessert Manufacturer
Mobile ❑ Food Service—Takeout ❑ Residential Kitchen for Retail Sale
❑ Food Service—Institution ❑ Residential Kitchen for Bed and
( Meals/Day) Breakfast Home
❑ Food Delivery ❑ Residential Kitchen for Bed and
21) Length Of Permit: _Breakfast Establishments ,,,,,,,,,,,,,,,,,,,,
.................................. - .....-..........---.----... .
(check one) RETAIL STORE RESTAURANT
Annual ❑Less than 1000sq.ft. $70 ❑ Less than 25 seats $140
Seasonal/Dates: ❑1000-10,OOOsq.ft. $280 ❑ Residential Kitchens $140
❑More than 10,000sq.ft. $420 ❑25.99 seats $280
❑More than 99 seats $420
Temporary/Dates/Time: .........................................-..................................................--...........................................
❑ Bed&Breakfast/Childcare Services/Nursing Home $100
ADDITIONAL PERMITS
❑MAKE ICE CREAM,YOGURT/SOFT SERVE $25
❑ PASTURIZATION $25
❑ALL NON-PROFIT' $25
1ricludin , church kitchens, state funded childcare&private club
23) Food Operations: Definitions: PHF-potentially hazardous food(tima/temperature controls required)
Non-PHFs-non-potentially hazardous food(no timeltemperature controls required)
(check all that apply): RTE-read to-eat foods Ex.sandwiches,salads,muffins which need no further processing
Sale of Commercially PHF Cooked to Order Hot PHF Cooked and Cooled or Hot Held
Pre-packaged Non-PHFs for More Than a Single Meal Service
Sale of Commercially Preparation of PHFs For Hot And PHF and RTE Foods Prepared.For Highly
Pre-packaged PHFs Cold Holding for Single Meal Service Susceptible Population Facility
Delivery of Packaged PHFs Sale of Raw Animal Foods Intended to be Vacuum Packaging/Cook Chill
Prepared by Consumer
Reheating of Commercially Customer Self-Service Use of Process Requiring A Variance
Processed Foods for and/or HACCP Plan(including bare hand
Service.Within 4 hours contact alternative,time as public health
control.
Customer Self-Service of Ice Manufactured and Packaged for Offers Raw or Undercooked Food of
Non-PHF and Non- Retail Sale Animal Origin
Perishable Foods Only
Preparation of Non-PHFs Juice Manufactured and Packaged for Prepares Food/Single Meals for Catered
Retail Sale Events or Institutional Food Service
Offers RTE PHF in Bulk Quantities
To be completed by the Board of Health
Retail Sale of Salvage,Out of Date
or Reconditioned Food Total Permit Fee:
Payment is due with application
I,the undersigned,attest to the accuracy of the information provided in this application and I affirm that the food establishment operation will
comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the Board of Health on how to obtain copies of 105 CMR
590.000 and the Federal Food Code.
24) Signature of Applicant:
Pursuant to MGL Ch.62C, sec.49A, I certify under the penalties of perjury that I,to my best knowledge and belief,
Have filed all state tax returns and paid state taxes required under law.
25) Social Security Number or Federal ID:
26) Signature of Individual or Corporate Name:
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CONVECTION FLO Job Item #
SERIES GAS DECK OVENS
�.• GAS DECK OVENS s
Single Double Triple
251 252 253
351 352 353
451 452 453
STANDARD
P" ❑ 60,000 to 80,000 BTUH per deck, natural or LP gas ILP not
CE approved
�O ' I ❑ 3000-6500 F (1490-3430C)throttling thermostat
❑ Top 8 bottom heat control damper
❑ Combination gas controls with valve, regulator b pilot safety
❑ Heavy-duty, slide-out flame diverters
❑ 8" (203mm) interior deck heights with 1 1/2" (38mm)thick
SPECIFICATIONSCordierite hearth decks
BAKERS PRIDE Convection Flo Series gas Deck Ovens are designed ❑ All stainless steel exteriors
for high volume pizza and all-purpose operations. ❑ Aluminized steel interiors
❑ Spring balanced, fully insulated doors
Ovens may be stacked three high. Oven exteriors are all heavy- ❑ Side or rear gas connections
gauge,type 403 stainless steel and are fully insulated for cooler
outer temperatures and consistent interior temperatures. ❑ 7-Gauge legs
❑ Fully insulated throughout
Interior oven frame is constructed of 1/4" (6mm) heavy-duty angle ❑ 1 Year limited part and labor warranty
iron frame, completely welded to form a single, unitized section.
The oven body and lining are then welded to the framework.
Oven interiors are manufactured of high-heat resistant 16-gauge
aluminized steel. Doors are fully insulated, spring balanced with
tubular steel handles and will remain open or closed until moved. ACCESSORIESOPTIONS&
All models feature independent, operator-controlled top 8 bottom
heat control damper. ❑ Steel decks
Convection Flo Series features a 300°-650°F (149°-343°C) ❑ 150°-550°F (65°-288°C)thermostat
throttling thermostat,8" (203mm) interior deck height with 1 1/211 ❑ Set of 4 casters-two with locks
(38mm)thick Cordierite hearth decks (steel decks optional) and are ❑ Stainless steel leg covers
supported by a 1/4" (6mm) angle iron frame. ❑ Special height legs
Combination gas control incorporates a manual gas valve, pilot ❑ Steam Injection
safety and pressure regulator. Easily removable, slide-out, heavy- O Automatic oven starter
duty flame diverters distribute the burner flame uniformly in the ❑ Draft flue for direct vent (not available on CE units)
burner chamber.A 3/4" (19mm) NET gas connection is located on
the left side and left rear of oven-operatorfinstaller may choose.
Heavy-duty, 7-gauge hot rolled steel legs are standard and finished
with durable Bakertone.
1 Year limited parts and labor warranty standard.
CERTIFICATIONS
NSF CE
BAKERS PRIDE OVEN COMPANY,INC.
30 Pine Street,New Rochelle,NY 10801 Continuous productimprovement e a policy of Bakers Pride Oven Company.
914/576-0200• 1-800-431-2745 •fax 914/576-0605 Therefore,specifications and design are subject to change without notification
www.bakerspride.com
I�
f— 43"
43• 314'NPT 11092mm1
11092mm1 GPS INLET
-._. . .... ..-, 1210mm V(203ril
8'9203mm1 24" 54' _ TNPT 16114.
81/4" �U ............... (Stumm) 11372mm1 GAS/INLETS 11581 an'at1210mm1� 523/4•
521/4' 11340mm1
D321mm1 �-
8'1203mm1 24" 64"
423/4' tet_..._ 1610mm1 11626mm1
D 086mmc-F
0" 3A 1/4'
O62mm1 19ttMan
l
LT7283/4'
1130mm1
L(411MM)
SINGLE UNIT
RH SIDE VIEW STACKED UNIT
RH SIDE VIEW
43"
'r—
1
1092mm1 '� 3/4'NPT GAS INLET
81/4"
T�1210mm1 8"(203mm)
24"
I610mm1
fi63/4' I I 'R9mm1 WIDTH4
(1663/4' 3/4 NPT 43/4'1121mm
GAS INLET DECK
8 1203mm1 18'
i .
—t _._.__ _..i 24• 11981mm1-LF --
3/4°NPT (Stumm)
423/4" GAS INLETS 521/4 )61/4" 81/8" Flue Vent 6'(152mml the 48'
(1086mm) TO nrml (1931mm) (20fimml (1092mm1
—* 34 5/8"
81203mm) 24" 54" 3/4'NPT 18)9mm1
-- - I610mm1 (1372mm) GAS INLET
183/4" 381/4"
(416mm 1912min
1/4"
STACKED UNIT 1286mm) FULL WIDTH 000fl OPENING 31/2"
6" 189mm1
RH SIDE VIEW (152mm) TDP VIEW
6" 6"
ALL DIMENSIONS NOMINAL ,f(152mm) (t 52mm)
12" 12"
(305mm) (305mm)
SHIPPING INFORMAI[ON
Shipping Weight Carton Dimemiona Crate Sim
Mm Depth III "We table
Read x'' "a0° laden as lydoe � adee a Nd xem For Direct Venting For Installation U AFT
251 820 372 53 1346 40 1016 37 940 44.4 1.4 Not available on CE units VerNilation Hood
351 958 434 52 1321 36 914 72 1829 76.2 2.7 MUST BE SPECIFIED AT TIME OF ORDER STANDARD
451 1093 496 52 1321 36 914 72 1829 76.2 2.7
SNppng CWa N 10
Ek'h oven W,Hwgeely
Haegh Meeks b kgs SNPm separate cartons hit" Run XW CONNECTION
SPECIFICNI IONS251 60,000 18 3/4"
Deek Size # Ovarall0imenaions 351 70,000 T1 3/4"
momHetet Doh Wine xenu •xe0, 451 80,000 24 3/4"
Indw Inds r INdea Indee Inds
251 3611/2 914816 8 1203 1 48 1219 43 1092 54 1372 Eampvenregevessepa......... '
CEcerMicanwnalevailaaleinlPpas
252 36x34 1/2 914z816 8 203 2 48 1219 43 1092 64 1626
253 3604 1/2 914876 8 203 3 48 1219 43 1092 78 1981
351 45x34 112 1143x876 8 203 1 57 1448 43 1092 54 1372 em Cargail Caeewea® CrmeeeaaD C.araael
352 45x34 1/2 1143x876 8 203 2 57 1448 43 1092 64 1626 lade° hi353 4504 1/2 1143x876 8 203 3 57 1448 43 1092 78 1981 Left Side 0 0 1 25 -
451 5434 1/2 1372x876 8 203 1 66 1676 43 1092 54 1372 Right Side 0 0 3 7fi
452 54x34 1/2 1372x876 8 203 2 fifi 1676 43 1092 64 1626 Rear 2 51 3 7fi
453 54x34 1/2 1372x876 8 203 3 fifi 1676 43 1092 78 1981 mEumpea,c°wmmny cpawies anarvpnn PmeNe.In NON COMOUS74LE l ae°es°nry
•Heglxintlades 30'p62amistandoN legsmmotle6151,1151,4151 •Height ecludes6"NU mml rheelaN kgs w models 153.3153.4153 •'Nbell.Carver/Cwnttles anN in COMAOSPINE k..NOT In NaO Aree..
'Are,hen=16'1406 mml srentleNlegswmotlek 151,3152?152 CEapprovaduNR mayeerbenWkedti
BAKERS PRIDE OVEN COMPANY,INC. Continuous producfimprovement is a policy of Bakers Pride Oven Company.
30 Pine Street,New Rochelle,NY 10801 Therefore,specifications and design are subject to change without notification
914/576-0200• 1-800-431-2745°fax 914/576-0605 TSW 07/05
wwwItakerspride.com
62 RESTAURANT&WINE BAR \ '
i ) 6606
City of Salem 10/7/2015
permit 90.00
EIVE®
OCT 0 8OF
30AR0 OF HLEAI.TN
I
Salem Five-Operatin remodel application 90.00